Iman Sharif

Association Between Television, Movie, and Video Game Exposure and School Performance

BACKGROUND. The relationship between media exposure and school performance has not been studied extensively in adolescents. OBJECTIVE. The purpose of this work was to test the relative effects of television, movie, and video game screen time and content on adolescent school performance. METHODS. We conducted a population-based cross-sectional survey of middle school students (grades 5–8) in the Northeastern United States. We looked at weekday television and video game screen time, weekend television and video game screen time, cable movie channel availability, parental R-rated movie restriction, and television content restriction. The main outcome was self-report of school performance (excellent, good, average, or below average). We used ordinal logistic-regression analysis to test the independent effects of each variable, adjusting for demographics, child personality, and parenting style. RESULTS. There were 4508 students who participated in the study; gender was equally represented, and 95% were white. In multivariate analyses, after adjusting for other covariates, the odds of poorer school performance increased with increasing weekday television screen time and cable movie channel availability and decreased with parental restriction of television content restriction. As compared with children whose parents never allowed them to watch R-rated movies, children who watched R-rated movies once in a while, sometimes, or all of the time had significantly increased cumulative odds of poorer school performance. Weekend screen time and video game use were not associated with school performance. CONCLUSIONS. We found that both content exposure and screen time had independent detrimental associations with school performance. These findings support parental enforcement of American Academy of Pediatrics guidelines for media time (particularly weekdays) and content limits to enhance school success.

Relationship between Child Health Literacy and Body Mass Index in Overweight Children

OBJECTIVE To test the relationship between child health literacy and body mass index (BMI) Z-score in overweight children. METHODS Cross-sectional survey of overweight children and parents. Parent and child health literacy was measured by the Short Test of Functional Health Literacy (STOFHLA). Linear regression tested for predictors of childhood BMI Z-score, adjusting for confounders. RESULTS Of 171 total children, 107 (62%) participated, of whom 78 (73%) had complete data for analysis. Mean child BMI Z-score (SD) was 2.3 (0.40); median child age (interquartile range) was 11.5 (10-16); 53% were female; 80% were Medicaid recipients. Mean child STOFHLA was 22.9 (9.0); mean parental STOFHLA was 29.1 (8.6). Child STOFHLA correlated negatively with BMI Z-score (r=-0.37, p=0.0009) and positively with child eating self-efficacy (r=0.40, p<0.0001). After adjusting for confounders, child STOFHLA was independently associated with child BMI Z-score (standardized B=-0.43, p<0.0001). Overall adjusted r-squared for the regression model was 38%. Child STOFHLA contributed 13% to the overall model. CONCLUSIONS Child health literacy was negatively correlated with BMI Z-scores in overweight children, suggesting the need to consider health literacy in the intersection between self-efficacy and behavior change when planning interventions that aim to improve child BMI.

Association between health literacy and child and adolescent obesity

OBJECTIVE We tested the association between child and parental health literacy (HL) and odds of child and adolescent obesity. METHODS We conducted an anonymous cross-sectional survey of a convenience sample of English-speaking child-parent dyads. Newest Vital Sign (NVS) measured HL. We used multivariable logistic regression to test adjusted association between child and parental NVS and obesity. Analyses were stratified for school-aged children (aged 7-11) vs. adolescents (aged 12-19). RESULTS We surveyed 239 child-parent dyads. Median child age was 11 [inter-quartile range 9-13]; 123 (51%) were male; 84% Medicaid recipients; 27% obese. For children, the odds of obesity [adjusted odds ratio (95% confidence interval)] decreased with higher parent NVS [0.75 (0.56,1.00)] and increased with parent obesity [2.53 (1.08,5.94)]. For adolescents, odds of obesity were higher for adolescents with the lowest category of NVS [5.00 (1.26, 19.8)] and older parental age [1.07 (1.01,1.14)] and lower for Medicaid recipients [0.21 (0.06,0.78)] and higher parental education [0.38 (0.22,0.63)]. CONCLUSION Obesity in school-aged children is associated with parental factors (obesity, parental HL); obesity in adolescents is strongly associated with the adolescents HL. PRACTICE IMPLICATIONS Strategies to prevent and treat obesity should consider limited HL of parents for child obesity and of adolescents for adolescent obesity.

