Publications by authors named "Jane M Garbutt"

45 Publications

The Third Rail of Pediatric Communication: Discussing Firearm Risk and Safety in Well-Child Exams.

Health Commun 2021 Apr 13;36(4):508-520. Epub 2019 Dec 13.

School of Journalism, University of Missouri.

This research endeavors to understand how pediatricians and parents discuss - or do not discuss - firearm risks for children during well-child visits. Through individual semi-structured interviews with 16 pediatric providers and 20 parents, the research explores discursive barriers to open conversation, perspectives on anticipatory guidance, and new ideas for culturally competent messaging. The research focuses particularly on how parents' and providers' perspectives on firearm risk communication are tied to cultural norms and expectations. One salient theme that emerged is that the American Academy of Pediatrics recommendation that pediatricians ask parents about ownership status is deemed undesirable by pediatricians and parents because of the delicate intercultural setting. Born out of pediatric and parent experiences, and mindful of culturally salient barriers, this study offers alternative strategies for discussing firearm risk in well-child exams.
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http://dx.doi.org/10.1080/10410236.2019.1700883DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771016PMC
April 2021

Designing for Accelerated Translation (DART) of Emerging Innovations in Health.

J Clin Transl Sci 2019 Jun 30;3(2-3):53-58. Epub 2019 Jul 30.

Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA.

Accelerating innovation translation is a priority for improving healthcare and health. Although dissemination and implementation (D&I) research has made significant advances over the past decade, it has attended primarily to the implementation of long-standing, well-established practices and policies. We present a conceptual architecture for speeding translation of promising innovations as candidates for iterative testing in practice. Our framework to aims to clarify whether, when, and how to act on evolving evidence to improve healthcare. We view translation of evidence to practice as a dynamic process and argue that much evidence can be acted upon even when uncertainty is moderately high, recognizing that this evidence is evolving and subject to frequent reevaluation. The DART framework proposes that additional factors-demand, risk, and cost, in addition to the evolving evidence base-should influence the pace of translation over time. Attention to these underemphasized factors may lead to more dynamic decision-making about whether or not to adopt an emerging innovation or de-implement a suboptimal intervention. Finally, the DART framework outlines key actions that will speed movement from evidence to practice, including forming meaningful stakeholder partnerships, designing innovations for D&I, and engaging in a learning health system.
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http://dx.doi.org/10.1017/cts.2019.386DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746422PMC
June 2019

Low Back Pain--Related Disability in Parkinson Disease: Impact on Functional Mobility, Physical Activity, and Quality of Life.

Phys Ther 2019 10;99(10):1346-1353

Department of Neurology, Program in Physical Therapy, Department of Neuroscience, Department of Radiology, and Program in Occupational Therapy, Washington University School of Medicine in Saint Louis.

Background: People with Parkinson disease (PD) frequently experience low back pain (LBP), yet the impact of LBP on functional mobility, physical activity, and quality of life (QOL) has not been described in PD.

Objective: The objectives of this study were to describe body positions and functional activities associated with LBP and to determine the relationships between LBP-related disability and PD motor sign severity, physical activity level, and QOL.

Design: The study was a cross-sectional study.

Methods: Thirty participants with idiopathic PD (mean age = 64.6 years [SD = 10.3]; 15 women) completed the Revised Oswestry Disability Questionnaire (RODQ), a measure of LBP-related disability. PD motor symptom severity was measured using the Movement Disorder Society-Unified Parkinson Disease Rating Scale Part III (MDS-UPRDS III). The Physical Activity Scale for the Elderly (PASE) was used to measure self-reported physical activity. The Parkinson Disease Questionnaire-39 (PDQ-39) was used to measure QOL. Descriptive statistics were used to characterize LBP intensity and LBP-related disability. Spearman correlations were used to determine relationships between the RODQ and the MDS-UPDRS III, PASE, and PDQ-39.

Results: LBP was reported to be of at least moderate intensity by 63.3% of participants. LBP most frequently impaired standing, sleeping, lifting, and walking. The RODQ was significantly related to the MDS-UPDRS III (r = 0.38), PASE (r = -0.37), PDQ-39 summary index (r = 0.55), PDQ-39 mobility subdomain (r = 0.54), and PDQ-39 bodily pain subdomain (r = 0.44).

Limitations: Limitations included a small sample of people with mild to moderate PD severity, the fact that RODQ is a less frequently used measure of LBP-related disability, and the lack of a non-PD control group.

Conclusions: LBP affected walking, sleeping, standing, and lifting in this small sample of people with mild to moderate PD. Greater LBP-related disability was associated with greater motor sign severity, lower physical activity level, and lower QOL in people with PD.
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http://dx.doi.org/10.1093/ptj/pzz094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6821152PMC
October 2019

Opioids in Adolescents' Homes: Prevalence, Caregiver Attitudes, and Risk Reduction Opportunities.

Acad Pediatr 2019 Jan - Feb;19(1):103-108. Epub 2018 Jul 6.

Department of Pediatrics (JM Garbutt, K Kulka, S Dodd, and R Sterkel, and K Plax).

Objective: The most common source of misused opioids is pain relievers prescribed for family and friends. This study was conducted to assess knowledge, attitudes, and behaviors of adolescents' caregivers regarding prescribed opioids in the home.

Methods: The self-administered survey was completed by caregivers in the waiting rooms of 12 pediatric practices in the Midwest. Eligibility required living in a home where youth age ≥10 years were frequently present. Out of 793 eligible caregivers, 700 (88.3%) completed the survey, 76.8% of whom were the parent.

