Universal lipid screening in adolescents to identify familial hypercholesterolemia in a large healthcare system.

BACKGROUND: Familial hypercholesterolemia (FH) is an inherited condition that likely affects 1 in 300 people often requiring pharmacologic intervention in childhood. OBJECTIVES: We hypothesized that current strategies for pediatric lipid screening fail to detect and treat most FH, but data analysis may suggest specific methods to improve outcomes. METHODS: We retrospectively searched 392,129 patient records of 11-17-year-olds in Kaiser Permanente Southern California for data related to recommended universal pediatric lipid screening. We categorized subjects as Probable or Possible FH and evaluated FH pharmacotherapy status. RESULTS: 37% of the population received lipid screening with 0.13% (1 in 769) having Probable or Possible FH. Results at each step of the process showed progressive decreases in detection and treatment. We characterized 1 in 3448 subjects as Probable FH which is only 8.7% of cases expected from the prevalence of FH in the population. 45% of Probable FH cases received ongoing pharmacotherapy which is 1 in 7688 of the cohort (3.9% of expected cases). One major correctable reason for this drop-off was using obesity to target screening and treatment decisions rather than following the recommended universal screening. We found a strong association of obesity with screening (risk ratio (RR) 2.74 [confidence interval (CI) 2.71-2.76]), but not with FH (RR 0.72, CI 0.47-1.10). CONCLUSION: This current universal lipid screening strategy, likely typical of US practice, fails to detect and treat the supermajority of FH cases, increasing risk for adult coronary artery disease. To address the specific deficiencies we observed, we suggest improvements to detect and treat FH.

Sustainability of weight loss from a family-centered pediatric weight management program integrated in primary care.

BACKGROUND: A 6-month pediatric weight loss program showed modest success, but the sustainability of this success after 12 months was unclear. The present study aims tomeasure the medium-term effectiveness of family-based weight management in pediatric primary care to reduce body weight in children living with obesity. METHODS: In a retrospective cohort study, children ages 3 to 17 years with obesity in Kaiser Permanente Orange County, California, who enrolled in a weight management program between April 2014 and December 2018 (FB-WMG, n = 341) were compared to children referred but not enrolled (Ref-CG, n = 317) and controls matched by sex, age, zip code and BMI (Area-CG, n = 801). The relative distance from the median BMI-for-age at months 0, 6, and 12 were expressed as difference-in-differences (DID) using multivariable linear regressions with robust standard error. RESULTS: The baseline BMI-for-age was 98.6 (SD 1.08) percentile in FB-WMG, 98.2 (SD 1.22) percentile in Ref-CG, and 98.6 (1.13 in Area-CG). FB-WMG had a median of 3 visits (P25 1 visit, P75 5 visits) in the first 6 months. Despite a more considerable decrease in the relative distance to the median BMI-for-age in FB-WMG children with 3+ visits after 6 months, the success obtained was not sustained at 12 months (DID FB-WMG vs Area-CG -0.34, 95% CI - 3.00 to 2.33%, FB-WMG vs Ref-CG -0.39, 95% CI - 3.14 to 2.35%). At 12 months, there was no statistical significant difference between the three groups (FB-WWG, Ref-CG, Area-CG). CONCLUSIONS: The initial success in weight management was not sustained in the absence of continued support for healthy lifestyle changes. Based on current evidence, continued support is necessary to maintain and promote success beyond a brief 6 month intervention. Long-term pediatric weight management programs are needed to promote continuing progress.

Targeted Secondary Screening for Congenital Hypothyroidism in High-Risk Neonates: A 9 Year Review in a Large California Health Care System.

