Evelyn Cohen Reis

Screening Children to Identify Families at Increased Risk for Cardiovascular Disease

OBJECTIVES. Atherosclerotic cardiovascular disease is the leading cause of death in the United States. Atherosclerosis begins early in life; however, children and young and middle-aged adults are not universally screened for the presence of modifiable cardiovascular disease risk factors. The purpose of this study was to investigate whether cardiovascular disease risk-factor assessment in children can identify families who are at increased risk for cardiovascular disease. PARTICIPANTS AND METHODS. Family Strategies Concentrating on Risk Evaluation is a community-based participatory research study designed to stratify cardiovascular disease risk in a cohort of children and their parents. Eligible families, consisting of ≥1 child and ≥1 biological parent, are recruited through community and faith-based educational and screening programs. In a single, fasted study visit, participants undergo assessment of cardiovascular disease risk factors: obesity, hypertension, dyslipidemia, and metabolic syndrome. Associations of cardiovascular disease risk factors between children and their parents were assessed. RESULTS. Data were analyzed from 94 families: 108 parents (mean age: 38.5 ± 7.5 years), 141 children (mean age: 10.5 ± 3.4 years), and 170 child-parent pairs. Child-parent association was strong for many risk factors: BMI, waist circumference, systolic blood pressure, triglycerides, and total cholesterol. Several discrete-defined risk factors in children were found to be significant predictors of the presence of the same risk factors in their parents. Parents of children with hypertension, obesity, or hypertriglyceridemia had 15 times, 6 times, or 5 times increased odds, respectively, of having the same risk factors. CONCLUSIONS. Identification of several clinically apparent and silent cardiovascular disease risk factors in children predicts elevated cardiovascular disease risk in their parents. Because children access primary care more frequently than adults, children can potentially serve as the index case to identify families at increased risk for cardiovascular disease.

Dosing Error With Over-the-Counter Vitamin D Supplement: A Risk for Vitamin D Toxicity in Infants

Vitamin D, the “sunshine vitamin,” is back in the limelight.1 Reemergence of rickets among vulnerable infants (dark-skinned and/or breast-fed without vitamin D supplementation) and reports of excessive prevalence of vitamin D deficiency and insufficiency among children have reemphasized the importance of optimal intakes of vitamin D.2–5 The American Academy of Pediatrics (AAP) increased its recommended dietary allowance (RDA) of vitamin D for the prevention of vitamin D deficiency in infants and children from 200 IU to 400 IU in 2008.6–7 Recently, the Institute of Medicine (IOM) revised its RDA for vitamin D from 200 IU to 400 IU in infants (0 to 12 months) and from 200 IU to 600 IU in children (1 to 8 years).8 Without fortification, very few foods are rich in vitamin D. Humans meet their vitamin D needs from sunlight exposure, diet and/or supplements. Of these sources, photosynthesized vitamin D is the major contributor to human vitamin D status.9–11 Vitamin D-fortified milk and infant formula remains the main dietary source of vitamin D. An infant or a child must drink 4 servings (1 liter or 32 ounces) of vitamin D-fortified milk to meet the AAP recommended intake of vitamin D (400 IU/day), which seems to be a tall order for many. Therefore, vitamin D supplements become an important source of dietary vitamin D. In order to meet consumer desires to prevent deficiencies or optimize health benefits related to vitamin D, preparations of higher concentrations of over-the-counter vitamin D supplements have become readily available for the general public, with the potential for inadvertent overdosing in young infants and children.

Primary Care Providers' Initial Treatment Decisions and Antidepressant Prescribing for Adolescent Depression