Results: Among the 700 caregiver respondents, 34.6% reported opioids in the home (13.6% active prescriptions, 12.7% leftover medications, 8.3% both). Of those with an active prescription, 66.0% intended to keep any leftover medications for future needs (for the patient, 60.1%; for someone else, 5.9%). Of those with leftover medications, 60.5% retained them for the same reason (for the patient, 51.0%; for someone else, 9.5%). Others kept medications unintentionally, either because they never got around to disposing of them (30.6%), they did not know how to dispose of them properly (15.7%), or it never occurred to them to dispose of the medications (7.5%). Many caregivers were unaware that adolescents commonly misuse opioids (30.0%) and use them to attempt suicide (52.3%), and that opioid use can lead to heroin addiction (38.6%). According to the surveys, 7.1% would give leftover opioid medications to an adolescent to manage pain and 5.9% might do so.

Conclusions: Opioids are prevalent in homes in our community, and many parents are unaware of the risks they pose. Study findings can inform strategies to educate parents about opioid risk and encourage and facilitate timely, safe disposal of unused medications.
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http://dx.doi.org/10.1016/j.acap.2018.06.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6914255PMC
February 2020

Barriers and facilitators to HPV vaccination in primary care practices: a mixed methods study using the Consolidated Framework for Implementation Research.

BMC Fam Pract 2018 05 7;19(1):53. Epub 2018 May 7.

Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.

Background: In the United States, the effective, safe huma papilloma virus (HPV) vaccine is underused and opportunities to prevent cancer continue to be missed. National guidelines recommend completing the 2-3 dose HPV vaccine series by age 13, well before exposure to the sexually transmitted virus. Accurate characterization of the facilitators and barriers to full implementation of HPV vaccine recommendations in the primary care setting could inform effective implementation strategies.

Methods: We used the Consolidated Framework for Implementation Research (CFIR) to systematically investigate and characterize factors that influence HPV vaccine use in 10 primary care practices (16 providers) using a concurrent mixed methods design. The CFIR was used to guide collection and analysis of qualitative data collected through in-person semi-structured interviews with the primary care providers. We analyzed HPV vaccine use with data abstracted from medical charts. Constructs that most strongly influenced vaccine use were identified by integrating the qualitative and quantitative data.

Results: Of the 72 CFIR constructs assessed, seven strongly distinguished and seven weakly distinguished between providers with higher versus lower HPV vaccine coverage. The majority of strongly distinguishing constructs were facilitators and were related to characteristics of the providers (knowledge and beliefs; self-efficacy; readiness for change), their perception of the intervention (relative advantage of vaccinating younger vs. older adolescents), and their process to deliver the vaccine (executing). Additional weakly distinguishing constructs that were facilitators were from outer setting (peer pressure; financial incentives), inner setting (networks and communications and readiness for implementation) and process (planning; engaging, and reflecting and evaluating). Two strongly distinguishing constructs were barriers to use, one from the intervention (adaptability of the age of initiation) and the other from outer setting (patient needs and resources).

Conclusions: Using CFIR to systematically examine the use of this vaccine in independent primary care practices enabled us to identify facilitators and barriers at the provider, interpersonal and practice level that need to be addressed in future efforts to increase vaccine use in such settings. Our findings suggest that implementation strategies that target the provider and help them to address multi-level barriers to HPV vaccine use merit further investigation.
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http://dx.doi.org/10.1186/s12875-018-0750-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5938801PMC
May 2018

Theory-based development of an implementation intervention to increase HPV vaccination in pediatric primary care practices.

Implement Sci 2018 03 13;13(1):45. Epub 2018 Mar 13.

Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA.

Background: The national guideline for use of the vaccine targeting oncogenic strains of the human papillomavirus (HPV) is an evidence-based practice that is poorly implemented in primary care. Recommendations include completion of the vaccine series before the 13th birthday for girls and boys, giving the first dose at the 11- to 12-year-old check-up visit, concurrent with other recommended vaccines. Interventions to increase implementation of this guideline have had little impact, and opportunities to prevent cancer continue to be missed.

Methods: We used a theory-informed approach to develop a pragmatic intervention for use in primary care settings to increase implementation of the HPV vaccine guideline recommendation. Using a concurrent mixed methods design in 10 primary care practices, we applied the Consolidated Framework for Implementation Research (CFIR) to systematically investigate and characterize factors strongly influencing vaccine use. We then used the Behavior Change Wheel (BCW) and the Theoretical Domains Framework (TDF) to analyze provider behavior and identify behaviors to target for change and behavioral change strategies to include in the intervention.

Results: We identified facilitators and barriers to guideline use across the five CFIR domains: most distinguishing factors related to provider characteristics, their perception of the intervention, and their process to deliver the vaccine. Targeted behaviors were for the provider to recommend the HPV vaccine the same way and at the same time as the other adolescent vaccines, to answer parents' questions with confidence, and to implement a vaccine delivery system. To this end, the intervention targeted improving provider's capability (knowledge, communication skills) and motivation (action planning, belief about consequences, social influences) regarding implementing guideline recommendations, and increasing their opportunity to do so (vaccine delivery system). Behavior change strategies included providing information and communication skill training with graded tasks and modeling, feedback of coverage rates, goal setting, and social support. These strategies were combined in an implementation intervention to be delivered using practice facilitation, educational outreach visits, and cyclical small tests of change.