Secondary screening for missed congenital hypothyroidism (CH) has been introduced sporadically, but its necessity and optimal strategy have not been recognized. We hypothesized that a simple clinical protocol (performed by a medical group without a governmental mandate) targeting infants at high risk for missed CH can identify cases. We performed a 9-year retrospective review of 338,478 neonates within a California health plan following the introduction of thyrotropin (TSH) secondary screening for neonates at high risk for missed CH due to very-low-birthweight (VLBW), hospitalized congenital heart disease (CHD), and same-sex multiples (SSM). Screening performance by day 60 of life was 95% successful for VLBW and >50% for CHD and SSM, leading to an additional 35% CH treated cases despite re-testing only 1.7% of the cohort. Infants with VLBW or CHD were 33 times more likely (190 times more likely for CHD with Down Syndrome) to receive treatment for CH than random infants diagnosed by primary screening (p < 0.001), and 92% of these infants were not found by primary newborn screening. Currently, permanent disease has been documented in 84% of CH by primary screening compared to 27% by secondary screening (p < 0.001). This targeted secondary screening program identifies and treats additional CH cases after TSH-only newborn screening.

Multistage Adolescent Depression Screening: A Comparison of 11-Year-Olds to 12-Year-Olds.

INTRODUCTION: Adolescent depression screening is recommended starting at age 12 years, but younger children experience depression as well. Our objective was to determine whether screening for depression at age 11 years yields similar results to screening at age 12 years. METHODS: We conducted a retrospective chart review of 1000 11- and 12-year-olds in multiple pediatric offices of a large-group practice associated with a health maintenance organization in Southern California. All offices used a multistage depression screening process during well-child visits using the Patient Health Questionnaire for Adolescents, the global depression inquiry within a parent questionnaire, a chart-based review of mental health history, and brief patient/parent interview informed by the first 3 elements. RESULTS: The 11- and 12-year-old cohorts had similar completion rates for the Patient Health Questionnaire for Adolescents (99.2% vs 97.8%, P = 0.06), with similar mean total Patient Health Questionnaire for Adolescents scores (2.12 vs 2.22, P = 0.48). There was no significant difference for positive screenings determined by the pediatrician (12.0% vs 16.0%, P = 0.07), but parents of 12-year-olds were more likely have concerns for their child's mood (6.8% vs 10.5%, P = 0.04). There were similar percentages of referrals (6.2% vs 8.8%, P = 0.12), beneficial conversations related to depression and anxiety, (4.5% vs 4.8%, P = 0.85), and new mental health diagnoses (2.0% vs 2.3%, P = 0.79). DISCUSSION: The process, results, and outcomes of screenings are similar for 11- and 12-year-olds, with a tendency toward more positive findings in 12-year-olds. CONCLUSION: Multistage depression screening in 11-year-olds can be applied successfully in clinical practice, with most cases identifying youths without a prior mental health diagnosis.

Effectiveness of a Family-Centered Pediatric Weight Management Program Integrated in Primary Care.

INTRODUCTION: The evidence supporting the effectiveness of weight loss interventions with low to medium intensity is limited. OBJECTIVE: To measure the effectiveness of a family-based weight management intervention in pediatric primary care to reduce body weight in children. METHODS: Electronic medical record data of pediatric patients in Kaiser Permanente Orange County, California, who were enrolled in weight management between April 2014 and December 2018 (family-based behavior-changing weight management [FB-WMG], n = 162) and compared with a control group (CG) of patients who were referred but did not enroll (Ref-CG, n = 203) and an area-matched CG also matched by sex, age, zip code, and body mass index (BMI) (Area-CG, n = 287). BMI was measured at the first visit (or index date) and after 6 months. RESULTS: Children enrolled in the FB-WMG had 5 (interquartile range = 3-6) sessions over the first 6 months of the program. Most FB-WMG patients (69.1%) reduced or maintained BMI over 6 months, compared with 45.8% of Ref-CG (p < 0.001) and 57.8% of Area-CG (p = 0.02). In girls 3 to 12 years of age, 75% of participants reduced or maintained BMI, compared with 42% of Ref-CG (p < 0.001) and 59.8% of Area-CG (p = 0.07). On average, the difference in BMI change over the 6-month follow-up period was -0.85 kg/m² (95% confidence interval = -1.25 to -0.46 kg/m²) compared with Ref-CG and -0.28 kg/m² (95% confidence interval = -0.63 to 0.08 kg/m²) and Area-CG. CONCLUSION: Low- to moderate-intensity family-based weight management intervention in primary care can be successful after only 6 months compared with a referred control group.