A Novel Approach to Well-Child Visits for Latino Children under Two Years of Age.

Latinos are the fastest-growing ethnic minority group in the U.S. We propose a culturally-relevant group well-child care model for Latino families with children under two, implemented in an urban academic center with Medicaid-insured patients. Twenty-five families completed an average of 7.2 group visits of nine recommended well-childchecks.

Improving Documentation Timeliness: A "Brighter Future" for the Electronic Medical Record in Resident Clinics.

PROBLEM: Electronic medical records have many observed benefits but may cause work disruption, resulting in delayed documentation completion. The purpose of this project was to improve compliance with institutional standards of documentation of well child checks for residents and attendings without increasing stress. APPROACH: This project was completed at Children's Hospital Primary Care Clinic at Vanderbilt, which is staffed by 74 residents, supervised by 17 attendings. A longitudinal observational study using convenience sampling for the last full week of each month from October 2010-January 2012 was planned. Baseline documentation completion rates were assessed, then age-specific, structured data-entry forms were introduced beginning in March 2011. Run charts were created for completion data for all clinic visits in the sample. Physician self-report of satisfaction with and stress related to documentation was assessed through pre- and postintervention surveys. OUTCOMES: Data were derived for an average of 231 patient visits per month. The median percentage of documentation or attestations completed within the institutional standards increased from 54.7% to 78.9% for residents and from 38.2% to 83.5% for attendings. Physicians reporting high satisfaction with documentation increased from 20.5% to 85.7% (P < .01) for residents and from 11.1% to 76.9% (P < .01) for attendings. Residents reporting high stress with documentation decreased from 59.1% to 28.6% (P < .02). NEXT STEPS: Use of age-specific, structured data-entry forms achieved marked improvement in documentation timeliness, but there is still room for improvement. The authors are now teaching computer-based documentation in exam rooms and instituting accountability measures.

Missed opportunities for tuberculosis screening in primary care.

OBJECTIVE: To assess how frequently pediatric practitioners perform latent tuberculosis infection (LTBI) screening according to guidelines. We hypothesized that screening occurs less frequently among children whose parents do not speak English as the primary language. STUDY DESIGN: We conducted a retrospective cohort study of patients attending well-child visits in an urban academic pediatric primary care clinic between April 1, 2012, and March 31, 2013. We assessed documentation of 3 LTBI screening components and tested the association between parent primary language and tuberculin skin test (TST) placement and documentation of results. RESULTS: During the study period, 387 of 9143 children (4%) had no documentation of screening question responses. Among the other 8756 children, 831 (10%) were identified as at high risk for LTBI. Of these, 514 (62%) did not have documented TST placement in the appropriate time frame. Thirty-nine of 213 children (18%) who had a TST placed did not have documented results. Multivariable regression showed that parent language was not associated with TST placement or documentation of results, but non-Hispanic Black children were more likely to not have a documented test result (aOR, 2.12; 95% CI, 1.07-4.19; P=.03) when adjusting for age, sex, parent primary language, insurance status, day of the week, and study year of TST placement. CONCLUSION: Parent primary language was not associated with LTBI testing. However, we found substantial gaps in TST placement and documentation of TST results among high-risk children, the latter of which was associated with race/ethnicity. Targeted quality improvement efforts should focus on developing processes to ensure complete screening in high-risk children.

Strategies to identify and stratify children with special health care needs in outpatient general pediatrics settings.

Developing improved systems of care for children with special health care needs (CSHCN) requires accurate identification and stratification of this population. This study was designed to assess the ability of a brief screener to identify and stratify CSHCN in a primary care clinic to focus future quality improvement initiatives and allocate resources. All families presenting for health maintenance visits or acute care appointments at an academic primary care clinic between September 5, 2012 and September 28, 2012 were asked to complete the CSHCN Screener(©). This panel of patients was compared to registries previously created by: (1) retrospective chart reviews using published lists of International Statistical Classification of Diseases and Related Health Problems (ICD9) codes for CSHCN and (2) direct physician referral to a clinic case manager providing care coordination services to CSHCN. Screeners identified 246 CSHCN (16.8 % of unique completed screeners). Scores ranged from 0 to 5; higher scores indicate higher levels of complexity. Patients with positive screens had a mean score of 2.4. Patients previously identified by retrospective ICD9 search who completed a screener had a mean score of 1.6 with nearly one-half having negative screens. Patients previously identified by physician referral who completed a screener had a mean score of 2.7 with nearly one-half having scores of 4 or 5. The CSHCN Screener(©) can be utilized in an academic primary care clinic to prospectively identify CSHCN and potentially offers a more clinically meaningful method of identification given its inherent ability to stratify this population based on complexity of medical needs.

A reappraisal of adult abdominal surface anatomy.

Descriptions of clinically important surface landmarks often vary between and within contemporary anatomical texts. The aim of this study was to investigate the surface anatomy of major abdominal vessels, kidneys, spleen, gastroesophageal junction, and duodenojejunal flexure in living adults using computed tomography (CT). After excluding patients with distorting space-occupying lesions, scoliosis, abnormal lordosis, and obvious visceromegaly, 108 abdominal CT scans of supine adults (mean age 60 years, range 18-97 years; 64 female) at end tidal inspiration were available for analysis by dual consensus reporting. Intra-observer agreement was assessed by repeat blind assessment of a random sample of scans. The vertebral level of the aortic bifurcation and almost all of its major branches, and the origin of the inferior vena cava were consistent with current descriptions. Important differences from contemporary descriptions of surface anatomy were as follows: the renal arteries were most commonly at the L1 vertebral level (left 55%, right 43%); the midpoint of the renal hila was most frequently at L2 (left 68%, right 40%); the 11th rib was a posterior relation of the left kidney in only 28% of scans; and the spleen was most frequently located between the 10th and 12th ribs (48%) with its long axis in line with the 11th rib (55%). Although the majority of vascular surface landmarks are consistent with standard descriptions, the surface anatomy of the kidneys, renal arteries, and spleen needs to be revised in accordance with observations using modern imaging techniques in vivo.

Vocational assessment: a review of the literature from an occupation-based perspective.

The vast majority of the currently available vocational assessments are used to measure a worker's physical body functions and/or work capacity, while very few, if any, can be utilized to measure actual work performance. Within this research project, the authors conducted a brief review of the literature and synthesized the existing evidence related to some of the key vocational assessments that are utilized by occupational therapists. It was found that the current "gold standard" of vocational assessment is the Functional Capacity Evaluation, yet the evidence does not fully support its reliability and validity in determining an employee's ability to safely return to work. Alternative assessment options were explored, emphasizing the utilization of occupation-focused, performance-based assessment strategies. It is concluded that occupational therapists need to take action to develop and promote the use of performance-based measures of actual work ability. Occupational therapists must capitalize on their unique strengths of evaluating occupational performance and take the lead to develop standardized means of assessing, measuring, and predicting work performance and work status.