Conclusions: Using CFIR, the BCW and the TDF facilitated the development of a pragmatic, multi-component implementation intervention to increase use of the HPV vaccine in the primary care setting.
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http://dx.doi.org/10.1186/s13012-018-0729-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5850961PMC
March 2018

Physical therapy and deep brain stimulation in Parkinson's Disease: protocol for a pilot randomized controlled trial.

Pilot Feasibility Stud 2018 21;4:54. Epub 2018 Feb 21.

1Program in Physical Therapy, Washington University School of Medicine in Saint Louis, Campus Box 8502, 4444 Forest Park Blvd, St. Louis, MO 63108 USA.

Background: Subthalamic nucleus deep brain stimulation (STN-DBS) reduces tremor, muscle stiffness, and bradykinesia in people with Parkinson's Disease (PD). Walking speed, known to be reduced in PD, typically improves after surgery; however, other important aspects of gait may not improve. Furthermore, balance may worsen and falls may increase after STN-DBS. Thus, interventions to improve balance and gait could reduce morbidity and improve quality of life following STN-DBS. Physical therapy (PT) effectively improves balance and gait in people with PD, but studies on the effects of PT have not been extended to those treated with STN-DBS. As such, the efficacy, safety, and feasibility of PT in this population remain to be determined. The purpose of this pilot study is to address these unmet needs. We hypothesize that PT designed to target balance and gait impairment will be effective, safe, and feasible in this population.

Methods/design: Participants with PD treated with STN-DBS will be randomly assigned to either a PT or control group. Participants assigned to PT will complete an 8-week, twice-weekly PT program consisting of exercises designed to improve balance and gait. Control group participants will receive the current standard of care following STN-DBS, which does not include prescription of PT. The primary aim is to assess preliminary efficacy of PT on balance (Balance Evaluation Systems Test). A secondary aim is to assess efficacy of PT on gait (GAITRite instrumented walkway). Participants will be assessed OFF medication/OFF stimulation and ON medication/ON stimulation at baseline and at 8 and 12 weeks after baseline. Adverse events will be measured over the duration of the study, and adherence to PT will be measured to determine feasibility.

Discussion: To our knowledge, this will be the first study to explore the preliminary efficacy, safety, and feasibility of PT for individuals with PD with STN-DBS. If the study suggests potential efficacy, then this would justify larger trials to test effectiveness and safety of PT for those with PD with STN-DBS.

Trial Registration: NCT03181282 (clinicaltrials.gov). Registered on 7 June 2017.
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http://dx.doi.org/10.1186/s40814-018-0243-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5822622PMC
February 2018

Characteristics of youth agreeing to electronic sexually transmitted infection risk assessment in the emergency department.

Emerg Med J 2018 Jan 11;35(1):46-51. Epub 2017 Aug 11.

American Academy of Pediatrics, Chicago, Illinois, USA.

Objectives: Adolescents and young adults are at high risk for sexually transmitted infections (STIs). We previously reported an increase in STI testing of adolescents in our ED by obtaining a sexual history using an Audio-enhanced Computer-Assisted Self-Interview (ACASI). We now examine associations among demographics, sexual behaviour, chief complaint and willingness to be tested.

Methods: This was a prospective study conducted in a paediatric ED between April and December 2011. After triage, eligible patients between 15 and 21 years presenting with non-life-threatening conditions were asked to participate in the study. Consenting participants used an ACASI to provide their demographic data and answer questions about their sexual history and willingness to be tested. Our primary outcome was the association of demographics, chief complaint and ACASI recommendation with the participant's willingness to be tested.

Results: We approached 1337 patients, of whom 800 (59%) enrolled and completed the ACASI. Eleven who did not answer questions related to their sexual history were excluded from analysis. Of 789 participants, 461 (58.4%) were female and median age was 16.9 years (IQR 16.0-17.8); 509 (64.5%) endorsed a history of anal, oral and/or vaginal intercourse. Disclosing a sexual history and willingness to be tested did not differ significantly by gender. 131 (16.6%) had a chief complaint potentially referable to an STI; among the 658 participants with non-STI-related complaints, 412 (62.6%) were sexually active, many of whom disclosed risky behaviours, including multiple partners (46.4%) and inconsistent condom use (43.7%). The ACASI identified 419 patients as needing immediate STI testing; the majority (81%) did not have a chief complaint potentially related to STIs. 697 (88.3%) participants were willing to receive STI testing. Most (94.6%) of the patients with STI-related complaints were willing to be tested, and 92.1% of patients with a recommendation for immediate testing by the ACASI indicated a willingness to be tested.

Conclusions: Adolescents were willing to disclose sexual activity via electronic questionnaires and were willing to receive STI testing, even when their chief complaint was not STI related. The ACASI facilitated identification of adolescent ED patients needing STI testing regardless of chief complaint.
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http://dx.doi.org/10.1136/emermed-2016-206199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5783299PMC
January 2018

Insights from parents can guide asthma care for urban, minority children.

J Allergy Clin Immunol Pract 2017 Mar - Apr;5(2):516-518. Epub 2016 Nov 23.

Department of Pediatrics, Washington University in St Louis, St Louis, Mo.

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http://dx.doi.org/10.1016/j.jaip.2016.09.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5346337PMC
January 2019

What Are Parents Willing to Discuss with Their Pediatrician About Firearm Safety? A Parental Survey.

J Pediatr 2016 12 14;179:166-171. Epub 2016 Sep 14.

Department of Pediatrics, Washington University St Louis, St. Louis, MO.

Objective: To determine if parents are receptive to discussing firearm safety with their pediatrician.

