Home-Based Telemedicine in Rheumatology-A Scoping Review.

OBJECTIVE: We performed a scoping review of the relevant literature on home-based telehealth in rheumatology to understand its appropriate application in rheumatology practice. METHODS: We searched the Cochrane Library, PubMed, Web of Science, and scientific meeting abstracts to identify articles that specifically addressed telehealth suitability, barriers to telehealth, patient-reported outcomes (PROs) collected in telehealth settings, and telehealth satisfaction. From the initial search of 4,882 studies, 23 reports were included. In addition, 10 abstracts were also eligible for analysis, resulting in a total of 33 articles: 2 randomized clinical trials, 9 prospective cohort studies, and 22 retrospective studies. RESULTS: We found that triage appointments or predictive models could be helpful in selecting patients for telehealth and that telehealth interventions were appropriate for follow-up of patients with systemic lupus erythematosus and inflammatory arthritis, but that conducting new patient visits over telehealth was not ideal. Barriers to telehealth include patient factors (age, technology access) and need for physician/process factors (eg, physical examinations). PROs collected in regular practice can be incorporated into telehealth. Several small, single-center studies suggest that telehealth does not lead to negative outcomes compared with in-person visits, and overall, patients report high patient satisfaction with telehealth. In several scenarios, home-based telehealth was equivalent to in-person visits with regard to patient outcomes and satisfaction. CONCLUSION: The widespread potential of telehealth to manage and deliver care for people with rheumatic disease is significant. As such, further research in the form of randomized controlled trials can help contribute to growing evidence that shapes telehealth implementation for patients with rheumatic diseases.

Profiles of Autistic Youth with and Without Co-occurring Behavioral Health and Neurodevelopmental Disorders: A Latent Class Analysis.

OBJECTIVE: Autism spectrum disorder (ASD) diagnosis relies on clinical observation and documentation, but the presence of comorbidities can affect diagnostic validity across clinicians and exacerbate access to timely care. This study used latent class analysis to optimize subgroup identification based on functional level and associated comorbidities using the Behavior Assessment System for Children, Third Edition (BASC-3), and Vineland Adaptive Behavior Scales, Third Edition (Vineland-3), in a pediatric population referred for autism evaluation. METHODS: This retrospective study reviewed clinical data extracted over a 3-year period (2018-2021). A latent class analysis was used to explore the presence of latent groups guided by the likelihood ratio test and fit indices. Additional analyses contrasted ASD and non-ASD groups on the BASC-3 and Vineland-3 variables. RESULTS: There were 191 included participants (mean age 65.9 months, 76.4% male), of whom over half (60.7%) had an ASD diagnosis. Using 185 cases, the exploratory latent class analysis showed the emergence of 4 distinct subgroups. Composition of classes varied on ASD diagnosis, neurodevelopmental difficulties, behavioral health concerns, and intellectual disability. When contrasting ASD and non-ASD groups, significant between-group differences were observed across Vineland-3 variables and BASC-3 adaptive skills subscales indicating poorer social and adaptive functioning. CONCLUSION: Latent class analysis of commonly used behavioral and adaptive measures can help distinguish between subgroups of pediatric patients referred for ASD evaluations and assist in triage of cases based on severity.

Family Medicine Residency Program Directors' Perception of Curricular Elements Related to Autism: A CERA Study.

BACKGROUND AND OBJECTIVES: The family medicine (FM) approach to health care across the life span is well-suited to providing care for persons living with autism spectrum disorder (ASD). Little is known about ASD curricula in FM residency training and the characteristics of FM residency programs that prepare their residents to care for persons with this disorder. METHODS: Our study questions were part of a larger omnibus survey by the Council of Academic Family Medicine Educational Research Alliance (CERA) with data collection from November 16 to December 18, 2022, from FM residency program directors (PDs). ASD curricula were investigated using 10 questions, with descriptive analyses and nonparametric comparisons between program variables and ASD curriculum. RESULTS: The response rate was 42.18%, with FM PDs reporting that their programs were preparing residents in the care of youth (71.53%) and adults (68.33%) with ASD, but to a lesser extent (58.89%) in facilitating transitions of care. Programs with faculty champions, access to published curricula, sufficient patients with ASD, and engagement of interprofessional faculty reported a higher proportion of resident preparedness. PDs of community-based programs were most confident in their ability to teach ASD care and transitions of care. CONCLUSIONS: Most FM PDs modestly agreed that they are preparing residents to provide care to patients with ASD and their families. PDs of programs with greater access to resources (ie, published curriculum, faculty champions, sufficient patients with ASD, interprofessional faculty experts) believed that their residents were more prepared. Community-based FM educators may help lead the way in providing models for care and education in this regard.

