Jane McGrath

Prevalence of acanthosis nigricans and its association with hyperinsulinemia in New Mexico adolescents.

PURPOSE To determine whether the association between acanthosis nigricans (AN) and hyperinsulinemia is independent of obesity and other variables. METHODS A convenience sample of 675 New Mexico middle school students was screened to determine the presence of AN, obesity, and other variables, including: ethnicity, parental history of diabetes, and level of physical activity. Fasting glucose and insulin levels were drawn on 233 students to determine the association between risk factors and hyperinsulinemia. RESULTS Acanthosis nigricans (AN) was present in 18.9% of students screened. Twenty-one percent of the subsample had hyperinsulinemia. Based on these results, the estimated prevalence of hyperinsulinemia among all middle school students in New Mexico was 8.9%. Forty-seven percent (47.2%) of students who had AN and were obese had hyperinsulinemia, compared with 2.4% of students who did not have either of these conditions. In multiple logistic regression analysis, AN and obesity were independently and positively associated with hyperinsulinemia, whereas physical activity was protective. CONCLUSIONS The high prevalence of risk factors in this population makes diabetes prevention a priority for public health action. AN screening is an easily performed, noninvasive method for identifying adolescents at risk for type 2 diabetes.

School-Based Health Centers and Obesity Prevention: Changing Practice Through Quality Improvement

Objective To examine whether a quality improvement initiative aimed at medical providers in school-based health centers would improve the recognition and management of pediatric obesity. Participants and Methods. Thirteen school-based health centers, with a total of 22 providers and 6 clinical staff, were enrolled in the study. Quality improvement measures and best medical practices for assessing and treating pediatric obesity were provided during 1 learning collaborative and 2 on-site trainings. Measures included documentation of (1) a BMI percentile, (2) a corresponding weight-category diagnosis, (3) assessing readiness to change, (4) assessing readiness to change for patients with a BMI at ≥85th percentile, and (5) addressing 4 key messages that enhance a healthy lifestyle. Results Results of paired-sample t tests indicate that all 5 variables significantly increased from baseline to the midpoint data collection. From midpoint to the final data collection, documentation of BMI percentile and key messages increased, although not significantly. Documentation of weight-category diagnosis and readiness to change for patients with a BMI at ≥85th percentile decreased significantly, whereas documentation of readiness to change decreased, but not significantly. Conclusions This study offers promising evidence that school-based health center providers trained in a quality improvement initiative demonstrate consistent improvement in implementing the guidelines for treatment of pediatric overweight. Pediatrics 2009;123:S267–S271

The National Improvement Partnership Network: State-Based Partnerships That Improve Primary Care Quality

Improvement partnerships (IPs) are a model for collaboration among public and private organizations that share interests in improving child health and the quality of health care delivered to children. Their partners typically include state public health and Medicaid agencies, the local chapter of the American Academy of Pediatrics, and an academic health care organization or childrens hospital. Most IPs also engage other partners, including a variety of public, private, and professional organizations and individuals. IPs lead and support measurement-based, systems-focused quality improvement (QI) efforts that primarily target primary care practices that care for children. Their projects are most often conducted as learning collaboratives that involve a team from each of 8 to 15 participating practices over 9 to 12 months. The improvement teams typically include a clinician, office manager, clinical staff (nurses or medical assistants), and, for some projects, a parent; the IPs provide the staff and local infrastructure. The projects target clinical topics, chosen because of their importance to public health, local clinicians, and funding agencies, including asthma, attention-deficit/hyperactivity disorder, autism, developmental screening, obesity, mental health, medical home implementation, and several others. Over the past 13 years, 19 states have developed (and 5 are exploring developing) IPs. These organizations share similar aims and methods but differ substantially in leadership, structure, funding, and longevity. Their projects generally engage pediatric and family medicine practices ranging from solo private practices to community health centers to large corporate practices. The practices learn about the project topic and about QI, develop specific improvement strategies and aims that align with the project aims, perform iterative measures to evaluate and guide their improvements, and implement systems and processes to support and sustain those improvements. Since 2008, IPs have offered credit toward Part 4 of Maintenance of Certification for participants in some of their projects. To date, IPs have focused on achieving improvements in care delivery through individual projects. Rigorous measurement and evaluation of their efforts and impact will be essential to understanding, spreading, and sustaining state/regional child health care QI programs. We describe the origins, evolution to date, and hopes for the future of these partnerships and the National Improvement Partnership Network (NIPN), which was established to support existing and nurture new IPs.

Measuring Youth Health Engagement: Development of the Youth Engagement With Health Services Survey

PURPOSE The purpose of this study was to create and validate a survey instrument designed to measure Youth Engagement with Health Services (YEHS!). METHODS A 61-item YEHS! survey was created through a multistaged process, which included literature review, subject matter expert opinion, review of existing validated measures, and cognitive interviewing with 41 adolescents in Colorado and New Mexico. The YEHS! was then pilot tested with a diverse group of high school students (n = 354) accessing health services at one of eight school-based health centers in Colorado and New Mexico. We conducted psychometric analyses and examined correlations between the youth health engagement scales and measures of quality of care. RESULTS We created scales to measure two domains of youth health engagement: health access literacy and health self-efficacy. The youth health engagement scales demonstrated strong reliability (Cronbachs α .76 and .82) and construct validity (mean factor loading .71 and .76). Youth health engagement scores predicted higher experiences of care scores (p < .001) and receipt of more anticipatory guidance (p < .01). CONCLUSIONS This study supports the YEHS! as a valid and reliable measure of youth health engagement among adolescents using school-based health centers. We demonstrate an association between youth health engagement and two quality of care measures. Additional testing is needed to ensure the reliability and validity of the instrument in diverse adolescent populations.

