Faculty Bibliography

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.

BACKGROUND AND OBJECTIVES: A recent AAP policy statement recommends mL-exclusive dosing for pediatric liquid medications. Little is known about parent preferences regarding units, perceptions about moving to mL-only, and the role of health literacy and prior mL-dosing experience. METHODS: Cross-sectional analysis of data collected as part of a randomized controlled study in 3 urban pediatric clinics (SAFE-Rx for Kids study). English/Spanish-speaking parents (n=493) of children <8 years were randomized to 1 of 4 study arms and given labels/dosing tools which varied in label instruction format (text+pictogram, text-only) and units (mL-only, mL/tsp). OUTCOMES: teaspoon preference in dosing instructions, perceived difficulty with mL-only dosing. Predictor variable: health literacy (Newest Vital Sign; low[0-1], marginal[2-3], adequate[4-6]). Mediating variable: prior mL-dosing experience. RESULTS: Over two-thirds of parents had low or marginal health literacy. The majority (>70%) preferred to use mL, perceived mL-only dosing to be easy, and had prior mL-dosing experience; 11.5% had a teaspoon preference, 18.1% perceived mL-only dosing will be difficult, and 17.7% had no prior mL-dosing experience. Parents with lower health literacy had a higher odds of having a teaspoon preference (low vs. adequate: AOR=2.9[1.3-6.2]), and greater odds of perceiving difficulty with mL-only dosing (low vs. adequate: AOR=13.9[4.8-40.6]), marginal vs. adequate: AOR=7.1[2.5-20.4]). Lack of experience with mL-dosing partially mediated the impact of health literacy. CONCLUSIONS: Most parents were comfortable with mL-only dosing. Parents with low health literacy were more likely to perceive mL-only dosing to be difficult; educational efforts will need to target this group to ensure safe medication use.

OBJECTIVES: To determine whether parents who use a low literacy, pictogram- and photograph-based written asthma action plan have a better understanding of child asthma management compared to parents using a standard plan. METHODS: Randomized controlled study in 2 urban pediatric outpatient clinics. INCLUSION CRITERIA: English/Spanish-speaking parents of 2-12 year old asthmatic children. Parents were randomized to receive a low literacy or standard asthma action plan (American Academy of Allergy, Asthma and Immunology) for a hypothetical patient on controller and rescue medications. A structured questionnaire was used to assess whether there was an error in knowledge of 1)medications to give everyday and when sick, 2)need for spacer use, and 3)appropriate emergency response to give albuterol and seek medical help. Multiple logistic regression analyses performed adjusting for parent age, health literacy (Newest Vital Sign); child asthma severity, medications; site. RESULTS: 217 parents were randomized (109 intervention;108 control). Parents who received the low literacy plan were 1)less likely to make an error in knowledge of medications to take everyday and when sick compared to parents who received the standard plan (63.0 vs. 77.3%, p = 0.03; adjusted odds ratio [AOR] = 0.5[95% CI: 0.2-0.9]) and 2)less likely make an error regarding spacer use (14.0 vs. 51.1%, p<0.001; AOR = 0.1[0.06-0.3]). No difference in error in appropriate emergency response was seen (43.1 vs. 48.1%, p = 0.5). CONCLUSIONS: Use of a low literacy written asthma action plan was associated with better parent understanding of asthma management. Further study is needed to assess whether use of this action plan improves child asthma outcomes.