Study Design: Parents completed a self-administered paper survey during a pediatric office visit. Responses of those who confirmed and denied household firearms were compared using Fisher exact test.

Results: Between March 23 and May 21, 2015, 1246 of 1363 eligible parents (91.4%) completed the survey (22.6% African American, 79.5% at least some college education); 36% of respondents reported household firearms (owners). An additional 14.3% reported that their child was often in homes that contained firearms. Of the 447 owners, 25.1% reported ≥1 firearm was stored loaded, and 17.9% carried a firearm when leaving the house. Seventy-five percent of parents thought the pediatrician should advise about safe storage of firearms (owners 71.1%, others 77.5%), 16.9% disagreed (owners 21.9%, others 13.4%), and 8.2% were uncertain. Sixty-six percent thought pediatricians should ask about the presence of household firearms (owners 58.4%, others 70.9%), 23.2% disagreed (owners 31.5%, others 17.8%), and 10.5% were uncertain. Differences in parental opinions between owners and other parents were statistically significant. Twenty-two percent of owners would ignore advice to not have household firearms for safety reasons, and 13.9% would be offended by such advice. Only 12.8% of all parents reported a discussion about firearms with the pediatrician.

Conclusions: Avoiding direct questioning about firearm ownership and extending the discussion about why and how to ensure safe storage of firearms to all parents may be an effective strategy to decrease firearm-related injuries and fatalities in children.
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http://dx.doi.org/10.1016/j.jpeds.2016.08.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5123916PMC
December 2016

Effects of Obesity and Hypertension on Pulse Wave Velocity in Children.

J Clin Hypertens (Greenwich) 2017 Mar 11;19(3):221-226. Epub 2016 Aug 11.

Department of Pediatrics, Washington University School of Medicine, St. Louis, MO.

Pulse wave velocity (PWV) is a biomarker of arterial stiffness. Findings from prior studies are conflicting regarding the impact of obesity on PWV in children. The authors measured carotid-femoral PWV in 159 children aged 4 to 18 years, of whom 95 were healthy, 25 were obese, 15 had hypertension (HTN), and 24 were both obese and hypertensive. Mean PWV increased with age but did not differ by race or sex. In adjusted analyses in children 10 years and older (n=102), PWV was significantly higher in children with hypertension (PWV±standard deviation, 4.9±0.7 m/s), obesity (5.0±0.9 m/s), and combined obesity-hypertension (5.2±0.6 m/s) vs healthy children (4.3±0.7 m/s) (each group, P<.001 vs control). In our study, obesity and HTN both significantly and independently increased PWV, while African American children did not have a higher PWV than Caucasian children.
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http://dx.doi.org/10.1111/jch.12892DOI Listing
March 2017

Daily global stress is associated with nocturnal asthma awakenings in school-age children.

J Allergy Clin Immunol 2016 10 21;138(4):1196-1199.e3. Epub 2016 Apr 21.

Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo.

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http://dx.doi.org/10.1016/j.jaci.2016.01.054DOI Listing
October 2016

Provider Training to Screen and Initiate Evidence-Based Pediatric Obesity Treatment in Routine Practice Settings: A Randomized Pilot Trial.

J Pediatr Health Care 2017 Jan - Feb;31(1):16-28. Epub 2016 Feb 9.

Introduction: This randomized pilot trial evaluated two training modalities for first-line, evidence-based pediatric obesity services (screening and goal setting) among nursing students.

Method: Participants (N = 63) were randomized to live interactive training or Web-facilitated self-study training. Pretraining, post-training, and 1-month follow-up assessments evaluated training feasibility, acceptability, and impact (knowledge and skill via simulation). Moderator (previous experience) and predictor (content engagement) analyses were conducted.

Results: Nearly all participants (98%) completed assessments. Both types of training were acceptable, with higher ratings for live training and participants with previous experience (ps < .05). Knowledge and skill improved from pretraining to post-training and follow-up in both conditions (ps < .001). Live training demonstrated greater content engagement (p < .01).

Conclusions: The training package was feasible, acceptable, and efficacious among nursing students. Given that live training had higher acceptability and engagement and online training offers greater scalability, integrating interactive live training components within Web-based training may optimize outcomes, which may enhance practitioners' delivery of pediatric obesity services.
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http://dx.doi.org/10.1016/j.pedhc.2016.01.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4980292PMC
January 2018

Practice Variation in Management of Childhood Asthma Is Associated with Outcome Differences.

J Allergy Clin Immunol Pract 2016 May-Jun;4(3):474-80. Epub 2016 Jan 20.

Donald Strominger Professor of Pediatrics, Pediatric Allergy, Immunology, and Pulmonary Medicine, Washington University in St Louis, St Louis, Mo.

Background: Although specialist asthma care improves children's asthma outcomes, the impact of primary care management is unknown.

Objective: To determine whether variation in preventive and acute care for asthma in pediatric practices affects patients' outcomes.

Methods: For 22 practices, we aggregated 12-month patient data obtained by chart review and parent telephone interviews for 948 children, 3 to 12 years old, diagnosed with asthma to obtain practice-level measures of preventive (≥1 asthma maintenance visit/year) and acute (≥1 acute asthma visit/year) asthma care. Relationships between practice-level measures and individual asthma outcomes (symptom-free days, parental quality of life, emergency department [ED] visits, and hospitalizations) were explored using generalized estimating equations, adjusting for seasonality, specialist care, Medicaid insurance, single-family status, and race.