Objective: Adolescent depression is a serious and undertreated public health problem. Nonetheless, pediatric primary care providers (PCPs) may have low rates of antidepressant prescribing due to structural and training barriers. This study examined the impact of symptom severity and provider characteristics on initial depression treatment decisions in a setting with fewer structural barriers, an integrated behavioral health network. Methods: A cross-sectional survey was administered to 58 PCPs within a large pediatric practice network. PCP reports of initial treatment decisions were compared in response to 2 vignettes describing depressed adolescents with either moderate or severe symptoms. PCP depression knowledge, attitudes toward addressing psychosocial concerns, demographics, and practice characteristics were measured. Results: Few PCPs (25% for moderate, 32% for severe) recommended an antidepressant. Compared with treatment recommendations for moderate depression, severe depression was associated with a greater likelihood of child psychiatry referral (odds ratio [OR], 5.50; 95% confidence interval [CI], 2.47–12.2] p < .001). Depression severity did not affect the likelihood of antidepressant recommendation (OR, 1.58 [95% CI, 0.80–3.11] p = .19). Antidepressants were more likely to be recommended by PCPs with greater depression knowledge (OR, 1.72 [95% CI, 1.14–2.59] p = .009) and access to an on-site mental health provider (OR, 5.13 [95% CI, 1.24–21.2] p = .02) and less likely to be recommended by PCPs who reported higher provider burden when addressing psychosocial concerns (OR, 0.85 [95% CI, 0.75–0.98] p = .02). Conclusion: PCPs infrequently recommended antidepressants for adolescents, regardless of depression severity. Continued PCP support through experiential training, accounting for provider burden when addressing psychosocial concerns, and co-management with mental health providers may increase PCPs’ antidepressant prescribing.

Cluster randomized trial of a toolkit and early vaccine delivery to improve childhood influenza vaccination rates in primary care.

PURPOSE To increase childhood influenza vaccination rates using a toolkit and early vaccine delivery in a randomized cluster trial. METHODS Twenty primary care practices treating children (range for n=536-8183) were randomly assigned to Intervention and Control arms to test the effectiveness of an evidence-based practice improvement toolkit (4 Pillars Toolkit) and early vaccine supplies for use among disadvantaged children on influenza vaccination rates among children 6 months-18 years. Follow-up staff meetings and surveys were used to assess use and acceptability of the intervention strategies in the Intervention arm. Rates for the 2010-2011 and 2011-2012 influenza seasons were compared. Two-level generalized linear mixed modeling was used to evaluate outcomes. RESULTS Overall increases in influenza vaccination rates were significantly greater in the Intervention arm (7.9 percentage points) compared with the Control arm (4.4 percentage points; P<0.034). These rate changes represent 4522 additional doses in the Intervention arm vs. 1390 additional doses in the Control arm. This effect of the intervention was observed despite the fact that rates increased significantly in both arms - 8/10 Intervention (all P<0.001) and 7/10 Control sites (P-values=0.04 to <0.001). Rates in two Intervention sites with pre-intervention vaccination rates >58% did not significantly increase. In regression analyses, a childs likelihood of being vaccinated was significantly higher with: younger age, white race (Odds ratio [OR]=1.29; 95% confidence interval [CI]=1.23-1.34), having commercial insurance (OR=1.30; 95%CI=1.25-1.35), higher pre-intervention practice vaccination rate (OR=1.25; 95%CI=1.16-1.34), and being in the Intervention arm (OR=1.23; 95%CI=1.01-1.50). Early delivery of influenza vaccine was rated by Intervention practices as an effective strategy for raising rates. CONCLUSIONS Implementation of a multi-strategy toolkit and early vaccine supplies can significantly improve influenza vaccination rates among children in primary care practices but the effect may be less pronounced in practices with moderate to high existing vaccination rates. Clinical trial registry name/number: From Innovation to Solutions: Childhood Influenza/NCT01664793.

Influenza Vaccine Effectiveness for Fully and Partially Vaccinated Children 6 Months to 8 Years Old During 2011-2012 and 2012-2013: The Importance of Two Priming Doses.

