ABSTRACT
Background. The post-acute sequelae of SARS-CoV-2 (PASC) has emerged as a long-term complication in adults, but current understanding of the clinical presentation of PASC in children is limited. Our study objectives were to identify symptoms, health conditions, and medications associated with PASC in children. Methods. We conducted a retrospective cohort study using electronic health records from 9 US children's hospitals for individuals < 21 years who underwent polymerase chain reaction (PCR) testing for SARS-CoV-2 between March 1, 2020 - October 31, 2021 and had at least 1 encounter in the 3 years before testing. Our exposure of interest was SARS-CoV-2 PCR positivity. We identified syndromic (symptoms), systemic (conditions), and medication PASC features in the 28-179 days following the initial test date. Adjusted hazard ratios (aHRs) were obtained for 151 clinically predicted PASC features by contrasting PCR-positive with PCR-negative groups using proportional hazards models, adjusting for site, age, sex, testing location, race/ethnicity, and time-period of cohort entrance. We estimated the incidence proportion for any syndromic, systemic or medication PASC feature in the two groups to estimate PASC burden. Results. Among 659,286 children in the study sample, 59,893 (9.1%) tested positive by PCR for SARS-CoV-2. Most were tested in outpatient testing facility (50.3%) or office (24.6%) settings (Table 1). The most common syndromic, systemic, and medication features were loss of taste or smell (aHR 1.96 [95% CI 1.16-3.32), myocarditis (aHR 3.10 [95% CI 1.94-4.96]) (Figures 1 and 2), and cough and cold preparations (aHR 1.52 [95% CI 1.18-1.96]). The incidence of at least one systemic/syndromic/ medication feature of PASC was 42.0% among PCR-positive children versus 38.2% among PCR-negative children, with an incidence proportion difference of 3.8% (95% CI 3.3-4.3%). A higher strength of association for PASC was identified in those cared for in the ICU during the acute illness phase, children less than 5 years-old, and individuals with complex chronic conditions. Adjusted hazard ratios (aHR) with associated 95% CI among patients who tested positive for SARS-CoV-2 infection versus those who tested negative for the risk of each syndromic feature (symptom) using Cox proportional hazards models. Models were adjusted for age at cohort entrance, sex, race/ethnicity, institution, testing place location, presence of a complex medical condition and date of cohort entrance. Adjusted hazard ratios (aHR) with associated 95% CI among patients who tested positive for SARS-CoV-2 infection versus those who tested negative for the risk of each systemic feature using Cox proportional hazards models. Models were adjusted for age at cohort entrance, sex, race/ethnicity, institution, testing place location, and date of cohort entrance. For each health condition evaluated, patients with evidence of that condition 18 months before cohort entrance were excluded from the denominator in order to identify incident cases. Each ratio compares the risk of the outcome in children who tested positive for SARS-CoV-2 infection versus those who tested negative. Footnote: The diagnostic cluster for COVID-19 indicates children receiving care for the illness in the post-acute period. Conclusion. In this large-scale, exploratory study, the burden of PASC in children appeared to be lower than earlier reports. Acute illness severity, young age, and comorbid complex chronic disease increased the risk of PASC. (Figure Presented).
ABSTRACT
Purpose: The demand for pediatric gender-affirming care has increased throughout the COVID-19 pandemic, highlighting the need for telehealth-based specialist-to-primary care provider (PCP) consultative support. Accordingly, the purpose of this study was to identify PCPs’ perspectives on receiving training and consultation in pediatric gender-affirming care using three telehealth modalities, with the larger goal of informing the development of future consultative support offerings. Methods: PCPs who had previously reached out to the Seattle Children’s Gender Clinic for a gender care consultation were invited to participate in a semi-structured, one-hour Zoom interview. During the interview, three different telehealth modalities (tele-education, electronic consultation, telephonic consultation) were described and participants were asked to share their perspectives on 1) the benefits and drawbacks of each modality, 2) which modality would be most effective in supporting them in providing gender-affirming care in the primary care setting, and 3) factors that would make a consultation platform successful. Interviews were transcribed and analyzed using an inductive thematic analysis framework by two authors using Dedoose qualitative analysis software. All participants provided informed consent and all study procedures were approved by the Seattle Children’s Institutional Review Board. Results: Interviews were completed with 15 PCPs. For the tele-education platform, PCPs most often identified continuing medical education (67%) and the community or network it creates (47%) as benefits and the commitment required (73%) and scheduling difficulties (40%) as drawbacks. For the electronic consultation model, timeliness of response (67%) and convenience (53%) were cited as benefits and electronic medical record system requirements (60%) and difficulty conveying the message electronically (53%) were considered the main drawbacks. For the telephonic consultation, PCPs identified the ability to have a conversation (80%) and the timeliness of response (60%) as the main benefits and phone-tag (87%) and finding time to make the initial call (40%) as the main drawbacks. Regarding the most effective platform, responses were mixed: 27% endorsed the electronic consultation, 27% the tele-education platform, and 20% the telephonic consultation, with the remaining 27% suggesting a hybrid of the three models. Finally, responses regarding what would make a platform successful were much more varied across participants, with the most common responses including being non-judgmental and supportive (33%) and flexible with the ability to pivot to other platforms as needed (27%). Conclusions: With the increasing demand to provide gender-affirming care in the primary care setting, further training and support is necessary for pediatric PCPs to deliver this time-sensitive care. The results of this study indicate the need for a more flexible suite of gender-focused specialist-to-PCP telehealth-based consultative services to facilitate the provision of pediatric gender-affirming care. Sources of Support: This project was supported by the Seattle Children's Research Institute and AHRQ (K12HS026393-03;PI: Sequeira) and a grant from Pivotal Ventures.