Results: For every 10% increase in the proportion of children in the practice receiving preventive care, symptom-free days per child increased by 7.6 days (P = .02) and ED visits per child decreased by 16.5% (P = .002), with no difference in parental quality of life or hospitalizations. Only the association between more preventive care and fewer ED visits persisted in adjusted analysis (12.2% reduction; P = .03). For every 10% increase in acute care provision, ED visits per child and hospitalizations per child decreased by 18.1% (P = .02) and 16.5% (P < .001), respectively, persisting in adjusted analyses (ED visits 8.6% reduction, P = .02; hospitalizations 13.9%, P = .03).

Conclusions: Children cared for in practices providing more preventive and acute asthma care had improved outcomes, both impairment and risk. Persistence of improved risk outcomes in the adjusted analyses suggests that practice-level interventions to increase asthma care may reduce childhood asthma disparities.
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http://dx.doi.org/10.1016/j.jaip.2015.12.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4861671PMC
October 2017

Parental Use of Electronic Cigarettes.

Acad Pediatr 2015 Nov-Dec;15(6):599-604. Epub 2015 Aug 22.

Department of Pediatrics, Washington University, St Louis, Mo.

Objective: To describe parental use of electronic cigarettes (e-cigs) to better understand the safety risks posed to children.

Methods: Between June 24 and November 6, 2014, parents completed a self-administered paper survey during an office visit to 15 pediatric practices in a Midwestern practice-based research network. Attitudes towards and use of e-cigs are reported for those aware of e-cigs before the survey.

Results: Ninety-five percent (628 of 658) of respondents were aware of e-cigs. Of these, 21.0% (130 of 622) had tried e-cigs at least once, and 12.3% (77) reported e-cig use by ≥1 person in their household (4.0% exclusive e-cig use, 8.3% dual use with regular cigarettes). An additional 17.3% (109) reported regular cigarette use. Most respondents from e-cig-using homes did not think e-cigs were addictive (36.9% minimally or not addictive, 25.0% did not know). While 73.7% believed that e-liquid was very dangerous for children if they ingested it, only 31.2% believed skin contact to be very dangerous. In 36.1% of e-cig-using homes, neither childproof caps nor locks were used to prevent children's access to e-liquid. Only 15.3% reported their child's pediatrician was aware of e-cig use in the home.

Conclusions: E-cig use occurred in 1 in 8 homes, often concurrently with regular cigarettes. Many parents who used e-cigs were unaware of the potential health and safety hazards, including nicotine poisoning for children, and many did not store e-liquid safely. Pediatricians could provide education about e-cig associated safety hazards but are unaware of e-cig use in their patients' homes.
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http://dx.doi.org/10.1016/j.acap.2015.06.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4639418PMC
December 2016

Peer training to improve parenting and childhood asthma management skills: a pilot study.

Ann Allergy Asthma Immunol 2015 Feb 15;114(2):148-9. Epub 2014 Dec 15.

Department of Pediatrics, Washington University St Louis, St Louis, Missouri.

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http://dx.doi.org/10.1016/j.anai.2014.10.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4308445PMC
February 2015

A cluster-randomized trial shows telephone peer coaching for parents reduces children's asthma morbidity.

J Allergy Clin Immunol 2015 May 30;135(5):1163-70.e1-2. Epub 2014 Oct 30.

Department of Pediatrics, Washington University in St Louis, St Louis, Mo.

Background: Childhood asthma morbidity remains significant, especially in low-income children. Most often, asthma management is provided by the child's primary care provider.

Objective: We sought to evaluate whether enhancing primary care management for persistent asthma with telephone-based peer coaching for parents reduced asthma impairment and risk in children 3 to 12 years old.

Methods: Over 12 months, peer trainers provided parents with asthma management training by telephone (median, 18 calls) and encouraged physician partnership. The intervention was evaluated in a cluster-randomized trial of 11 intervention and 11 usual care pediatric practices (462 and 486 families, respectively). Patient outcomes were assessed by means of telephone interviews at 12 and 24 months conducted by observers blinded to intervention assignment and compared by using mixed-effects models, controlling for baseline values and clustering within practices. In a planned subgroup analysis we examined the heterogeneity of the intervention effect by insurance type (Medicaid vs other).

Results: After 12 months, intervention participation resulted in 20.9 (95% CI, 9.1-32.7) more symptom-free days per child than in the control group, and there was no difference in emergency department (ED) visits. After 24 months, ED visits were reduced (difference in mean visits/child, -0.28; 95% CI, -0.5 to -0.02), indicating a delayed intervention effect. In the Medicaid subgroup, after 12 months, intervention participation resulted in 42% fewer ED visits (difference in mean visits/child, -0.50; 95% CI, -0.81 to -0.18) and 62% fewer hospitalizations (difference in mean hospitalizations/child, -0.16; 95% CI, -0.30 to -0.014). Reductions in health care use endured through 24 months.

Conclusions: This pragmatic telephone-based peer-training intervention reduced asthma impairment. Asthma risk was reduced in children with Medicaid insurance.
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http://dx.doi.org/10.1016/j.jaci.2014.09.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4416070PMC
May 2015

Opportunities to reduce children's excessive consumption of calories from beverages.

Clin Pediatr (Phila) 2014 Oct 2;53(11):1047-54. Epub 2014 Jul 2.

Washington University in St Louis, St Louis, MO, USA

Objective: To describe children's consumption of sugar-sweetened beverages (SSBs) and 100% fruit juice (FJ), and identify factors that may reduce excessive consumption.

Design: A total of 830 parents of young children completed a 36-item questionnaire at the pediatricians' office.

