Virginia A. Moyer

Prevention of Dental Caries in Children From Birth Through Age 5 Years: US Preventive Services Task Force Recommendation Statement

DESCRIPTION: Update of the 2004 US Preventive Services Task Force (USPSTF) recommendation on prevention of dental caries in preschool-aged children. METHODS: The USPSTF reviewed the evidence on prevention of dental caries by primary care clinicians in children 5 years and younger, focusing on screening for caries, assessment of risk for future caries, and the effectiveness of various interventions that have possible benefits in preventing caries. POPULATION: This recommendation applies to children age 5 years and younger. RECOMMENDATION: The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride. (B recommendation) The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of routine screening examinations for dental caries performed by primary care clinicians in children from birth to age 5 years. (I Statement)

Screening for Primary Hypertension in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement

Description: Update of the 2003 U.S. Preventive Services Task Force (USPSTF) recommendation on screening for high blood pressure in children and adolescents. Methods: The USPSTF reviewed the evidence on screening and diagnostic accuracy of screening tests for blood pressure in children and adolescents, the effectiveness and harms of treatment of screen-detected primary childhood hypertension, and the association of hypertension with markers of cardiovascular disease in childhood and adulthood. Population: This recommendation applies to children and adolescents who do not have symptoms of hypertension. Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood.

Primary Care Interventions to Prevent Tobacco Use in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement

Description: Update of the 2003 U.S. Preventive Services Task Force (USPSTF) recommendation on primary care interventions to prevent tobacco use in children and adolescents. Methods: The USPSTF reviewed the evidence on the effectiveness of primary care interventions on the rates of initiation or cessation of tobacco use in children and adolescents and on health outcomes, such as respiratory health, dental and oral health, and adult smoking. The USPSTF also reviewed the evidence on the potential harms of these interventions. Population: This recommendation applies to school-aged children and adolescents. The USPSTF has issued a separate recommendation statement on tobacco use counseling in adults and pregnant women. Recommendation: The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents.

State of the Evidence on Acute Asthma Management in Children: A Critical Appraisal of Systematic Reviews

OBJECTIVE. Our goal was to evaluate clinical, methodologic, and reporting aspects of systematic reviews on the management of acute asthma in children. METHODS. We undertook a systematic review of systematic reviews on acute asthma management in children. We identified eligible reviews by searching the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, Medline, and Embase 1990 to March 2006. Data were extracted on clinical issues, methodologic characteristics, and results of the reviews. Methodologic quality was assessed with the Overview Quality Assessment Questionnaire and with additional questions on heterogeneity. Separate reporting on children in mixed adult-pediatric population reviews was assessed. Methodologic quality of systematic reviews published in peer-reviewed journals was compared with Cochrane reviews. RESULTS. A total of 23 systematic reviews were included: 14 were published in the Cochrane Library, and 9 were published in peer-reviewed journals. Eight reviews included children only, and 15 were mixed-population reviews. The majority of reviews defined the study population as having “acute asthma” without a more precise definition, and 16 different health outcomes were reported. The overall quality according to the Overview Quality Assessment Questionnaire was good, with Cochrane reviews showing minimal flaws and journal reviews showing minor flaws (median scores: 7 vs 5). Results on children were reported separately in 8 of 15 mixed-population reviews. Clinical heterogeneity was explored in only 2 of 23 reviews, and the methods used to identify and address heterogeneity were diverse. CONCLUSIONS. The methodologic quality of both the Cochrane and journal reviews on the management of acute asthma in children seems good, with Cochrane reviews being more rigorous. However, their usefulness for clinical practice is hampered by a lack of clear definitions of included populations, clinically important health outcomes, and separate reporting on children in mixed reviews. A major threat to these reviews’ validity is the insufficient identification and handling of heterogeneity.