Clinical Quality Improvement for Identification and Management of Overweight in Pediatric Primary Care Practices

The purpose of the Pediatric Overweight Quality Improvement Initiative (POWQII) was to demonstrate the feasibility and value of simple interventions for improving pediatric care and to address the additional needs of overweight and obese children. Practices were recruited from around New Mexico, with 16 pediatricians completing the POWQII within 9 to 12 months. Initially, documentation of BMI percentile across all practices was only 49%, increasing to more than 90% on average following the first intervention and eventually reaching an average of 99%. Nutrition and physical activity counseling started at 52% and 39%, respectively, increasing to 87% for nutrition and 77% for physical activity. Diagnosis of POW patients improved over the course of the POWQII (67% to 94%). This intervention’s potential impact can extend to a larger population of patients, resulting in twice as many receiving screening for POW and increasing best practices known to improve ongoing care and patient outcomes.

Secretory IgA in cervical mucus

PURPOSE Sexually active adolescent girls are uniquely vulnerable to sexually transmitted disease, including cervical cancer and AIDS. Little is known about the development of genital immunity in adolescents. Secretory IgA (sIgA) in cervical mucus is an important component of genital immunity. We studied sIgA levels in cervical mucus samples for both adolescent and adult females. METHODS Samples were collected in a university-based adolescent medicine clinic and a university student health center. Participants consisted of 13 sexually active adolescent girls and fourteen adult controls. Samples were collected in the course of routine pelvic exams. All subjects were at least two years post menarche. Mucus was aspirated directly from the cervical os. Diluted samples were liquefied with a proteolytic enzyme (bromelain). Secretory IgA levels were measured by radial immunodiffusion using IgA2 from pooled human plasma as a standard. RESULTS Secretory IgA levels for the adolescent group (mean 0.157 g/L SD 0.080) were slightly lower than for the adult group mean (0.199 g/L SD 0.130) although not statistically significant. CONCLUSIONS Cervical sIgA levels were comparable between sexually active adolescents and adults.

A statewide profile of frequent users of school-based health centers: implications for adolescent health care

BACKGROUND The purpose of this study is to describe patterns of care and service use among adolescent school-based health center (SBHC) users in New Mexico and contrast patterns and services between frequent and infrequent users. METHODS Medical claims/encounter data were analyzed from 59 SBHCs located in secondary schools in New Mexico during the 2011-2012 school year. We used Pearsons chi-square test to examine the differences between frequent (≥ 4 visits/year) and infrequent users in their patterns of SBHC care, and we conducted logistic regression to examine whether frequent use of the SBHC predicted receipt of behavioral, reproductive, and sexual health; checkup; or acute care services. RESULTS Most of the 26,379 adolescent SBHC visits in New Mexico were for behavioral health (42.4%) and reproductive and sexual health (22.9%). Frequent users have greater odds of receiving a behavioral, reproductive, and sexual health; and acute care visit than infrequent users (p < .001). American Indians, in particular, have higher odds of receiving behavioral health and checkup visits, compared with other races/ethnicities (p < .001). CONCLUSIONS SBHCs deliver core health care services to adolescents, including behavioral, reproductive, and checkup services, to high need populations. American-Indian youth, more than their peers, use SBHCs for behavioral health and checkups.

Improving Developmental Screening Among Pediatricians in New Mexico Findings From the Developmental Screening Initiative

Background. Seven pediatric primary care practices participated in New Mexico’s Developmental Screening Initiative in a year-long quality improvement project with the goal of implementing standardized developmental screening tools. Methods. The initiative utilized a learning collaborative approach and the Model for Improvement to promote best practice about developmental screening outlined by the American Academy of Pediatrics. Also, the project emphasized interagency collaboration to improve communication between medical providers and state and community agencies that provide services to children with developmental delays. Results. A total of 1139 medical records were reviewed by the 7 practices, at 5 intervals during the intervention. At baseline, there were dramatic differences among the practices, with some not engaged in screening at all. Overall, the use of standardized developmental screening increased from 27% at baseline to 92% at the end of the project.

Measuring Unmet Needs for Anticipatory Guidance Among Adolescents at School-Based Health Centers

PURPOSE Our previously validated Youth Engagement with Health Services survey measures adolescent health care quality. The survey response format allows adolescents to indicate whether their needs for anticipatory guidance were met. Here, we describe the unmet needs for anticipatory guidance reported by adolescents and identify adolescent characteristics related to unmet needs for guidance. METHODS We administered the survey in 2013-2014 to 540 adolescents who used school-based health centers in Colorado and New Mexico. A participant was considered to have unmet needs for anticipatory guidance if they indicated that guidance was needed on a given topic but not received or guidance was received that did not meet their needs. We calculated proportions of students with unmet needs for guidance and examined associations between unmet needs for guidance and participant characteristics using the chi-square test and logistic regression. RESULTS Among participants, 47.4% reported at least one unmet need for guidance from a health care provider in the past year. Topics with the highest proportions of adolescents reporting unmet needs included healthy diet (19.5%), stress (18.0%), and body image (17.0%). In logistic regression modeling, adolescents at risk for depression and those with minority or immigrant status had increased unmet needs for guidance. Adolescents reporting receipt of patient-centered care were less likely to report unmet needs for guidance. CONCLUSIONS The Youth Engagement with Health Services survey provides needs-based measurement of anticipatory guidance received that may support targeted improvements in the delivery of adolescent preventive counseling. Interventions to improve patient-centered care and preventive counseling for vulnerable youth populations may be warranted.