Incorporation of patient and family values and preferences for health-related outcomes in paediatric obesity management: A systematic review.

OBJECTIVE: A systematic review of value and preference studies conducted in children and their caregivers related to the estimated benefits and harms of interventions for managing paediatric obesity. METHODS: We searched Ovid Medline (1946-2022), Ovid Embase (1974-2022), EBSCO CINAHL (inception to 2022), Elsevier Scopus (inception to 2022), and ProQuest Dissertations & Theses (inception to 2022). Reports were eligible if they included: behavioural and psychological, pharmacological, or surgical interventions; participants between (or had a mean age within) 0-18 years old with overweight or obesity; systematic reviews, primary quantitative, qualitative, or mixed/multiple methods studies; and values and preferences as main study outcomes. At least two team members independently screened studies, abstracted data, and appraised study quality. RESULTS: Our search yielded 11 010 reports; eight met the inclusion criteria. One study directly assessed values and preferences based on hypothetical pharmacological treatment for hyperphagia in individuals with Prader-Willi Syndrome. Although not having reported on values and preferences using our a priori definitions, the remaining seven qualitative studies (n = 6 surgical; n = 1 pharmacological) explored general beliefs, attitudes, and perceptions about surgical and pharmacological interventions. No studies pertained to behavioural and psychological interventions. CONCLUSION: Future research is needed to elicit the values and preferences of children and caregivers using the best available estimates of the benefits and harms for pharmacological, surgical, and behavioural and psychological interventions.

Updating the Canadian clinical practice guideline for managing pediatric obesity: a protocol.

BACKGROUND: Since the first national guideline for managing obesity in adults and children in Canada was published in 2007, new evidence has emerged and guideline standards have evolved. Our purpose is to describe the protocol used to update the Canadian clinical practice guideline for managing pediatric obesity. METHODS: This guideline will update the pediatric components of the 2007 Canadian clinical practice guideline for the management of obesity. In partnership with Obesity Canada, we began preliminary work in 2019; activities are scheduled for completion in 2022. The guideline will follow standards developed by the National Academy of Medicine and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group. Guideline development will be informed by 5 complementary literature reviews: a scoping review that focuses on clinical assessment in pediatric obesity management and 4 systematic reviews to synthesize evidence regarding families' values and preferences as well as the safety and effectiveness of interventions (psychological and behavioural; pharmacotherapeutic; and surgical). We will use standard systematic review methodology, including summarizing and assessing the certainty of evidence and determining the strength of recommendations. Competing interests will be managed proactively according to recommendations from the Guidelines International Network. Diverse stakeholders, including families and clinicians, will be engaged throughout guideline development. INTERPRETATION: The guideline will support Canadian families and clinicians to make informed, value-sensitive and evidence-based clinical decisions related to managing pediatric obesity. The guideline and accompanying resources for end-users will be published in English and French, and we will partner with Obesity Canada to optimize dissemination using integrated and end-of-project knowledge translation.

Welcoming Feedback: Using Family Experience to Design a Pediatric Weight Management Program.

OBJECTIVE: To describe an approach using principles of experience-based codesign (EBCD) and quality improvement (QI) to integrate family experience into the development of a pediatric weight management program. METHODS: Clinic development occurred in 3 plan, do, study, act (PDSA) cycles that were driven by family experience data. During these cycles, families were engaged in feedback sessions that informed program development. Staff reflected on feedback and designed and tested changes that would improve service delivery. RESULTS: The first PDSA cycle resulted in the fundamental program parameters and a formalized patient engagement strategy. The second cycle focused on pilot programming, and feedback was used to develop the structured group program. During the third cycle, feedback sessions were embedded into the structured group programs. Program changes included focusing on health rather than weight-based outcomes, adjusting the timing of program offerings, increasing experiential learning opportunities, and providing more opportunities for peer support. CONCLUSIONS: Both EBCD and QI methodologies informed the process of family engagement and program development. This pragmatic approach might be useful for the development of other family-centered pediatric programs.

Risk Factors for Fractures in Children Hospitalized in Intensive and Intermediate Care Units.

BACKGROUND AND OBJECTIVES: Fragility fractures are increasingly recognized in hospitalized children. Our study aim was to identify risk factors for fracture in children hospitalized in intensive and intermediate care units. METHODS: We conducted a retrospective, case-control study comparing the clinical characteristics of children with fractures (cases) to children without fractures (controls) matched for age, sex, hospital unit, admission quarter and year, ICU length of stay, severity of illness, and resource utilization. Bivariate comparisons and matched multivariable logistic regression modeling were used to determine associations between potential risk factors and fracture. RESULTS: Median age at fracture for the 35 patients was 5.0 months (interquartile range 2.0 to 10.0 months) and at a comparable interval for the 70 matched controls was 3.5 months (interquartile range 2.0 to 7.0 months). In bivariate analyses, factors associated with fracture included: primary diagnosis of tracheoesophageal fistula, esophageal atresia and stenosis; diagnosis of kidney disease; and per 5-day increase in median cumulative ICU days at risk. In the final model, a respiratory disease diagnosis (odds ratio 3.9, 95% confidence interval 1.1-13.7) and per 5-day increase in median cumulative ICU days at risk (odds ratio 1.3, 95% confidence interval 1.0-1.6) were significant independent risk factors for fracture. CONCLUSIONS: Children prone to fracture in the hospital are young, medically complex patients who require extended periods of intensive level medical care and potentially life-sustaining treatment modalities. The children who would benefit most from fracture reduction efforts are those with respiratory disease and prolonged ICU stays.

