Improving Adolescent Depression Screening in Pediatric Primary Care.

OBJECTIVE: Depression among adolescents is a leading public health problem. Although screening for adolescent depression in primary care is strongly recommended, screening rates remain low. Effective quality improvement (QI) initiatives can facilitate change. This study aims to assess the impact of a QI learning collaborative on adolescent depression screening and initial plans of care in primary care. METHODS: Seventeen pediatric-serving practices in Vermont participated in a QI learning collaborative aimed at improving practitioner knowledge and office systems around adolescent depression screening. Monthly medical record reviews provided monitoring of adolescent depression screening and initial plans of care over 7 months for QI. Randomly sampled annual medical record review data allowed comparison of screening and initial plans of care after the QI learning collaborative between participating and 21 control practices. RESULTS: As practices improved their office systems around adolescent depression screening and initial plans of care, data showed marked improvement in depression screening at all 17 practices, from 34% to 97% over 7 months. Adolescents at participating practices had 3.5 times greater odds (95% confidence interval [CI], 1.14-10.98, P = .03) of being screened for depression and 37.5 times greater odds (95% CI, 7.67-183.48, P < .0005) of being screened with a validated tool than adolescents at control practices, accounting for patient characteristics. CONCLUSIONS: There were significant within practice increases in adolescent depression screening after a QI learning collaborative, as well as in comparison with control practices 1 year later.

Radiation and Brain Tumors: An Overview.

The use of radiation is an essential part of both modern cancer diagnostic assessment and treatment. Next-generation imaging devices create 3D visualizations, allowing for better diagnoses and improved planning of precision treatment. This is particularly important for primary brain cancers such as diffuse intrinsic pontine glioma or the most common primary brain tumor, glioblastoma, because radiotherapy is often the only treatment modality that offers a significant improvement in survival and quality of life. In this review, we give an overview of the different imaging techniques and the historic role of radiotherapy and its place in modern cancer therapy. Finally, we discuss three key areas of risks associated with the use of ionizing radiation: (1) brain tumor induction mainly as a consequence of the diagnostic use of radiation; (2) cognitive decline as a consequence of treating childhood brain tumors as an example of long term consequences often neglected in favor of highlighting secondary primary cancers; and (3) pro-proliferative and pro-invasive alterations that occur in tumor cells that survive radiotherapy. Throughout the discussion, we highlight areas of potential future research.

Quality Improvement to Immunization Coverage in Primary Care Measured in Medical Record and Population-Based Registry Data.

OBJECTIVES: Despite the proven benefits of immunizations, coverage remains low in many states, including Vermont. This study measured the impact of a quality improvement (QI) project on immunization coverage in childhood, school-age, and adolescent groups. METHODS: In 2013, a total of 20 primary care practices completed a 7-month QI project aimed to increase immunization coverage among early childhood (29-33 months), school-age (6 years), and adolescent (13 years) age groups. For this study, we examined random cross-sectional medical record reviews from 12 of the 20 practices within each age group in 2012, 2013, and 2014 to measure improvement in immunization coverage over time using chi-squared tests. We repeated these analyses on population-level data from Vermont's immunization registry for the 12 practices in each age group each year. We used difference-in-differences regressions in the immunization registry data to compare improvements over time between the 12 practices and those not participating in QI. RESULTS: Immunization coverage increased over 3 years for all ages and all immunization series (P ≤ .009) except one, as measured by medical record review. Registry results aligned partially with medical record review with increases in early childhood and adolescent series over time (P ≤ .012). Notably, the adolescent immunization series completion, including human papillomavirus, increased more than in the comparison practices (P = .037). CONCLUSIONS: Medical record review indicated that QI efforts led to increases in immunization coverage in pediatric primary care. Results were partially validated in the immunization registry particularly among early childhood and adolescent groups, with a population-level impact of the intervention among adolescents.

Cell Death Induction in Cancer Therapy - Past, Present, and Future.