Results: Children consumed soda (62.2%), other SSBs (61.6%), and FJ (88.2%): 26.9% exceeded the American Academy of Pediatrics' recommended daily FJ intake. 157 (18.9%) children consumed excessive calories (>200 kcal/d) from beverages (median = 292.2 kcal/d, range 203.8-2177.0 kcal/d). Risk factors for excessive calorie consumption from beverages were exceeding recommendations for FJ (odds ratio [OR] = 119.7, 95% confidence interval [CI] = 52.2-274.7), being 7 to 12 years old (OR = 4.3, 95%CI = 1.9-9.9), and having Medicaid insurance (OR = 2.6, 95%CI = 1.1-6.0). Parents would likely reduce beverage consumption if recommended by the physician (65.6%).

Conclusions: About 1 in 5 children consumes excessive calories from soda, other SSBs and FJ, with FJ the major contributor.
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http://dx.doi.org/10.1177/0009922814540989DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4157093PMC
October 2014

Primary care visits for asthma monitoring over time and association with acute asthma visits for urban Medicaid-insured children.

J Asthma 2014 Nov 9;51(9):907-12. Epub 2014 Jun 9.

Department of Emergency Medicine, Boston Children's Hospital , Boston , USA .

Objectives: To examine the association between numbers of primary care provider (PCP) visits for asthma monitoring (AM) over time and acute asthma visits in the emergency department (ED) and at the PCP for Medicaid-insured children.

Methods: We prospectively enrolled 2-10 years old children during ED asthma visits. We audited hospital and PCP records for each subject for three consecutive years. We excluded subjects also receiving care from asthma subspecialists. PCP AM visits were those with documentation that suggested discussion of asthma management but no acute asthma symptoms or findings. PCP "Acute Asthma" visits were those with documentation of acute asthma symptoms or findings, regardless of treatment. ED asthma visits were those with documented asthma treatment. Generalized liner models were used to analyze the association between numbers of AM visits and acute asthma visits to the ED and PCP.

Results: One hundred three subjects were analyzed. Over the 3 years, the mean number of AM visits/child was 2.5 ± 2.3 (standard deviation), range 0-10. Only 50% of subjects had at least 1 PCP visit with an asthma controller medication documented. The mean number of ED asthma visits/child was 3.2 ± 2.8; range 1-18. The mean number of PCP Acute Asthma visits/child was 0.7 ± 1.6; range 0-11. Increasing AM visits was associated with more ED visits (estimate 0.088; 95% CI 0.001, 0.174), and more PCP Acute Asthma visits (estimate 0.297; 95% CI 0.166, 0.429). Increasing PCP visits for any diagnosis was not associated with ED visits (estimate 0.021; 95% CI -0.018, 0.06).

Conclusions: Asthma monitoring visits and documented controller medication for these urban Medicaid-insured children occurred infrequently over 3 years, and having more asthma monitoring visits was not associated with fewer ED or PCP acute asthma visits.
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http://dx.doi.org/10.3109/02770903.2014.927483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5831129PMC
November 2014

Using parental perceptions of childhood allergic rhinitis to inform primary care management.

Clin Pediatr (Phila) 2014 Jul 6;53(8):758-63. Epub 2014 May 6.

Washington University in St Louis, St Louis, MO, USA.

Objective: To describe parents' experience with their child's allergic rhinitis (AR) to inform management by the primary care provider (PCP).

Study Design: Two hundred parents with a child 7 to 15 years old with AR symptoms within the past 12 months completed a paper survey.

Results: The child's AR was identified as a significant problem in spring (89.3%), fall (63.4%), summer (50.3%), and winter (21.4%); 51.3% had persistent disease. AR symptoms most commonly interfered with the child's outdoor activities and sleeping, and frequently bothered the parent and other family members. Most parents (88.3%) wanted to know what their child was allergic to and had many concerns about treatment options. A total of 62.9% had sought AR care from the PCP in the past 12 months.

Conclusions: Many families experience significant morbidity from their child's AR and turn to their PCP for help. We identified opportunities for the PCP to reduce AR morbidity.
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http://dx.doi.org/10.1177/0009922814533590DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4222999PMC
July 2014

Nonrespiratory symptoms before loss of asthma control in children.

J Allergy Clin Immunol Pract 2013 May-Jun;1(3):304-6.e1-2. Epub 2013 Feb 28.

Department of Pediatric Allergy and Pulmonary, Washington University School of Medicine, St. Louis, Mo.

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http://dx.doi.org/10.1016/j.jaip.2013.01.012DOI Listing
September 2014

Rural, suburban, and urban differences in factors that impact physician adherence to clinical preventive service guidelines.

J Rural Health 2014 23;30(1):7-16. Epub 2013 May 23.

Washington University School of Medicine, Washington University in St. Louis, St. Louis, Missouri; Prevention Research Center in St. Louis, Brown School, Washington University in St. Louis, St. Louis, Missouri.

Purpose: Rural-urban disparities in provision of preventive services exist, but there is sparse research on how rural, suburban, or urban differences impact physician adherence to clinical preventive service guidelines. We aimed to identify factors that may cause differences in adherence to preventive service guidelines among rural, suburban, and urban primary care physicians.

Methods: This qualitative study involved in-depth semistructured interviews with 29 purposively sampled primary care physicians (10 rural, 10 suburban, 9 urban) in Missouri. Physicians were asked to describe barriers and facilitators to clinical preventive service guideline adherence. Using techniques from grounded theory analysis, 2 coders first independently conducted content analysis then reconciled differences in coding to ensure agreement on intended meaning of transcripts.