The ethical perspectives of using animals in pediatric health.

While there are ethical standards for human biomedical research, animals have historically not benefitted from the same levels of protection. Cultural shifts in response to studies demonstrating animal capacity to suffer have resulted in laws defining minimum ethical standards for the treatment of various animal populations. However, none of these pertain to service or therapy animals nor do they define ethical considerations regarding training, placement, environment, and duty limitations specific to this population. The potential for harm and inability to provide consent should raise ethical questions of animal assisted interventions (AAI), including how to best balance the risk: benefit ratio for both animal and human participants. While service animals have specific definitions, therapy and emotional support animals are much less clearly defined and therefore have far less standardized practices regarding their training, certification, and process for matching to handlers. This can lead to animals being inadequately trained to cope with the stresses of their jobs or being placed in incompatible environments. Meanwhile, service animals' duties are constant, and the animal has little ability to consent to or withdraw from participation, leading to overwork, without the opportunity to engage in activities that align with the animals' natural preferences. Emotional support animals are the least defined of these populations, receive no formal training, and are at increased risk of inadequate care, unstable housing, and abuse from handlers who may also be poorly prepared to properly handle their needs. To uphold our moral obligations to the animals that serve to improve our own mental wellness and physical independence, urgent actions are needed to improve the protections in place for these populations.

Extracting Data from the Electronic Health Record of Patients with ADHD Reveals Pediatricians' Discussions of Educational Support and Document Collection.

Primary care physicians (PCPs) have an important role in the identification and management of Attention Deficit Hyperactivity Disorder (ADHD). There is a paucity of research on PCPs' practices related to the discussion of educational interventions. We conducted a retrospective chart review using Natural Language Processing to extract data on how often PCPs in an outpatient clinic: 1) discuss educational support with patients and caregivers; and 2) obtain educational records. About three-quarters of patients had at least one term related to educational support included in at least one note, but only 13 percent of patients had at least one educational record uploaded into the electronic health record (EHR). There was no association between having an educational document uploaded into the EHR and inclusion of a term related to educational support in a note. Almost half (48 percent) of these records were unclearly labeled. Further education of PCPs is warranted to increase discussions of educational support and obtaining educational records, as is collaboration with health information management professionals around labeling.

Personal Financial Well-being of Family Medicine Residents and Residency Curricula: A CERA Study.

Introduction: Personal financial wellness is a milestone in graduate medical education. Prior surveys addressing financial wellness have not included family medicine (FM) residents and to date, no literature has explored the relationship between perceived financial well-being and personal finance curriculum in residency. Our study aimed to measure the financial well-being of residents and its association with the delivery of financial curricula in residency and other demographics. Methods: Our survey was included in the Council of Academic Family Medicine Educational Research Alliance (CERA) omnibus survey sent to 5,000 FM residents. We use the Consumer Financial Protection Bureau (CFPB) financial well-being guide and scale to measure financial well-being and categorize into low, medium, and high ranges. Results: Two hundred sixty-six residents (response rate of 5.32%) responded with a mean financial well-being score of 55.7 (SD 12.1), in the medium score range. Financial well-being was positively associated with any form of personal financial curricula in residency, year in residency, income and citizenship. Most residents 204 (79.1%) agreed/strongly agreed that personal financial curricula are important to their education, and 53 (20.7%) never received personal financial curricula. Conclusions: Personal financial well-being scores of family medicine residents are considered medium per the CFPB ranges we assigned. We find a positive and significant association with the presence of personal financial curricula in residency. Future studies should evaluate the effectiveness of different formats of personal finance curriculum in residency on financial well-being.

