A primary care learning collaborative to improve office systems and clinical management of pediatric asthma.

OBJECTIVE: Pediatric asthma is a common, relapsing-remitting, chronic inflammatory airway disease that when uncontrolled often leads to substantial patient and health care system burden. Improving management of asthma in primary care can help patients stay well controlled. METHODS: The Vermont Child Health Improvement Program (VCHIP) developed a quality improvement (QI) learning collaborative with a primary objective to improve clinical asthma management measures through improvement in primary care office systems to support asthma care. Seven months of medical record review data were evaluated for improvements on eight clinical asthma management measures. Pre and post office systems inventory (OSI) self-assessments detailing adherence to improvement strategies were analyzed for improvement. Logistic regressions were used to test for associations between OSI strategy post scores and the corresponding clinical asthma management measures by month seven. RESULTS: This study found significant improvement from baseline to month seven on seven of the eight clinical asthma management measures and between pre and post OSI for seven of the nine strategies assessed (N = 19 practices). Additionally, one point higher average OSI scores on the assessment and monitoring of asthma severity, asthma control, asthma action plans, and asthma education strategies were associated with significantly greater odds of improvement in their respective clinical asthma management measures. CONCLUSIONS: A QI learning collaborative approach in primary care can improve office systems and corresponding clinical management measures for pediatric patients with asthma. This suggests that linking specific office systems strategies to clinical measures may be a helpful tactic within the learning collaborative model.

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.

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.

Head lice.

Head lice infestation is associated with limited morbidity but causes a high level of anxiety among parents of school-aged children. Since the 2002 clinical report on head lice was published by the American Academy of Pediatrics, patterns of resistance to products available over-the-counter and by prescription have changed, and additional mechanical means of removing head lice have been explored. This revised clinical report clarifies current diagnosis and treatment protocols and provides guidance for the management of children with head lice in the school setting.

Strength-based interviewing.

Health care for adolescents needs to include both assessment of risk and identification of strengths. Clinicians need practical ways to identify strengths, or assets, by using a proven framework. After eliciting the strengths, clinicians must be ready to help adolescents recognize and build on them. In addition, many will want to go the next step and use this strength-based approach with shared decision-making techniques, including motivational interviewing.

Inspiring healthy adolescent choices: a rationale for and guide to strength promotion in primary care.

The social, emotional, and biological health of adolescents requires their development as autonomous beings who make responsible decisions about their own health. Clinicians can assist in this development by adopting a strength-based approach to adolescent health care, which applies concepts from positive youth development to the medical office setting.

American Academy of Pediatrics guidelines for the prevention and treatment of head lice infestation.

The American Academy of Pediatrics (AAP) established diagnosis and treatment guidelines for pediculosis in 2002. Ideally, diagnosis should be based on the observation of a live louse. The presence of nits is also used by many people to positively diagnose an infestation, although a nit located farther from the scalp than 1 cm is unlikely to be viable. Other material on the scalp may be mistaken for nits, leading to misdiagnosis. Because lice are not associated with serious medical problems, the primary consideration of the AAP regarding treatment is the safety of pediculicides and other products used to treat head lice. From a pediatrician's perspective, no significant risk is acceptable. Over-the-counter (OTC) pyrethroid products (pyrethrin and permethrin) are commonly used by parents to treat their children and are generally considered safe for most people. Pyrethroids are not completely ovicidal, however, so a second application is required. Misuse and overuse of these products have contributed to the development of resistance. Prescription products include permethrin 5%, lindane, and malathion 0.5%. Resistance to permethrin 5% and lindane has been documented. In addition, lindane is associated with serious adverse events and should be used with caution only in a select population. Malathion 0.5% is about 98% ovicidal, and no resistance has been reported. Malathion is highly effective, but AAP guidelines note that the product is flammable and serious adverse effects can occur with ingestion. Very few cases of ingestion have occurred, and no reported cases of flammability, but children being treated with malathion should be carefully supervised, and this pediculicide should not be used unless treatment with OTC products has failed. AAP guidelines also state that no-nit policies in schools are detrimental, causing lost time in the classroom, inappropriate allocation of the school nurse's time for lice screening, and a response to infestations that is out of proportion to their medical significance. Accurate diagnosis, safe treatment options, and a common-sense approach to managing infestations in schools are recommended.

Sexual orientation and adolescents.

The American Academy of Pediatrics issued its first statement on homosexuality and adolescents in 1983, with a revision in 1993. This report reflects the growing understanding of youth of differing sexual orientations. Young people are recognizing their sexual orientation earlier than in the past, making this a topic of importance to pediatricians. Pediatricians should be aware that some youths in their care may have concerns about their sexual orientation or that of siblings, friends, parents, relatives, or others. Health care professionals should provide factual, current, nonjudgmental information in a confidential manner. All youths, including those who know or wonder whether they are not heterosexual, may seek information from physicians about sexual orientation, sexually transmitted diseases, substance abuse, or various psychosocial difficulties. The pediatrician should be attentive to various potential psychosocial difficulties, offer counseling or refer for counseling when necessary and ensure that every sexually active youth receives a thorough medical history, physical examination, immunizations, appropriate laboratory tests, and counseling about sexually transmitted diseases (including human immunodeficiency virus infection) and appropriate treatment if necessary. Not all pediatricians may feel able to provide the type of care described in this report. Any pediatrician who is unable to care for and counsel nonheterosexual youth should refer these patients to an appropriate colleague.

Sexual orientation of adolescent girls.

It is important for healthcare providers to have a clear understanding of sexual orientation and other components of sexual identity (genetic gender, anatomic gender, gender identity, gender role, and sexual behavior). Knowledge of how a lesbian identity is formed will aide providers in guiding these girls through adolescence. Societal stigma often forces isolation that leads to many risky behaviors that affect health (alcohol and drug use; risky sexual behaviors; truancy and dropping out; running away and homelessness; and depression and suicide). Health providers need to ensure a safe and understanding environment for these girls, to enhance their physical, emotional, and social development to healthy adulthood.

Head lice.

Head lice infestation is associated with little morbidity but causes a high level of anxiety among parents of school-aged children. This statement attempts to clarify issues of diagnosis and treatment of head lice and makes recommendations for dealing with head lice in the school setting.