Background: Few studies have examined the effectiveness of full versus partial vaccination with inactivated trivalent influenza vaccines (IIV3) as defined by the US CDC Advisory Committee on Immunization Practices. Methods: Respiratory swabs were collected from outpatients aged 6 months to 8 years with acute cough for ⩽7 days in clinics in 5 states during the 2011–2012 and 2012–2013 influenza seasons. Influenza was confirmed by real-time reverse transcription polymerase chain reaction assay. Receipt of current season IIV3 and up to 4 prior vaccinations was documented from medical records and immunization registries. Using a test-negative design, vaccine effectiveness (VE) was estimated adjusting for age, race/ethnicity, medical conditions, study site and month of enrollment. Results: We did not observe higher VE for children fully versus partially vaccinated with IIV3, as defined by US Advisory Committee on Immunization Practice, although our sample of partially vaccinated children was relatively small. However, among children aged 2–8 years in both seasons and against A(H3N2) and B influenza illness separately, VE point estimates were consistently higher for children who had received 2 doses in the same prior season compared with those without (VE range of 58%–80% vs. 33%–44%, respectively). Across seasons, the odds of A(H3N2) illness despite IIV3 vaccination were 2.4-fold (95% confidence interval: 1.4–4.3) higher among children who had not received 2 doses in the same prior season. We also noted residual protection among unvaccinated children who were vaccinated the previous season (VE range = 36%–40% across outcomes). Conclusion: Vaccination with IIV3 may provide preventive benefit in subsequent seasons, including possible residual protection if vaccination is missed. Two vaccine doses in the same season may be more effective than alternative priming strategies.

Improving adolescent HPV vaccination in a randomized controlled cluster trial using the 4 Pillars™ practice Transformation Program

OBJECTIVE Uptake of meningococcal vaccine (MCV) and tetanus, diphtheria and pertussis (Tdap) vaccine among adolescents has approached Healthy People 2020 goals, but human papillomavirus (HPV) vaccination has not. This study evaluated an intervention using the 4 Pillars™ Practice Transformation Program to increase HPV, MCV and Tdap uptake among adolescents in primary care practices. METHODS Practices with at least 50 patients 11-17years old with estimated vaccination rates less than national goals, were assigned to intervention (n=11) and control (n=11) groups in a randomized controlled cluster trial; 9 intervention and 11 control sites completed the study. The baseline and active study periods were 7/1/2013-6/30/2014 and 7/1/2014-3/31/2015, respectively. Vaccination and demographic data for patients who had a visit in both study periods were derived from de-identified EMR extractions. Primary outcomes were vaccination rates and percentage point (PP) changes. Data were analyzed in 2015-16. RESULTS Among the cohort of 10,861 adolescent patients, 38% were 11-13years old; 50% were female; 18% were non-white; and 64% were commercially insured. Average baseline HPV initiation rates were 52.5% for intervention and 61.8% for control groups. After 9months, the intervention sites increased HPV initiation 10.2PP compared with 7.3PP in control sites (P<0.001); HPV series completion rates did not differ between groups. Implementation of >10 strategies to improve rates significantly increased the likelihood of HPV series initiation (OR=2.06, 95% CI=1.43, 2.96). CONCLUSIONS Using >10 strategies from the 4 Pillars™ Practice Transformation Program is effective for increasing HPV series initiation among adolescents. Clinical trial registry number: NCT02165722.

Primary care providers' beliefs about teen and parent barriers to depression care

Objective: Only one-third of US adolescents with depression obtain treatment for depression. Teen and parent barriers differ, but both contribute to low treatment rates. Primary care providers (PCPs) may be able to elicit and address such barriers, but little is known about their perceptions of teen and parent barriers, and whether they recognize these differences. Methods: We administered a survey to 58 PCPs assessing their perceptions of the importance of specific barriers to depression care for teens and parents using McNemars test to examine differences. Results: Most PCPs believed barriers for parents included difficulty making appointments, worry about what others would think, and cost. PCPs believed barriers for teens included not wanting treatment and worry about what others would think. PCPs believed parents and teens differed in the extent to which they would perceive cost, difficulty in making appointments, and not wanting care as a barrier (p < .001). Conclusions: Primary care providers recognize that teens and parents have different barriers to care, but may have discordant perceptions of the importance of certain barriers for teens and their parents. PCPs may need to probe parents and teens individually about barriers, which impede depression care to enhance shared decision making and treatment uptake.