Autism Spectrum Disorder, Extremism, and the Role of Developmental-Behavioral Pediatric Clinicians.

ABSTRACT: Extremism is a global phenomenon, with an increasing domestic and international presence. Extremists recruit persons to their causes through online forums that spread hate-filled narratives and promote violence. Individuals with autism spectrum disorder may be vulnerable to recruitment through these online forums, and clinicians who work with autistic adolescents, young adults, and their families should familiarize themselves with the risk and identify strategies based on a multidisciplinary approach in the early identification, holistic prevention, and care-based intervention strategies of at-risk adolescents. This special article, representing an international collaboration between developmental-behavioral pediatrics, law enforcement, and psychology, hopes to shed light on the issue for clinicians.

Taste Perceptions of Common Pediatric Antibiotic Suspensions and Associated Prescribing Patterns in Medical Residents.

OBJECTIVE: Palatability of medication is an important factor for adherence, especially in pediatric populations that tend to use oral suspensions for antibiotic therapy. Our study is the first to evaluate the impact of taste on prescribing patterns of antibiotic suspensions. The objective was to determine if taste testing common antibiotic suspensions altered prescribing patterns of medical residents, through data extracted from the electronic health record. METHODS: After assessing 5 "primer" tastes (sweet, salty, bitter, sour, umami [savory]), residents were randomized to sample 6 antibiotic suspensions to rate their taste perception. A 12-month retrospective and prospective analysis of outpatient prescribing practices of the residents followed, and the results were compared to the resident cohort randomized to no taste test. RESULTS: The 43 residents prescribed 207 liquid antibiotic prescriptions for 176 patients, with no difference in patient characteristics between residents in the taste test versus non-taste test group. Although amoxicillin was most preferable and amoxicillin-clavulanate least, the only significant finding was a greater prescribing rate of cefdinir among those who had tasted it and an inverse relationship between cephalexin taste preference and percentage prescribing amoxicillin in the taste group. Residents who tasted were poor in identifying primer tastes, but this did not impact prescribing patterns. CONCLUSIONS: Among 6 commonly prescribed antibiotic suspensions, amoxicillin remains a highly preferred taste among prescribers. Interestingly, after the taste test there was a significantly greater prescribing rate of cefdinir among those who had tasted it and somewhat lower prescribing rate for amoxicillin-clavulanate.

OpenNotes: Anticipatory Guidance and Ethical Considerations for Pediatric Psychologists in Interprofessional Settings.

OBJECTIVES: The 21st Century Cures Act included an "OpenNotes" mandate to foster transparent communication among patients, families, and clinicians by offering rapid electronic access to clinical notes. This article seeks to address concerns about increased documentation burden, vulnerability to patient complaints, and other unforeseen consequences of patients having near-real-time access to their records. METHODS: This topical review explores both extant literature, and case examples from the authors' direct experience, about potential responses/reactions to OpenNotes. RESULTS: The ethics of disclosing medical information calls for nuanced approaches: Although too little access can undermine a patient's autonomy and the capacity for truly egalitarian shared decision-making, unfettered access to all medical information has significant potential to harm them. Suggested strategies for mitigating risks in premature disclosure include patient and provider education and "modularizing" sensitive information in notes. CONCLUSION: The OpenNotes era has ushered in the possibilities of greater patient and family collaboration in shared decision-making and reduced barriers to documentation sharing. However, it has raised new ethical and clinician documentation considerations. In addition to clinician education, patients and families could benefit from education around the purpose of clinical documentation, how to utilize OpenNotes, and the benefits of engaging in dialogue regarding the content and tone of documentation.

Global Trends in Telehealth Among Clinicians in Developmental-Behavioral Pediatric Practice: A COVID-19 Snapshot.