Determinants of knowledge gain in evidence-based medicine short courses: an international assessment

Background Health care professionals worldwide attend courses and workshops to learn evidence-based medicine (EBM), but evidence regarding the impact of these educational interventions is conflicting and of low methodologic quality and lacks generalizability. Furthermore, little is known about determinants of success. We sought to measure the effect of EBM short courses and workshops on knowledge and to identify course and learner characteristics associated with knowledge acquisition. Methods Health care professionals with varying expertise in EBM participated in an international, multicentre before–after study. The intervention consisted of short courses and workshops on EBM offered in diverse settings, formats and intensities. The primary outcome measure was the score on the Berlin Questionnaire, a validated instrument measuring EBM knowledge that the participants completed before and after the course. Results A total of 15 centres participated in the study and 420 learners from North America and Europe completed the study. The baseline score across courses was 7.49 points (range 3.97–10.42 points) out of a possible 15 points. The average increase in score was 1.40 points (95% confidence interval 0.48–2.31 points), which corresponded with an effect size of 0.44 standard deviation units. Greater improvement in scores was associated (in order of greatest to least magnitude) with active participation required of the learners, a separate statistics session, fewer topics, less teaching time, fewer learners per tutor, larger overall course size and smaller group size. Clinicians and learners involved in medical publishing improved their score more than other types of learners; administrators and public health professionals improved their score less. Learners who perceived themselves to have an advanced knowledge of EBM and had prior experience as an EBM tutor also showed greater improvement than those who did not. Interpretation EBM course organizers who wish to optimize knowledge gain should require learners to actively participate in the course and should consider focusing on a small number of topics, giving particular attention to statistical concepts.

Use of Clinical Preventive Services in Infants, Children, and Adolescents

At each stage from birth to young adulthood, the use of clinical preventive services (CPSs) provides an opportunity to intervene early to improve outcomes for many costly and complex conditions and to modify important disease-defining risk factors.1 A number of important provisions of the Affordable Care Act (ACA) will provide impetus to improve the use of CPSs, in particular, the provision that such services are now covered without cost sharing.2 The Centers for Disease Control and Prevention (CDC) has collected baseline data and reported detailed information on a select set of CPSs for children to serve as a benchmark to measure change following ACA implementation.3 The selected CPSs were identified by the CDC because they represent important public health issues for which CPSs exist, the service was underused before ACA implementation, and national data (largely parent and self-report or provider office-based surveys) were available to establish a baseline (defined as prior to 2012). Other important CPSs for children were not included in the report because of the lack of national data to track the clinical service (eg, screening for body mass index was considered, but surveillance data on screening in clinical care were not available), or the utilization of the CPS was already at high levels (eg, many infant immunizations). Not all of the CPSs included in the CDC report have a US Preventive Services Task Force (USPSTF) grade A or B or a comparable evidence review process recommendation (eg, Advisory Committee on Immunization Practices); but all, with the exception of dental visits and preventive services by dentists, like dental sealants, are now covered under the ACA.3

The Need to Build Capability and Capacity in Quality Improvement and Patient Safety

The use of quality improvement (QI) methods and safety principles can improve child health outcomes and reduce harm. Multi-institution collaboratives have achieved improved results by identifying and implementing best practices and by using rigorous improvement methodology.1 Children’s hospitals and their partner academic institutions have redesigned not only specific aspects of patient treatment but also the fundamental processes that determine how care is given and how the work within hospitals is carried out and communicated. Although this progress is to be commended, more needs to be done. Significant variations in care and outcomes, and gaps in the capability of physicians to engage in and lead QI, continue to exist. These deficiencies could be remedied by increasing the availability of improvement curricula, training opportunities, and skilled faculty. An integrated approach to building capacity for quality and safety would connect children’s hospitals and their academic partners, addressing alignment of quality priorities and resources across organizations, education and training for physicians in the science of improvement, and recognition of the legitimacy of QI activities for professional development and career progression.2 Multiple national organizations have developed programs intended to support and catalyze these goals. The Accreditation Council for Graduate Medical Education and the American Board of Pediatrics have recognized the need both to educate those who care for children on the front lines and to develop improvement leaders who can build effective teams, manage quality projects, and apply improvement knowledge and skills. By setting requirements for education and certification, these organizations have helped the professional mandate to ensure that physicians are prepared to engage in QI and safety work. The Accreditation Council for Graduate Medical Educations Next Accreditation System will focus on an outcomes-based program evaluation, built on the expectation that a resident will become progressively more competent throughout training.3 The Pediatrics … Address correspondence to Carole M. Lannon, MD, MPH, Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229. E-mail: carole.lannon{at}cchmc.org

