Tina L. Cheng

The Scientific Evidence for Child Health Insurance

Discusses two critical policy options related to child health insurance: reauthorization and potential expansion of the State Childrens Health Insurance Program (SCHIP), and expansion of health insurance to all children.

Preconception Women's Health and Pediatrics: An Opportunity to Address Infant Mortality and Family Health

THE U.S. INFANT mortality rate remains unacceptably high, with large disparities found by race. Increasingly, research has demonstrated that interventions must go beyond ensuring access to care and prenatal focus to address the preconception health of women. Critical fetal development occurs in the earliest weeks after conception, often before a woman is aware of her pregnancy. The Maternal Child Health Bureau’s life course initiatives and the Centers for Disease Control’s preconception health initiatives are placing infant mortality and child health in a life course context, that is, uniting the reproductive health and pediatric longitudinal perspectives. In the recent report “Clinical Preventive Services forWomen”, the Institute ofMedicine recommended annual well-women visits incorporating preconception care, and Healthy People 2020 includes a section of objectives on preconception health and behaviors. With growing scientific recognition that early antecedents of child and adult health start prenatally and even preconceptionally, women’s health is key. Pediatric clinicians have been leaders in the efforts to reduce infant mortality and in family-centered care, but how can pediatrics further contribute? A golden opportunity exists to serve as preconception care (PCC) clinicians for preconceptional adolescents and interconceptional mothers seen in practice.

Merging systems: integrating home visitation and the family-centered medical home.

To improve the health of children and bend the health care cost curve we must integrate the individual and population approaches to health and health care delivery. The 2012 Institute of Medicine (IOM) report Primary Care and Public Health: Exploring Integration to Improve Population Health laid out the continuum for integration of primary care and public health stretching from isolation to merging systems. Integration of the family-centered medical home (FCMH) and home visitation (HV) would promote overall efficiency and effectiveness and help achieve gains in population health through improving the quality of health care delivered, decreasing duplication, reinforcing similar health priorities, decreasing costs, and decreasing health disparities. This paper aims to (1) provide a brief description of the goals and scope of care of the FCMH and HV, (2) outline the need for integration of the FCMH and HV and synergies of integration, (3) apply the IOM’s continuum of integration framework to the FCMH and HV and describe barriers to integration, and (4) use child developmental surveillance and screening as an example of the potential impact of HV-FCMH integration.

Home Visiting and the Family-Centered Medical Home: Synergistic Services to Promote Child Health

From the Division of General Pediatrics, Boston Children’s Hospital, Boston, Mass (Dr Toomey); and Department of General Pediatrics and Adolescent Medicine, Johns Hopkins University, Baltimore, MD (Dr Cheng) Address correspondence to Sara L. Toomey, MD, MPhil, MPH, MSc, Division of General Pediatrics, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115 (e-mail: sara.toomey@childrens.harvard.edu).

Tracking the careers of academic general pediatric fellowship program graduates: academic productivity and leadership roles.

OBJECTIVEnLittle is known about the careers of graduates of academic general pediatric (AGP) fellowship programs. We evaluated the careers of 2 cohorts of AGP fellowship graduates: an early cohort trained during 1978 to 1988, and a later cohort trained during 1989 to 1999.nnnMETHODSnWe surveyed all known AGP fellowship graduates in both cohorts by using a confidential mailed survey. We assessed graduates current professional work and analyzed curricula vitae for principal investigator (PI) grants; first-authored, peer-reviewed publications; and leadership positions.nnnRESULTSnFrom the early cohort, 95 of 131 eligible graduates (73%) responded; from the later cohort, 93 of 133 (70%) responded. Two thirds of each cohort remain in academics; of these, nearly half are on tenure tracks and over half have major educational roles within their university. The percentage in the early cohort who have been PI on a research grant by 5, 10, and 15 years postfellowship was 44%, 53%, and 54%, respectively; in the later cohort, it was 62%, 75%, and 75%, respectively (P = .004 vs early cohort). During the 10 years postfellowship, the early and later cohorts averaged 5.5 and 7.4 first-authored, peer-reviewed papers, respectively (P = .4). By 10 years, a high proportion of both cohorts had become division chief (19% vs 16%), had other academic leadership positions (43% vs 59%), or were leaders in professional organizations (20% vs 30%; all P = NS).nnnCONCLUSIONSnGraduates of AGP fellowship programs have achieved considerable academic success. Recently trained fellows appear even more successful. The academic outcomes of these AGP fellows bode well for the future of AGP.

The wisdom, the will, and the wallet: leadership on behalf of kids and families.