Family-Centered Rounds Views of Families, Nurses, Trainees, and Attending Physicians

Objective. To study the impact of family-centered rounds for general pediatrics inpatients. Methods. An observation tool and participant surveys was developed. The authors analyzed rounding time and rounds participants. Associations between family presence and participants’ satisfaction were analyzed. Results. Data were collected on 295 patients and from 257 staff members. Average rounding time was reduced with increased family and nurse presence (8.7 minutes with both, 12.7 minutes without family, P = .0001). Families reported high satisfaction regardless of participants. Families present on rounds reported increased knowledge of team members’ roles (54% vs 35%, P = .04). Attending physicians more often reported ease in managing rounds with families present. Senior residents perceived decreased autonomy with high family participation (11%) versus low family participation (70%; P = .02). Improved nurse satisfaction was associated with increased family and nurse participation. Conclusion. Family participation may shorten inpatient rounds. Families and staff were satisfied with family-centered rounds, though senior resident autonomy requires attention.

Correlates of Patient Portal Enrollment and Activation in Primary Care Pediatrics

OBJECTIVE To identify the demographic, practice site, and clinical predictors of patient portal enrollment and activation among a pediatric primary care population. METHODS We conducted a cross-sectional analysis of the primary care database of an academic childrens hospital that introduced a patient portal in December 2007. RESULTS We analyzed data for 84,015 children. Over a 4-year period, 38% enrolled in the portal; of these, 26% activated the account. The adjusted odds of portal enrollment was lower for adolescents, Medicaid recipients, low-income families, Asian or other race, and Hispanic ethnicity, and higher for patients with more office encounters, and presence of autism on the problem list. Once enrolled, the odds of portal activation [adjusted odds ratio (95% confidence interval)] was decreased for: Medicaid [0.55 (0.50-0.61)] and uninsured [0.79 (0.64-0.97)] (vs private insurance), black [0.53 (0.49-0.57)] and other [0.80 (0.71-0.91)] (vs white race), Hispanic ethnicity [0.77 (0.62-0.97)], and increased for: infant age [1.26 (1.15-1.37)] (vs school age), attendance at a resident continuity practice site [1.91 (1.23-2.97)], living further away from the practice (vs under 2 miles)[4.5-8.8 miles: 1.14 (1.02-1.29); more than 8.8 miles: 1.19 (1.07-1.33)], having more office encounters (vs 1-3) [4-7 encounters: 1.40 (1.24-1.59); 8-12 encounters: 1.58 (1.38-1.81); 13+ encounters: 2.09 (1.72-2.55)], and having 3 or more items on the problem list (vs 0) [1.19 (1.07-1.33)]. CONCLUSIONS Sociodemographic disparities exist in patient portal enrollment/activation in primary care pediatrics. Attendance at a resident continuity practice site, living farther away from the practice, having more office encounters, and having more problem list items increased the odds of portal activation.

Can the Newest Vital Sign Be Used to Assess Health Literacy in Children and Adolescents

Context. We evaluated the validity of the Newest Vital Sign (NVS) as a brief screen for health literacy in children. Objectives. To (a) test the hypothesis that child performance on the NVS correlates with performance on a test of child reading comprehension and (b) establish age-based cutoffs for expected performance on the NVS. Design. Children aged 7 to 17 years were administered the NVS followed by the Gray Silent Reading Test (GSRT). Results. The NVS score correlated strongly with GSRT score (ρ = 0.71, P < .0001) and increased with age. Children aged 7 to 9 years had a median NVS score of 1 (interquartile range = 1-2); children aged 10 to 17 years had a median score of 3 (interquartile range = 2-4), P < .0001. Conclusion. The NVS performs well in this population. Children aged 10 to 17 years with an NVS score lower than 2 may have low health literacy.

A New Model to Decrease Time-to-Appointment Wait for Gastroenterology Evaluation

OBJECTIVE: To describe the implementation and evaluation of a quality improvement intervention to increase new-patient access and decrease time-to-appointment wait for gastroenterology care. METHODS: We used a new model of care for gastroenterology evaluation. For specified clinical complaints, we offered new-patient appointments that were scheduled with a general pediatrician as an alternative to a subspecialist. A nurse navigator assisted in triaging patients. We analyzed all patient encounters over an 8-month period. To verify decreased time-to-appointment wait, mystery shoppers made semimonthly calls to centralized scheduling. We surveyed parents/families after visits with the pediatrician or subspecialists regarding satisfaction. RESULTS: The “access” pediatrician evaluated and treated ∼40% of all new patients presenting to the division during the study period. Approximately 10% of new patients evaluated by the pediatrician (4% overall) were referred on to the subspecialist; fewer patients were reevaluated by the pediatrician in follow-up. The pediatrician ordered a minimal number of procedures. Semimonthly sampling revealed that overall new-patient access improved from an average time-to-appointment wait of 25 days to <1 day. Parent/family satisfaction was high for the patients evaluated by the pediatrician. CONCLUSIONS: Embedding a general pediatrician within a subspecialty division, and navigating patients to this provider, can increase access to treatment of new low- to moderate-complexity patients. The access pediatrician can maintain patient satisfaction, provide high-quality care, and decrease need for subspecialist evaluation. The model, in the setting of a large academic medical center, may provide a solution for barriers to patient care such as lengthy time-to-appointment wait.