ABSTRACT
Purpose: Pediatric gender centers have seen a notable increase in demand for gender-affirming care services during the COVID-19 pandemic. This increased need has contributed to delays in youth accessing this time-sensitive care and amplified the importance of primary care providers (PCPs) playing an active role supporting gender diverse youth in the post-pandemic world. To guide interventions to support PCPs in gender-affirming care, we sought to understand how often PCP’s see gender diverse youth in primary care and assess PCP comfort facilitating conversations about gender identity in this setting. The objectives of this study were to (1) understand whether PCPs are routinely discussing pronouns and gender identity with adolescents and (2) explore barriers to and the impact of having such discussions in primary care. Methods: This project integrated data from a needs assessment survey and from semi-structured, qualitative interviews with pediatric PCPs. The 15-item survey was administered to PCPs in a large, hospital-affiliated, pediatric primary care network in the northeastern US to better understand PCPs experiences providing adolescent healthcare. Hour long, semi-structured interviews were conducted with pediatric PCPs in the pacific northwest using an interview guide developed in partnership with two PCP stakeholders. Survey responses were analyzed descriptively. Interviews were transcribed and analyzed by two authors in Dedoose qualitative analysis software via inductive thematic analysis using an iteratively designed codebook that was adjudicated to consensus. Results: Of the pediatric PCPs surveyed (n=85), the majority were pediatricians (67%) and most had been in practice for more than 5 years (75%). Almost all (92%) PCPs reported caring for at least one gender diverse youth in their practice in the last year. However, PCPs reported discussing pronouns (15%) and gender identity (29%) during annual well visits with adolescent patients much less frequently than discussing mood (98%), motor vehicle safety (77%) and sexuality (61%). Relatedly, gender-affirming care (60%) was the topic most frequently selected by PCPs for additional education. In separate PCP interviews, participants (n=15) indicated that while they felt discussions about pronouns and gender identity were important, they experienced specific structural and interpersonal barriers that prevented these conversations from occurring. These barriers included poor health system infrastructure (like forms and electronic health records), staff concerns, uncertainty around language, lack of awareness and fear. PCPs also discussed that when they asked about pronouns and gender identity, it normalized conversations about gender, helped facilitate family support, created welcoming environments in the health system and allowed for earlier identification of youth in need of support. Conclusions: Pediatric PCPs recognize the critical role they play in supporting gender-diverse youth and their families, particularly around normalizing conversations about gender identity. However, multiple individual and clinic-level barriers to asking about pronouns and gender identity remain. These results highlight the continued need to provide resources, education and support to PCPs in discussing these topics in the primary care setting to facilitate access to time-sensitive gender-affirming care. Sources of Support: This project was supported by the Seattle Children's Research Institute Career Development and AHRQ K12HS026393-03 (PI: Sequeira).
ABSTRACT
Introduction: Diabetes clinics have rapidly adopted the use of telemedicine to support ambulatory diabetes care during the COVID-19 pandemic. Objectives: The aim of this study was to explore barriers to and facilitators of the integration of telemedicine in ambulatory diabetes care for adolescents with type 1 diabetes (T1D). Methods: Eight focus groups of parents (n=19) and diabetes care team members (n=18) were conducted in the Seattle, WA metropolitan area. Semi-structured questions were used to elicit views about their experience with telemedicine diabetes clinic visits during the COVID-19 pandemic. Analysis was conducted using an iteratively developed codebook and themes were mapped onto the technology acceptance model (TAM). Results: Barriers (n=5) and facilitators (n=5) were mapped to TAM domains (Table). Facilitators of perceived usefulness and perceived ease of use domains included (1) clinic visit accessibility that aligned with adolescent lifestyle, (2) access to context of daily life at home, and (3) adolescent literacy with videoconferencing technology. Barriers included (1) inability to conduct a physical exam and incorporate findings, (2) inconsistent availability of diabetes technology data, and (3) inability to ensure confidential communication with adolescent. Participant attitudes toward ongoing use of telemedicine were informed by the anticipated level of adolescent engagement in a virtual setting and equity determinants, including the challenges related to attending clinic visits. All participants, especially parents, saw the value in a hybrid model of telemedicine/inperson visits as beneficial for future ambulatory diabetes care. Conclusions: Parents and diabetes care team members report that telemedicine visits are useful and align well with communication and lifestyle needs of adolescents. However, diabetes clinics need to address accessibility issues, improve appointment preparation, and develop techniques for confidential communication. (Table Presented).