Introducing Quality Reports

Nearly a decade has passed since the Institute of Medicine released its landmark report Crossing the Quality Chasm ,1 which called for a redesign of the health care system to deliver care that is safe, effective, patient-centered, timely, efficient, and equitable. The importance of engaging in this process is underscored by the requirement that pediatricians now participate in quality-improvement activities to maintain board certification. Unfortunately, opportunities to share the results of well-designed quality-improvement projects, regardless of their success, have been limited. This is a critical missed opportunity for spreading innovation. Recognizing this need, this month we introduce a new section in Pediatrics , Quality Reports, under the direction of assistant editor Alex Kemper, MD; this section will feature reports of the implementation and outcomes of quality-improvement projects. In addition to providing insight about improving care delivery, we hope that these reports … Address correspondence to Alex R. Kemper, MD, MPH, MS, Department of Pediatrics, Duke University, 2400 Pratt St, Room 0311 Terrace Level, Durham, NC 27705. E-mail: alex.kemper{at}duke.edu

Editorial Transitions: Continuing to Build on the Strong Foundation of Our Predecessors

This month marks the 61st anniversary of the inaugural issue of Pediatrics and, with it, a change in editorial leadership as the two of us (Drs First and Moyer) assume the roles of editor and deputy editor, respectively. We are amazed that only 4 editors have preceded us over the past 6 decades: Hugh McCullough (1948–1954), Charles D. May (1955–1961), Clement Smith (1962–1973), and, with the longest tenure of any peer-reviewed journal editor in this country, Jerold F. Lucey (1974–2008). Each of these 4 individuals brought new features and innovation to the journal—but always with the purpose of making sure that the information contained within was of great relevance to the members of the American Academy of Pediatrics (AAP). Dr Lucey in particular introduced commentaries and articles that went from the bench to the bedside and into the community; he also introduced the foreign-language editions and the online version of the journal to reach out to pediatricians all over the world and enable international pediatricians to share more of their research discoveries with us. During his … Address correspondence to Lewis R. First, MD, MS, University of Vermont College of Medicine, Department of Pediatrics, 89 Beaumont Ave, Burlington, VT 05405. E-mail: lewis.first{at}uvm.edu

To Integrity and Beyond

At its annual meeting in October 2010, the editorial board of Pediatrics discussed a number of substantive issues related to the integrity of the scientific content of the journal. Topics included better identification of potential conflicts of interest, criteria for authorship, clinical trials registration, and clarifying our policies regarding industry-sponsored studies. As readers might imagine, these topics generated lively discussion. The editorial board ultimately reached consensus on each of these subjects, and this commentary describes the results of our deliberations. The trust that our readers have in the scientific content of the journal rests in part on their confidence that any potential conflict of interest has been openly declared. The Institute of Medicine in its 2009 report defined a potential conflict of interest as “a set of circumstances that creates a risk that professional judgment or actions regarding a primary interest will be unduly influenced by a secondary interest.”1 It is important to understand that declaring a potential conflict does not imply that judgment has been influenced, only that the conditions exist under which it could be perceived to have been. Reviewers and readers may make their own assessments of whether judgment has been influenced. A potential secondary interest may be financial or nonfinancial and may be directly or indirectly related to the submitted manuscript. A directly related financial interest, for example, would exist if the author were an employee of the sponsoring commercial entity. A nonfinancial secondary interest might include “the desire for professional advancement, recognition for personal achievement, and favors to friends and family or to students and colleagues.”1 Secondary interests that are not related to the submitted work (eg, a consultancy in an unrelated field) do not create a potential conflict and, thus, do not need to be reported. However, if an author is not … Address correspondence to Virginia A. Moyer, MD, MPH, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030. E-mail: vamoyer{at}texaschildrens.org