Faculty Bibliography

OBJECTIVES/OBJECTIVE:Time spent commuting is associated with obesity. The objective of this study was to assess the relationship between neighborhood-level commute to work (CTW) times and self-reported health behaviors and food access. METHODS:We conducted a cross-sectional analysis of caregivers with infants as part of the Greenlight study, a multisite obesity trial in Chapel Hill, NC; New York, New York; Nashville, TN and Miami, FL. Zip-code based commute estimates were determined using the U.S. Census' American Community Survey. Self-reported health behavior and food access data were collected via directed interview. Logistic and linear regression models determined associations between neighborhood CTW times and health behaviors and food access. RESULTS:The average neighborhood CTW time for all zip codes was 29 mins (N=846). Caregivers in longer CTW time neighborhoods were more likely to endorse fewer food choices (AOR=1.39; 95% CI 1.15,1.69; p=0.001) and difficulty accessing markets with fresh produce (AOR=1.51; 95% CI 1.02, 2.25; p=0.04). Neighborhood CTW time >30 mins were associated with less caregiver physical activity (AOR=0.58; 95% CI 0.34, 0.98; p=0.044). Neighborhood CTW time was inversely related to infant television time (adjusted mean 399 min/day for ≤30min; 256min/day for >30 minutes; p=0.025). New York families in longer CTW neighborhoods were more likely to report difficulty accessing markets with fresh produce (AOR= 1.80, 95% CI 1.03, 3.14; p=0.039). CONCLUSIONS:Neighborhood CTW times are associated with several self-reported health behaviors and perceived food access among caregivers with children. Neighborhood CTW times may represent city-specific features including transportation infrastructure which may impact the health of families.

The NIH-funded SAFE Rx for Kids study has identified best practices for the labeling/dosing of pediatric liquid medications. Findings support use of pictographic instructions and optimized provision of dosing tools, along with careful selection of the unit of measurement used.

OBJECTIVE:Food insecurity is associated with childhood obesity possibly mediated through caregiver feeding practices and beliefs. We examined if caregiver feeding practices differed by household food security status in a diverse sample of infants. We hypothesize feeding practices differ based on food security status. PATIENTS AND METHODS/METHODS:Baseline cross-sectional analysis of data from a randomized controlled trial to prevent obesity. Included in the analysis was 842 caregivers of 2-month-old infants presenting for well-child care at 4 academic institutions. Food insecurity exposure was based on an affirmative answer to one of two items in a 2-item validated questionnaire. Chi-square tests examined the association between parent feeding practices and food security status. Logistic regression adjusted for covariates. Differences in caregiver feeding practices by food security status and race/ethnicity were explored with an interaction term (food security status x race/ethnicity). RESULTS:43% of families screened as food insecure. In adjusted logistic regression, parents from food-insecure households were more likely to endorse that "the best way to make an infant stop crying is to feed him/her" (aOR: 1.72, 95% CI: 1.28-2.29); and "When my baby cries, I immediately feed him/her" (aOR: 1.40, 95%CI: 1.06-1.83). Food insecure caregivers less frequently endorsed paying attention to their baby when s/he is full or hungry (OR 0.57 95%CI: 0.34-0.96). Racial/ethnic differences in beliefs and behaviors were observed by food security status. CONCLUSIONS:During early infancy, feeding practices differed among caregivers by household food security status. Further research is needed to examine whether these practices are associated with increased risk of obesity and obesity-related morbidity.

OBJECTIVE:To determine whether medical errors, family experience, and communication processes improved after implementation of an intervention to standardize the structure of healthcare provider-family communication on family centered rounds. DESIGN/METHODS:Prospective, multicenter before and after intervention study. SETTING/METHODS:Pediatric inpatient units in seven North American hospitals, 17 December 2014 to 3 January 2017. PARTICIPANTS/METHODS:All patients admitted to study units (3106 admissions, 13171 patient days); 2148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents. INTERVENTION/METHODS:Families, nurses, and physicians coproduced an intervention to standardize healthcare provider-family communication on ward rounds ("family centered rounds"), which included structured, high reliability communication on bedside rounds emphasizing health literacy, family engagement, and bidirectional communication; structured, written real-time summaries of rounds; a formal training programme for healthcare providers; and strategies to support teamwork, implementation, and process improvement. MAIN OUTCOME MEASURES/METHODS:Medical errors (primary outcome), including harmful errors (preventable adverse events) and non-harmful errors, modeled using Poisson regression and generalized estimating equations clustered by site; family experience; and communication processes (eg, family engagement on rounds). Errors were measured via an established systematic surveillance methodology including family safety reporting. RESULTS:26.5% (12.7% to 7.3%), P=0.02) increased. Trainee teaching and the duration of rounds did not change significantly. CONCLUSIONS:Although overall errors were unchanged, harmful medical errors decreased and family experience and communication processes improved after implementation of a structured communication intervention for family centered rounds coproduced by families, nurses, and physicians. Family centered care processes may improve safety and quality of care without negatively impacting teaching or duration of rounds. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT02320175.