Findings: Patient epidemiologic differences, distance to health care services, and care coordination were reported as prominent factors that produced differences in preventive service guideline adherence among rural, suburban, and urban physicians. Epidemiologic differences impacted all physicians, but rural physicians highlighted the importance of occupational risk factors in their patients. Greater distance to health care services reduced visit frequency and was a prominent barrier for rural physicians. Care coordination among health care providers was problematic for suburban and urban physicians. Patient resistance to medical care and inadequate access to resources and specialists were identified as barriers by some rural physicians.

Conclusions: The rural, suburban, or urban context impacts whether a physician will adhere to clinical preventive service guidelines. Efforts to increase guideline adherence should consider the barriers and facilitators unique to rural, suburban, or urban areas.
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http://dx.doi.org/10.1111/jrh.12025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3882340PMC
April 2015

The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial.

Clin Pediatr (Phila) 2013 Nov 3;52(11):1014-21. Epub 2013 Oct 3.

1Washington University in St. Louis, St. Louis, MO, USA.

Background. Although common practice, evidence to support treatment of croup with prednisolone is scant. Methods. We conducted a community-based randomized trial to compare the effectiveness of prednisolone (2 mg/kg/d for 3 days, n = 41) versus 1 dose of dexamethasone (0.6 mg/kg) and 2 doses of placebo (n = 46). Participants were children 1 to 8 years old with croup symptoms ≤48 hours, categorized as mild (42%) or moderate (58%). Results. There were no differences for those treated with dexamethasone or prednisolone for additional health care for croup (2% vs 7%, P = .34), duration of croup symptoms (2.8 vs 2.2 days, P = .63), nonbarky cough (6.1 vs 5.9 days, P = .81), nights with disturbed sleep for the parent (0.68 vs 1.21 nights, P = .55), and days with stress (1.39 vs 1.56 days, P = .51). Conclusion. There were no detected differences in outcomes between the 2 croup treatments for either child or parent.
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http://dx.doi.org/10.1177/0009922813504823DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4019394PMC
November 2013

A telephone coaching intervention to improve asthma self-management behaviors.

Pediatr Nurs 2013 May-Jun;39(3):125-30, 145

St. Louis Children's Hospital Answer Line, St. Louis Children's Hospital, St. Louis, MO, USA.

Long recognizing that asthma, one of the most common chronic childhood diseases, is difficult to manage, the National Asthma Education Prevention Program developed clinical practice guidelines to assist health care providers, particularly those in the primary care setting. Yet, maintenance asthma care still fails to meet national standards. Therefore, in an attempt to improve and support asthma self-management behaviors for parents of children 5 to 12 years of age with persistent asthma, a novel nurse telephone coaching intervention was tested in a randomized, controlled trial. A detailed description of the intervention is provided along with parent satisfaction results, an overview of the training used to prepare the nurses, and a discussion of the challenges experienced and lessons learned.
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August 2013

Parents' experiences with pediatric care at retail clinics.

JAMA Pediatr 2013 Sep;167(9):845-50

Importance: Little is known about the use of retail clinics (RCs) for pediatric care.

Objective: To describe the rationale and experiences of families with a pediatrician who also use RCs for pediatric care.

Design And Setting: Cross-sectional study with 19 pediatric practices in a Midwestern practice-based research network.

Participants: Parents attending the pediatrician’s office.

Main Outcomes And Measures: Parents’ experience with RC care for their children.

Results: In total, 1484 parents (91.9% response rate) completed the self-administered paper survey. Parents (23.2%) who used the RC for pediatric care were more likely to report RC care for themselves (odds ratio, 7.79; 95% CI, 5.13-11.84), have more than 1 child (2.16; 1.55-3.02), and be older (1.05; 1.03-1.08). Seventy-four percent first considered going to the pediatrician but reported choosing the RC because the RC had more convenient hours (36.6%), no office appointment was available (25.2%), they did not want to bother the pediatrician after hours (15.4%), or they thought the problem was not serious enough (13.0%). Forty-seven percent of RC visits occurred between 8 am and 4 pm on weekdays or 8 am and noon on the weekend. Most commonly, visits were reportedly for acute upper respiratory tract illnesses (sore throat, 34.3%; ear infection, 26.2%; and colds or flu, 19.2%) and for physicals (13.1%). While 7.3% recalled the RC indicating it would inform the pediatrician of the visit, only 41.8% informed the pediatrician themselves.

Conclusions And Relevance: Parents with established relationships with a pediatrician most often took their children to RCs for care because access was convenient. Almost half the visits occurred when the pediatricians’ offices were likely open.
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http://dx.doi.org/10.1001/jamapediatrics.2013.352DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4019395PMC
September 2013

Pediatric providers' attitudes toward retail clinics.

J Pediatr 2013 Nov 28;163(5):1384-8.e1-6. Epub 2013 Jun 28.

Washington University in St Louis, St Louis, MO. Electronic address:

Objective: To describe pediatric primary care providers' attitudes toward retail clinics and their experiences of retail clinics use by their patients.

Study Design: A 51-item, self-administered survey from 4 pediatric practice-based research networks from the midwestern US, which gauged providers' attitudes toward and perceptions of their patients' interactions with retail clinics, and changes to office practice to better compete.