Implementing Medication Reconciliation in Outpatient Pediatrics

OBJECTIVE: To describe the implementation of a system-wide, electronic medical record (EMR)-based quality improvement intervention targeting medication reconciliation (MedRec) in outpatient pediatrics and to test variables associated with the performance of MedRec. METHODS: This was a retrospective study using serial cross-sections of outpatient pediatric visits over a 5-year period set in a multispecialty childrens integrated health care network in Florida, Delaware, Pennsylvania, and New Jersey. We reviewed 2 745 523 outpatient pediatric visits between 2005 and 2010. In 2007, the performance of MedRec was identified as critical to improving patient safety at our organization. A comprehensive intervention involved changes in the EMR, automated generation of medication lists, educational modules, and provider compliance reports. In 2009, quality-based financial incentives to physicians to perform MedRec were added. The outcome measure was documentation of MedRec performance. RESULTS: MedRec improved consistently over time, from a nadir of 0% in 2005 to a maximum of 71% in 2010. Performance of MedRec varied according to practice location as the intervention was rolled out. Throughout the study period, documentation of MedRec was consistently less likely for sick visits (adjusted odds ratio [aOR] for each year ranged from 0.44 to 0.68) but more likely if the provider placed a medication order during the visit (aOR: 1.70–2.15). Beginning in 2009, visits with providers eligible for the quality-based financial incentive were more likely to have had MedRec performed (aOR: 2.02 [2009] and 2.31 [2010]). CONCLUSIONS: A system-wide, EMR-based, outpatient pediatric quality improvement intervention was successful in improving documentation of the performance of MedRec, a national patient safety goal.

Concomitant fundoplication increases morbidity of gastrostomy tube placement

BACKGROUND Fundoplication is often performed in conjunction with gastrostomy tube (GT) placement in children, but there is a great deal of variation in rates of and indications for this procedure. Little is known about the impact of fundoplication on peri-operative outcomes. This study examines a national cohort of pediatric patients to compare risk-adjusted surgical outcomes in patients undergoing GT placement with or without concomitant fundoplication. METHODS We identified all patients undergoing GT placement in the 2012 National Surgical Quality Improvement Program - Pediatric. We evaluated demographics, comorbidities, complications, and length of stay for GT with fundoplication versus GT alone. We defined composite morbidity as a dichotomous variable for the presence of any complication. Logistic regression was performed to identify predictors of morbidity after adjusting for covariates. RESULTS 1289 GT patients were identified, and 148 (11.5%) underwent concurrent fundoplication. The fundoplication patients were more likely to be younger, have cardiac risk factors, and be on respiratory support. They also had higher rates of surgical site infection (7.4% vs 3.7%, p=0.03) and composite morbidity (16.9% vs 8.7%, p=0.001), and longer LOS (median 5 vs 3 days, p=<0.0001) compared to GT only. After adjusting for covariates, fundoplication was a predictor of composite morbidity and increased LOS. CONCLUSION Concomitant fundoplication is an independent risk factor for 30-day post-operative morbidity in patients undergoing GT placement. These findings do not negate the value of fundoplication but underscore the importance of careful patient selection, and should be taken into consideration when discussing risks and benefits with families.

Access to Subspecialty Care: Bringing Back the Specialty of General Pediatrics

T he gap between the shortage of pediatric subspecialists and the increasing demand for subspecialty consultation have led to long waiting times for subspecialty appointments. In our hospital, waiting times for new patient appointments ranged from 1 day (nephrology) to 77 days (neurology) in January 2011. In an effort to improve access to our services, Nemours leadership issued a call to action: Offer new patients 5-day access. To meet the challenge, an access team (Pediatric Department administration, scheduling manager, and division chiefs) met weekly, beginning in January 2011. During monthly leadership meetings (LeadQuest), division chiefs participated in “action learning” sessions to collaborate on approaches to improving patient access. Access also remained on the agenda for every monthly division chief, department, and strategy management meeting. We lived and breathed access. A gap analysis (new patient slots/new patient demand) assessed 14 divisions and guided strategies to accommodate new patients: adding clinical sessions, shortening visit lengths, simplifying visit types, staggered vacations, and so on. Between January and June 2011, we optimized standard practices in the field of “advanced access.” For each subspecialty, gap analysis data helped determine a ratio of “5-day access” slots (ie, new patient visit available for scheduling no earlier than 5 days in advance) versus regular slots. After-hours clinic sessions were added to provide convenience for families and to address limitations in examination room space.