OBJECTIVE: This study aims to describe the extent of telehealth use by global developmental-behavioral pediatrics (DBP) clinicians and barriers (if any) in adopting telehealth during the coronavirus disease 2019 (COVID-19) pandemic. METHODS: A survey was disseminated to DBP clinicians through contact with international professional organizations to determine the use of telehealth in DBP care, before and since the beginning of the COVID-19 pandemic. Descriptive statistics and χ2 tests were used for analysis. RESULTS: A total of 271 respondents from 38 countries completed the survey. The number of respondents offering telehealth increased from 36% to 88% after the pandemic, with the greatest shift to telehealth among high-income countries (HICs). Among respondents using telehealth, 75.1% were conducting interactive video visits, with HICs using more telehealth modalities embedded in electronic health records. Most patients (98.7%) were at home for the telehealth encounter. Almost half (46.5%) could not include an interpreter in telehealth visits. Barriers reported by telehealth users included concerns about limited patient access to technology (74.3%), home environment distractions (56.5%), preference for in-person care (53.6%), telehealth effectiveness (48.1%), workflow efficiency (42.2%), and cost/reimbursement (32.1%). CONCLUSION: Global DBP clinicians rapidly adopted telehealth and continued to have interprofessional practice while doing so, with the largest adoption occurring in HICs. Provider concerns about effectiveness and patient access to technology emerged as key organizational and patient barriers, respectively. Increased provider confidence in telehealth and its sustained use in the future depends on supportive regulatory policies and availability and use of measures to monitor quality and effectiveness.

Society for Developmental & Behavioral Pediatrics Position Statement on Telehealth.

ABSTRACT: Telehealth has long held promise as a way to increase access to subspecialty care for children and families, including in developmental and behavioral pediatrics (DBP). The coronavirus disease 2019 (COVID-19) pandemic necessitated rapid uptake of telehealth to continue care delivery that was facilitated by "temporary" policy changes related to the pandemic. As a result, the field of DBP has recognized telehealth as a potential model of care for performing home-based diagnostic assessments, providing medication management follow-up, and delivering therapeutic interventions for children with neurodevelopmental disorders. Telehealth has been helpful in mitigating barriers families often face when attending in-person visits (lack of transportation and child care, missed work hours, etc) but has also highlighted additional determinants of health that need to be addressed to provide equitable access to care (broadband connectivity, device access, digital literacy, access to interpretation and sign language services, etc). Anticipating the lifting of pandemic-related emergency declaration and expiration of temporary policies around telehealth, the ability to continue to deliver DBP care by telehealth is uncertain. The purpose of this policy statement is to advocate for legislation and policies that support ongoing, equitable, home-based telehealth care for patients seen by DBP providers while ensuring equitable access to DBP in general. In addition, there is a need to recognize the benefits and challenges of telehealth versus in-person care and to identify clinical scenarios that favor 1 model of care versus the other.

Assessment of Agreement Between Human Ratings and Lexicon-Based Sentiment Ratings of Open-Ended Responses on a Behavioral Rating Scale.

To date, there is a paucity of research conducting natural language processing (NLP) on the open-ended responses of behavior rating scales. Using three NLP lexicons for sentiment analysis of the open-ended responses of the Behavior Assessment System for Children-Third Edition, the researchers discovered a moderately positive correlation between the human composite rating and the sentiment score using each of the lexicons for strengths comments and a slightly positive correlation for the concerns comments made by guardians and teachers. In addition, the researchers found that as the word count increased for open-ended responses regarding the child's strengths, there was a greater positive sentiment rating. Conversely, as word count increased for open-ended responses regarding child concerns, the human raters scored comments more negatively. The authors offer a proof-of-concept to use NLP-based sentiment analysis of open-ended comments to complement other data for clinical decision making.

Low Rates of Clinician Monitoring for Second Generation Antipsychotic Medications in Community Pediatric Practice.

Second generation antipsychotic (SGA) medications are frequently prescribed to pediatric patients in the United States. This retrospective observational study sought to ascertain the extent of adherence to established pediatric SGA monitoring guidelines in community practice. The team used the electronic health record to determine clinician adherence to SGA monitoring guidelines at baseline, 12-week, and annual times relative to prescribing an SGA. At the time of their SGA prescription, 5.5% of pediatric patients had received all of the orders according to the monitoring guidelines. Annually, 2.5% of patients had received the necessary orders to completely adhere to monitoring guidelines; 42% of patients received no monitoring orders. Monitoring was more likely for children who had multiple types of providers and interacted with the healthcare system beyond a traditional office visit. This research informs healthcare providers about the gap between prescribing and monitoring for SGA medications in community practice for pediatric populations.