Enhancing Patient Safety in Pediatric Primary Care: Implementing a Patient Safety Curriculum.

OBJECTIVE: We developed and implemented a patient safety (PS) curriculum targeted at clinicians and nonclinical office practice staff within a large primary care pediatric network. METHODS: Curricular content was informed by medical literature, local PS experts, and malpractice claims data. Sessions were centered on illustrative closed malpractice cases or informed by identified safety events. Participants provided subjective responses to the postsession evaluations. RESULTS: Invited participants from 12 practices included both clinical and nonclinical practice staff (up to 24 attendees per session). Participants reported that they were confident in their knowledge and skills. Several participants engaged in improvement projects that included active surveillance of high-risk patients, improvements in referral and test result management processes, and the distribution of patient educational materials. CONCLUSIONS: We successfully developed and implemented a multifaceted PS curriculum for pediatric providers. Participants enjoyed the sessions and several engaged in new PS projects as a result of the program.

The Burden of Psychosocial Stressors and Urgent Mental Health Problems in a Pediatric Weight Management Program.

OBJECTIVE: To systematically screen for behavioral and mental health problems and psychosocial stressors (PS) in newly referred patients and adult caregivers (PACs) in a pediatric weight management program. METHODS: We used the Strengths and Difficulties Questionnaire (SDQ), the Center for Epidemiologic Studies Depression Scale (CES-D) for caregivers and patients ≥18 years, and assessed urgent mental health concerns and psychosocial stressors. RESULTS: A total of 243 PACs were screened; data were unavailable for 6. Compared with US normative data for the SDQ-Parent Proxy Version, the proportion of patients in our sample with borderline/abnormal total difficulties and conduct problems scores was greater for all age groups. Among adult caregivers with complete CES-D, 18.4% were at risk for depression. Eleven percent of patients screened positive for urgent mental health problems. Overall, 43% of patients and 57.4% of caregivers had PS. CONCLUSIONS: Systematic screening identified untreated symptoms and significant PS. Addressing these complex problems likely requires collaborative approaches with community providers.

Trainee and program director perceptions of quality improvement and patient safety education: preparing for the next accreditation system.

OBJECTIVE: To assess the current state of quality improvement and patient safety (QIPS) education at a large teaching hospital. METHODS: We surveyed 429 trainees (138 residents, 291 clinical fellows) and 38 program directors (PDs; 2 were PDs of >1 program) from 39 Accreditation Council for Graduate Medical Education-accredited training programs. RESULTS: Twenty-nine PDs (76.3%) and 259 trainees (60.3%) responded. Most trainees (68.8%) reported participation in projects culminating in scholarly products (39.9%) or clinical innovations (44%). Most PDs reported that teaching (88.9%) and project supervision (83.3%) are performed by expert faculty. Nearly half of the PDs (45.8%) and trainees (49.6%) perceived project-based learning to be of equal value to formal curricula. Compared with trainees, a greater proportion of PDs reported needs for funding for projects, teaching faculty to provide mentorship, and faculty development (P < .05). CONCLUSIONS: Providing additional financial, administrative, and operational support could enhance the value of curricula and projects. Developing expert teaching faculty is paramount.

Depression screening in adolescents in the United States: a national study of ambulatory office-based practice.

OBJECTIVE: To determine the frequency of depression screening during ambulatory, office-based visits for adolescents seen in general/family medicine or pediatric practices in the United States using nationally representative data; to determine the patient-, provider-, and visit-level factors associated with depression screening during ambulatory visits to inform recommendations to promote screening. METHODS: This cross-sectional study used the 2005-2010 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys. Data were limited to ambulatory, office-based visits to general/family medicine or pediatrics clinics for adolescents aged 12 to 18 years who did not have a documented diagnosis of depression. RESULTS: Depression screening was rare (0.2%; 95% confidence interval [CI] 0.1-0.3), and it was 80% less likely to occur during visits for Hispanic compared to non-Hispanic white adolescents (adjusted odds ratio [aOR] 0.2, 95% CI 0.1-0.7). Depression screening was 9.1 times more likely in the Northeast compared to the West (aOR 9.1, 95% CI 2.2-38.1) if there were no visits within past 12 months compared to 6 or more visits (aOR 6.1; 95% CI 1.8-20.4), and if stress management (aOR 24.2, 95% CI 11.8-49.5) or other mental health counseling (aOR 5.2, 95% CI 1.2-23.6) were provided. CONCLUSIONS: Depression screening for adolescents is rare and is associated with racial/ethnic and regional disparities. The integration of behavioral and mental health services within the patient-centered medical home might assist providers in identifying and treating depression and in addressing such disparities.