Eczema action plans (EAPs) are written, customizable documents that guide patients through the self-management of atopic dermatitis. Here, we distributed a survey regarding the use patterns and perceptions of eczema action plans to 1068 members of the Society for Pediatric Dermatology and received 87 responses. Although a strong majority of respondents endorsed the ability of EAPs to improve adherence (79%) and improve prevention and/or management of flares (70%), reported rates of EAP editing or provision sharply decline from initial to follow-up visits (61%-33%). The development of a standardized, low-literacy web-based tool could improve the efficacy of EAPs for patients and physicians by improving comprehensibility and retention.

BACKGROUND/OBJECTIVES/OBJECTIVE:Little is known about the reading grade level (readability), appropriateness of design (suitability), and content variability of written eczema action plans (EAPs), which can impact the effectiveness of these patient education tools. Here, we assess the readability, suitability, and content of EAPs currently used by pediatric dermatologists in the United States. METHODS:This was a cross-sectional study of EAPs submitted by members of the Society for Pediatric Dermatology (n = 26). Readability, suitability, and content of sampled plans were systematically assessed. RESULTS:Mean (SD) reading grade level was 9.0 (2.1); one in five was written at the recommended level of 6th grade or lower. While the majority of EAPs were found to be adequately suitable, one in five was unsuitable and only two superior. Documents scored most poorly in layout/design and learning stimulation. Plans scored best in the categories of content and literacy demand. EAPs focused on similar content themes, though specific recommendations and descriptors of atopic dermatitis (AD) disease states varied considerably. CONCLUSIONS:The health literacy burden of EAPs in the United States could be lowered by improving their readability, incorporating graphics, stimulating reader engagement, and developing standards for how AD flares are defined.

INTRODUCTION/BACKGROUND:To prevent errors, healthcare professional and safety organizations recommend using milliliters (mL) alone for oral liquid medication dosing instructions and devices. In 2018, for federal incentives under the Quality Payment Program, one requirement is for Electronic Health Records (EHRs) to automatically use mL alone whenever oral liquid medications are prescribed. Current perceptions and practices of primary care providers (PCPs) regarding dosing units for oral liquid medications were assessed. METHODS:Pediatricians, family practitioners, nurse practitioners, and internists participating in the 2015 DocStyles web-based survey were asked about their perceptions and practices regarding dosing units for oral liquid medications. RESULTS:Three-fifths of PCPs (59.0%) reported that using mL alone is safest for dosing oral liquid medications; however, nearly three-quarters (72.0%) thought that patients/caregivers prefer instructions that include spoon-based units. Within each specialty, fewer PCPs reported they would prescribe using mL alone than reported that using mL alone is safest (P<.0001 for all). Among PCPs who think mL-only dosing is safest, those who perceived patients/caregivers prefer spoon-based units were less likely to prescribe using mL alone (odds ratio: 0.45, 95% CI: 0.34-0.59). Pediatricians were more likely than other PCPs to report that it is safest to use mL alone (80.8% vs 54.7%) and that they would use mL alone when prescribing (56.8% vs 30.9%) (P<.0001 for both). CONCLUSIONS:Because fewer than two-thirds of pediatricians and one-third of other PCPs would use mL alone in dosing instructions, additional education to encourage prescribing and communicating with patients/caregivers using mL alone may be needed.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Despite recommendations supporting human papillomavirus (HPV) vaccination, pediatric vaccination rates remain suboptimal in the United States; lack of tools to support provider counseling is one barrier. We sought to evaluate HPV-related counseling materials for readability, suitability, and content, and assess parent perceptions of materials, using a health literacy perspective. METHODS:A systematic search was conducted for written materials developed for HPV vaccination counseling by examining state Department of Health Web sites and associated links to local and national organizations. Materials were assessed for the following: 1) readability (Flesch Reading Ease, Flesch-Kincaid, Gunning Fog, Simple Measure of Gobbledygook, Fry), 2) suitability (understandability and actionability) (Suitability Assessment of Materials; Patient Education Materials Assessment Tool for Printable Materials), and 3) coverage of 8 key content areas (recommended by Centers for Disease Control and Prevention). Semistructured interviews were conducted with English-speaking parents or caregivers of children 9 to 17 years of age from 3 pediatric clinics (New York, Ohio, Illinois) serving predominantly low-income families to assess perceptions and usefulness of 4 handouts selected for review. RESULTS:Thirty-eight documents were assessed. Mean ± standard deviation (SD) reading grade level was 9.4 ± 2; 10.5% (n = 4) had a reading level of 6th grade or below; 68.4% (n = 26) were considered not suitable. Mean understandability was 41.7% and mean actionability was 20.7%. Only 5.3% (n = 2) addressed all 8 content areas mean ± SD (number of areas = 6.7 ± 1.2). Brochure comprehensiveness and inclusion of a personal story were cited as factors that would be helpful in influencing parents to vaccinate against HPV. CONCLUSIONS:Few written materials for HPV vaccination counseling were optimal from a health literacy best practices perspective. Content comprehensiveness was important for informed decision making.