Increasing Childhood Influenza Vaccination: A Cluster Randomized Trial

BACKGROUND Since the 2008 inception of universal childhood influenza vaccination, national rates have risen more dramatically among younger children than older children and reported rates across racial/ethnic groups are inconsistent. Interventions may be needed to address age and racial disparities to achieve the recommended childhood influenza vaccination target of 70%. PURPOSE To evaluate an intervention to increase childhood influenza vaccination across age and racial groups. METHODS In 2011-2012, a total of 20 primary care practices treating children were randomly assigned to the intervention and control arms of a cluster randomized controlled trial to increase childhood influenza vaccination uptake using a toolkit and other strategies including early delivery of donated vaccine, in-service staff meetings, and publicity. RESULTS The average vaccination differences from pre-intervention to the intervention year were significantly larger in the intervention arm (n=10 practices) than the control arm (n=10 practices); for children aged 9-18 years (11.1 pct pts intervention vs 4.3 pct pts control, p<0.05); for non-white children (16.7 pct pts intervention vs 4.6 pct pts control, p<0.001); and overall (9.9 pct pts intervention vs 4.2 pct pts control, p<0.01). In multi-level modeling that accounted for person- and practice-level variables and the interactions among age, race, and intervention, the likelihood of vaccination increased with younger age group (6-23 months); white race; commercial insurance; the practices pre-intervention vaccination rate; and being in the intervention arm. Estimates of the interaction terms indicated that the intervention increased the likelihood of vaccination for non-white children in all age groups and white children aged 9-18 years. CONCLUSIONS A multi-strategy intervention that includes a practice improvement toolkit can significantly improve influenza vaccination uptake across age and racial groups without targeting specific groups, especially in practices with large percentages of minority children.

Maintenance of Increased Childhood Influenza Vaccination Rates 1 Year After an Intervention in Primary Care Practices

OBJECTIVE Influenza vaccination rates among some groups of children remain below the Healthy People 2020 goal of 70%. Multistrategy interventions to increase childhood influenza vaccination have not been evaluated recently. METHODS Twenty pediatric and family medicine practices were randomly assigned to receive the intervention in either year 1 or year 2. This study focuses on influenza vaccine uptake in the 10 year 1 intervention sites during intervention and the following maintenance year. The intervention included the 4 Pillars Immunization Toolkit-a practice improvement toolkit, early delivery of donated vaccine for disadvantaged children, staff education, and feedback on progress. During the maintenance year, practices were not assisted or contacted, except to complete follow-up surveys. Students t tests assessed vaccine uptake of children aged 6 months to 18 years, and multilevel regression modeling in repeated measures determined variables related to the likelihood of vaccination. RESULTS Influenza vaccine uptake increased 12.4 percentage points (PP; P < .01) during active intervention and uptake was sustained (+0.4 PP; P > .05) during maintenance, for an average change of 12.7 PP over all sites, increasing from 42.2% at baseline to 54.9% (P < .001) during maintenance. In regression modeling that controlled for age, race, and insurance, likelihood of vaccination was greater during intervention than baseline (odds ratio 1.47; 95% confidence interval 1.44-1.50; P < .001) and greater during maintenance than baseline (odds ratio 1.50; 95% confidence interval 1.47-1.54; P < .001). CONCLUSIONS In primary care practices, a multistrategy intervention that included the 4 Pillars Immunization Toolkit, early delivery of vaccine, and feedback was associated with significant improvements in childhood influenza vaccination rates that were maintained 1 year after active intervention.

Reducing Racial Disparities in Influenza Vaccination Among Children with Asthma

INTRODUCTION A multifaceted intervention to raise influenza vaccination rates was tested among children with asthma. METHODS In a pre/post study design, 18 primary care practices implemented the 4 Pillars Immunization Toolkit along with other strategies. The primary outcome was the difference in influenza vaccination rates at each practice among children with asthma between the baseline year (before the intervention) and at the end of year 2 (after the intervention), both overall and by race (White vs. non-White). RESULTS Influenza vaccination rates increased significantly in 13 of 18 practices. The percentage of vaccinated non-White children increased from 46% to 61% (p < .01), and the percentage of vaccinated White children increased from 58% to 65% (p < .001). Likelihood of vaccination was significantly lower for non-White children before the intervention (odds ratio = 0.66; 95% confidence interval = 0.59-0.73; p < .001), but this difference was eliminated after the intervention (odds ratio = 0.95; 95% confidence interval = 0.85-1.05; p = .289). DISCUSSION A multi-strategy, evidence-based intervention significantly increased influenza vaccination uptake and reduced racial disparities among children with asthma.