The induction of apoptosis, a physiological type of cell death, is currently the primary therapeutic aim of most cancer therapies. As resistance to apoptosis is an early hallmark of developing cancer, the success of this treatment strategy is already potentially compromised at treatment initiation. In this review, we discuss the tumor in Darwinian terms and describe it as a complex, yet highly unstable, ecosystem. Current therapeutic strategies often focus on directly killing the dominant subclone within the population of mutated cancer cells while ignoring the subclonal complexity within the ecosystem tumor, the complexity of the direct tumor/ microenvironment interaction and the contribution of the ecosystem human - that is, the global environment which provides the tumor with both support and challenges. The Darwinian view opens new possible therapeutic interventions, such as the disruption of the microenvironment by targeting nonmutated cells within the tumor or the interaction points of mutant tumor cells with their environment, and it forces us to reevaluate therapeutic endpoints. It is our belief that a central future challenge of apoptosis-inducing therapies will be to understand better under which preconditions which treatment strategy and which therapeutic endpoint will lead to the highest quality and quantity of a patient's life.

Increasing Immunization Compliance by Reducing Provisional Admittance.

Students in Vermont with incomplete or undocumented immunization status are provisionally admitted to schools and historically had a calendar year to resolve their immunization status. The process of resolving these students' immunization status was challenging for school nurses. We conducted a school-based quality improvement effort to increase student compliance with Vermont immunization regulations using a collaborative learning approach with public health school liaisons and school nurses from public schools to reduce provisional admittance in 2011-2012. Strategies included using a tracking system, accessing the immunization registry, promoting immunization importance, tracking immunization plans, and working with medical homes to update records. Participating school nurses observed decreases in the number of provisionally admitted students, although this reduction was not significantly different than matched comparison schools. We also found the number of provisionally admitted students fluctuated throughout the year and resolving the immunization status of New Americans and exchange students required special attention. Our approach supports the coordinated school health model and demonstrates the critical role school nurses play in improving population health outcomes.

Improving newborn preventive services at the birth hospitalization: a collaborative, hospital-based quality-improvement project.

OBJECTIVE: The goal was to test the effectiveness of a statewide, collaborative, hospital-based quality-improvement project targeting preventive services delivered to healthy newborns during the birth hospitalization. METHODS: All Vermont hospitals with obstetric services participated. The quality-improvement collaborative (intervention) was based on the Breakthrough Series Collaborative model. Targeted preventive services included hepatitis B immunization; assessment of breastfeeding; assessment of risk of hyperbilirubinemia; performance of metabolic and hearing screens; assessment of and counseling on tobacco smoke exposure, infant sleep position, car safety seat fit, and exposure to domestic violence; and planning for outpatient follow-up care. The effect of the intervention was assessed at the end of an 18-month period. Preintervention and postintervention chart audits were conducted by using a random sample of 30 newborn medical charts per audit for each participating hospital. RESULTS: Documented rates of assessment improved for breastfeeding adequacy (49% vs 81%), risk for hyperbilirubinemia (14% vs 23%), infant sleep position (13% vs 56%), and car safety seat fit (42% vs 71%). Documented rates of counseling improved for tobacco smoke exposure (23% vs 53%) and car safety seat fit (38% vs 75%). Performance of hearing screens also improved (74% vs 97%). No significant changes were noted in performance of hepatitis B immunization (45% vs 30%) or metabolic screens (98% vs 98%), assessment of tobacco smoke exposure (53% vs 67%), counseling on sleep position (46% vs 68%), assessment of exposure to domestic violence (27% vs 36%), or planning for outpatient follow-up care (80% vs 71%). All hospitals demonstrated preintervention versus postintervention improvement of > or = 20% in > or = 1 newborn preventive service. CONCLUSIONS: A statewide, hospital-based quality-improvement project targeting hospital staff members and community physicians was effective in improving documented newborn preventive services during the birth hospitalization.