Most Second-Generation Antipsychotic Prescriptions in Community Practice Are Neither FDA-Approved nor Within Prescribing Guideline Recommendations.

OBJECTIVE: Second-generation antipsychotic (SGA) prescription use has become increasingly prevalent in the pediatric population, despite metabolic adverse effects. A significant number of SGA medications are prescribed for indications that are not approved by the FDA. This study aimed to quantify clinician adherence to the FDA and professional society indication, age, and dosing guidelines when prescribing SGA medications for pediatric patients. METHODS: We used electronic health record data from 3 health care systems. We analyzed outpatient encounters where a pediatric patient was prescribed an SGA during an 18-month time frame. Clinician prescribing patterns were compared to a therapeutic regimen table created using professional society guidelines and FDA medication labels. RESULTS: Most of the encounters listed an indication that was not documented as a recommended use (84.3%). Most prescriptions aligned with the generalized dose guidelines (93.8%) and age guidelines (94.9%). Clinicians were more likely to follow indication guidelines when prescribing risperidone, the highest adherence medication, compared with quetiapine, the lowest adherence medication (odds ratio [OR], 2.5; 95% CI, 1.1-6.0). Compared with prescriptions for younger children, clinicians were more likely to follow indication guidelines for children aged 13 to 15 years (OR, 2.8; 95% CI, 1.1-7.2) and 16 to 18 years (OR, 3.1; 95% CI, 1.2-8.1). CONCLUSION: Community clinicians overall demonstrated a low level of adherence to indication guidelines when prescribing SGA medications to pediatric populations, while maintaining higher adherence to age and dosing guidelines. Older children were more likely to receive an SGA prescription for recommended indications compared with younger children.

Need for Integrated Behavior Health Model in Primary Care.

Children and adolescents with clinically concerning behavioral health conditions face several barriers to accessing specialized mental health care. One proposed solution is to improve and expand integrated care provided in the primary health care provider's office. Several strategies can increase pediatrician comfort and willingness to collaborate in diagnosing and treating behavioral health conditions, and increased utilization of new technologies (such as telehealth) are likely to play an increasingly important role in the process.

The Many Roles of Pediatric Integrated Behavioral Health Specialists.

The primary care pediatric setting is intended to provide continuous and comprehensive care throughout a child's life, ensuring overall well-being. Routinely scheduled well-child visits are ideal to assess developmental progress, environmental health, behavior/psychosocial issues, and other concerns. Delivering integrated behavioral health (IBH) in the primary care setting may aid in identifying any early concerns or difficulties and provides resources and support when these issues first emerge; thus, promoting the child's well-being. IBH should be engaged early and often to establish a relationship with families and follow them as the child develops, regardless of the presence of a precipitating behavior concern.

An Interdisciplinary Approach to Reducing Errors in Extracted Electronic Health Record Data for Research.

Erroneous electronic health record (EHR) data capture is a barrier to preserving data integrity. We assessed the impact of an interdisciplinary process in minimizing EHR data loss from prescription orders. We implemented a three-step approach to reduce data loss due to missing medication doses: Step 1-A data analyst updated the request code to optimize data capture; Step 2-A pharmacist and physician identified variations in EHR prescription workflows; and Step 3-The clinician team determined daily doses for patients with multiple prescriptions in the same encounter. The initial report contained 1421 prescriptions, with 377 (26.5 percent) missing dosages. Missing dosages reduced to 361 (26.3 percent) prescriptions following Step 1, and twenty-three (1.7 percent) records after Step 2. After Step 3, 1210 prescriptions remained, including 16 (1.3 percent) prescriptions missing doses. Prescription data is susceptible to missing values due to multiple data capture workflows. Our approach minimized data loss, improving its validity in retrospective research.