I t has been a genuine pleasure to serve as the president of the Academic Pediatric Association (APA). The APA plays a critical leadership role in setting the agendas that shape clinical care, education, research, and advocacy on behalf of kids and families. Today, I wanted to reflect on leadership lessons I have learned and relate them to the challenges we face to improve the health and well-being of children and families. I refer to these challenges as ‘‘the wisdom,’’ ‘‘the will,’’ and ‘‘the wallet.’’ Clearly, much has changed in the last decades, not only in health care delivery but also in the broader conditions that influence the health of children. Some of these changes have been good, some not so good. It is frequently said that as a profession, we are too often reactive instead of proactive regarding changes in our health system. I contend that there will continue to be dramatic change, and that as leaders and as an organization, we need to envision change, embrace change, and push the change to make sure every child—regardless of the conditions of their birth—has the opportunity to grow up to be a healthy productive adult. We need to be proactive and prepare for the future by shaping the changes necessary to achieve our mission and improve child health and development. The mission of the APA is ‘‘to improve the health of all children and adolescents through leadership in education of child health professionals, research and dissemination of knowledge, patient care, and advocacy, in partnership with patients, families and communities.’’ So today I thought we should take a moment to look into our crystal ball of the future and dream about changing the future for kids and families. What is the needed change? Do we have the wisdom, the will, and the wallet to make change on behalf of children and families? Change is certainly needed. A 2007 UNICEF Innocenti Report Card last year entitled ‘‘An Overview of Child

Caregiver Health Promotion in Pediatric Primary Care Settings: Results of a National Survey

Objective To assess practice patterns, barriers, and facilitators related to caregiver health promotion in pediatric primary care settings. Study design We conducted a mail‐based survey of a nationally representative sample of 1000 childrens primary care physicians (trained in pediatrics, family medicine, or medicine‐pediatrics). We assessed engagement in 6 caregiver health issues (maternal depression, tobacco use, intimate partner violence, family planning, health insurance, and tetanus, diphtheria, and acellular pertussis immunization status) along with barriers and facilitators related to engagement. We used multivariable logistic regression to identify physician and practice correlates of engagement. Results The response rate was 30%. The majority of respondents (79.3%) regularly addressed at least 3 caregiver health issues during well infant/child visits, most commonly maternal depression, tobacco use, and tetanus, diphtheria, and acellular pertussis immunization immunization status. Screening was the most common activity. In adjusted analyses, pediatricians were less likely to screen for intimate partner violence and family planning compared with other providers. There were no other differences in engagement by physician specialty. Lack of time was the most commonly endorsed barrier (by 85.2% of respondents). Co‐location of auxiliary services was the most frequently cited facilitator for the majority of issues. Conclusions Childrens primary care physicians and their care teams routinely engage in a variety of activities promoting caregiver health, largely independent of training background and despite multiple practice‐related barriers. Co‐location of auxiliary services could support the efforts of pediatric care teams. Future efforts that investigate care models which address these barriers and facilitators will help to realize the potential of pediatric settings to impact adult health.

A History of the Academic Pediatric Association's Public Policy and Advocacy Initiatives

From the Division of General Pediatrics, Children’s Hospital Boston and Harvard Medical School, Boston, Mass (Drs Palfrey and Schuster), and the Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Md (Dr Cheng) The authors have no conflicts of interest to disclose. Address correspondence to Judith S. Palfrey, MD, Division of General Pediatrics, Children’s Hospital Boston and Harvard Medical School, 300 Longwood Ave, Boston, Massachusetts 02115 (e-mail: judith.palfrey@childrens.harvard.edu).

National Estimates of Advice to Quit and Child-Focused Smoking Counseling Provided to Parents Who Smoke

Parents who smoke place both themselves and their children at increased risk for developing multiple health problems, and both adult and pediatric clinical practice guidelines recommend that healthcare providers counsel parents who smoke regarding smoking cessation. 3 Advice from healthcare providers may focus on the harms towards a parent’s own health, but may also highlight the deleterious effects of secondhand smoke exposure on children. The extent to which parents who smoke receive these different counseling messages remains largely unknown. Using nationally representative data, we characterized how often parents receive certain types of counseling from healthcare providers and factors correlated with counseling receipt.

Concordance among children, caregivers, and clinicians on barriers to controller medication use

ABSTRACT Objective: While much research has addressed asthma medication adherence, few have combined quantitative and qualitative data, and none has addressed the triad of child, caregiver, and clinician simultaneously. This study assessed, with mixed methods, barriers to medication adherence within this triad. Methods: We conducted interviews with publicly-insured children with asthma, their caregivers, and their primary-care clinicians. Children (7–17 years) had been prescribed daily inhaled corticosteroids and visited the ED for asthma (past year). Participants answered open-ended and survey questions, rating suggested barriers to medication use (never vs. ever a barrier). McNemars tests compared report of barriers by each group (children, caregivers, clinicians), and assessed concordance within triads. Results: Fifty child–caregiver dyads participated (34 clinicians). Children (40% female; median age 10 years) had mostly non-Hispanic black (90%) caregivers with less than or equal to high-school education (68%). For barriers, children and clinicians were more likely than caregivers to report medications running out. Clinicians were also more likely to cite controllers being a “pain to take” (vs. children) and forgetfulness (vs. caregivers) (all p < .05). There was a lack of within-triad concordance regarding barriers to adherence, especially regarding medication running out, worrying about taking a daily medication, and medication being a pain to take. Qualitative data revealed themes of competing priorities, home routines, and division of responsibility as prominent contributors to medication adherence. Conclusions: There was significant disagreement among children, caregivers, and clinicians regarding barriers to daily use of asthma medications. To tailor asthma management conversations, clinicians should understand family-specific barriers and child–caregiver disagreements.