Results: A total of 226 providers participated (50% response). Providers believed that retail clinics were a business threat (80%) and disrupted continuity of chronic disease management (54%). Few (20%) agreed that retail clinics provided care within recommended clinical guidelines. Most (91%) reported that they provided additional care after a retail clinic visit (median 1-2 times per week), and 37% felt this resulted from suboptimal care at retail clinics "most or all of the time." Few (15%) reported being notified by the retail clinic within 24 hours of a patient visit. Those reporting prompt communication were less likely to report suboptimal retail clinic care (OR 0.20, 95% CI 0.10-0.42) or disruption in continuity of care (OR 0.32, 95% CI 0.15-0.71). Thirty-six percent reported changes to office practice to compete with retail clinics (most commonly adjusting or extending office hours), and change was more likely if retail clinics were perceived as a threat (OR 3.70, 95% CI 1.56-8.76); 30% planned to make changes in the near future.

Conclusions: Based on the perceived business threat, pediatric providers are making changes to their practice to compete with retail clinics. Improved communication between the clinic and providers may improve collaboration.
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http://dx.doi.org/10.1016/j.jpeds.2013.05.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812257PMC
November 2013

Clinical and laboratory factors associated with negative oral food challenges.

Allergy Asthma Proc 2012 Nov-Dec;33(6):467-73

Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO 63110, USA.

Children with food-specific IgE (FSIgE) ≤2 kUa/L to milk, egg, or peanut (or ≤5kUa/L to peanut without history of previous reaction) are appropriate candidates for oral food challenge (OFC) to investigate resolution of food allergy, because these FSIgE cutoffs are associated with ∼50% likelihood of negative OFC. This study was designed to identify characteristics of children undergoing OFC, based on these FSIgE levels, who are most likely to show negative OFC. We collected demographics, severity of previous reaction, history of atopic diseases, total IgE and FSIgE values, and skin tests results on children who underwent OFCs to milk, egg, or peanut, based on the recommended FSIgE cutoffs. We identified independent factors associated with negative OFCs. Four hundred forty-four OFCs met our inclusion criteria. The proportions of negative OFCs performed based on FSIgE cutoffs alone were 58, 42, and 63% to milk, egg, and peanuts, respectively. Regression models identified independent factors associated with negative OFCs: lower FSIgE levels (all three foods), higher total IgE (milk), consumption of baked egg products (egg), and non-Caucasian race (eggs and peanuts). Combinations of these factors identified subgroups of children with proportions of negative OFCs of 83, 75, and 75% for milk, eggs, and peanuts, respectively. Combinations of clinical and laboratory elements, together with FSIgE values, might identify more children who are likely to have negative OFCs compared with current recommendations using FSIgE values alone. Once validated in a different population, these factors might be used for selection of patients who are most likely to show negative OFCs.
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http://dx.doi.org/10.2500/aap.2012.33.3607DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3522388PMC
June 2013

What are parents worried about? Health problems and health concerns for children.

Clin Pediatr (Phila) 2012 Sep 26;51(9):840-7. Epub 2012 Jul 26.

Washington University, St Louis, MO 63110, USA.

Unlabelled: Patient-centered care requires pediatricians to address parents' health concerns, but their willingness to solicit parental concerns may be limited by uncertainty about which topics will be raised. The authors conducted surveys of parents to identify current health-related issues of concern.

Methods: Participants rated 30 items as health problems for children in their community (large, medium, small, or no problem) and volunteered concerns for their own children.

Results: A total of 1119 parents completed the survey. Allergies (69%), lack of exercise (68%), asthma (65%), attention deficit hyperactivity disorder (65%), Internet safety (63%), obesity (59%), smoking (58%), and bullying (57%) were identified as important problems (large or medium) with variation among demographic subgroups. Concerns for their own children included healthy nutrition; obesity; lack of exercise, healthy growth and development; safety and injury prevention; and mental health issues.

Conclusion: Parents' health concerns for children are varied and may differ from those routinely addressed during well-child care.
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http://dx.doi.org/10.1177/0009922812455093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3608110PMC
September 2012

Providing depression care in the medical home: what can we learn from attention-deficit/ hyperactivity disorder?

Arch Pediatr Adolesc Med 2012 Jul;166(7):672-3

Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8116, St Louis, MO 63110, USA.

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http://dx.doi.org/10.1001/archpediatrics.2011.1565DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3607309PMC
July 2012

Deriving competencies for mentors of clinical and translational scholars.

Clin Transl Sci 2012 Jun 10;5(3):273-80. Epub 2012 Jan 10.

Irving Institute for Clinical and Translational Research, Columbia University Medical Center, New York, New York, USA.

Although the importance of research mentorship has been well established, the role of mentors of junior clinical and translational science investigators is not clearly defined. The authors attempt to derive a list of actionable competencies for mentors from a series of complementary methods. We examined focus groups, the literature, competencies derived for clinical and translational scholars, mentor training curricula, mentor evaluation forms and finally conducted an expert panel process in order to compose this list. These efforts resulted in a set of competencies that include generic competencies expected of all mentors, competencies specific to scientists, and competencies that are clinical and translational research specific. They are divided into six thematic areas: (1) Communication and managing the relationship, (2) Psychosocial support, (3) Career and professional development, (4) Professional enculturation and scientific integrity, (5) Research development, and (6) Clinical and translational investigator development. For each thematic area, we have listed associated competencies, 19 in total. For each competency, we list examples that are actionable and measurable. Although a comprehensive approach was used to derive this list of competencies, further work will be required to parse out how to apply and adapt them, as well future research directions and evaluation processes.
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http://dx.doi.org/10.1111/j.1752-8062.2011.00366.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3476465PMC
June 2012