Lessons Learned from an Academic Partnership to Review Pennsylvania Network for Student Assistance Services' Annual Survey

INTRODUCTION

Pennsylvania's Student Assistance Program (SAP) began in the mid-1980s to address student barriers to academic success. SAP teams, groups of trained school and community professionals, review referrals, and connect students to services. State leadership conducts an annual SAP team survey, but capacity to evaluate data and affect change is limited. In 2020, leadership partnered with [institution name] to collaboratively review the survey data.

METHODS

Frequencies and percentages were calculated. Open responses were coded. Logistic regression models evaluated the association between SAP team size, team meeting frequency, and team maintenance.

RESULTS

The 2019 to 2020 survey had 1003 respondents. Median number of SAP team members was 8 (range 1-21). The majority (54%) indicated their SAP team met once per week/cycle for 30 to 90+ minutes. Larger teams met more often. Annual team maintenance occurred for 38% of teams, and was more common for larger teams. SAP team members identified mental health (68%), trauma (44%), and parent engagement (36%) as top training needs.

CONCLUSIONS

An academic partnership successfully provided the capacity to review SAP survey responses, and informed evidenced-based discussion of best practice guidelines and realignment of staff professional development opportunities.

Impact of Wellness Policy Review, Wellness Council Activity, and Student Health Objectives on Overall School Wellness Climate

BACKGROUND

The whole school, whole community, whole child (WSCC) model suggests wellness councils, ongoing review of wellness policy, and a plan for evaluating set objectives are some of the key features needed to support school wellness infrastructure. This study explored the relationship between implementation of these infrastructure features and overall school wellness environment assessment scores among a sampling of Pennsylvania schools.

METHODS

The Healthy Champions program provides Pennsylvania schools an opportunity to self-assess their wellness environments across several school wellness topics. Staff enrolled their school in the program by completing a self-report electronic assessment. Enrollment data from the 2020/2021 program year were analyzed using the Kruskal-Wallis test and linear fixed model to identify the impact of varied implementation levels across 3 wellness infrastructure activities. Interactions between these variables and overall assessment score were also analyzed.

RESULTS

Of the 645 Pennsylvania schools enrolled and analyzed, we observed higher mean wellness environment assessment scores (∆ 0.74 95% CI 0.40-1.07; p < 0.001) among schools that reported some frequency of all 3 wellness infrastructure activities, compared to schools that reported no frequency for the activities.

IMPLICATIONS

Schools with existing policies and practices related to the 3 wellness infrastructure activities should consider the degree of implementation to best support overall wellness in their school setting. Additional research to explore implementation barriers and supports is needed.

CONCLUSIONS

Analyses indicated that overall wellness environment assessment scores are impacted by implementation thresholds for wellness council meeting frequency, revision of wellness policy, and review of student health promotion objectives.

Cooking with the Community: Addressing Food Insecurity Through Equipment Provision and Professional Instruction

Introduction

Food insecurity is a common problem with many associated negative downstream health impacts. Despite government sponsored and private supports, many individuals struggle with making healthy, nutritious meals. Penn State's Cooking with the Community program was constructed with the objective of providing cooking equipment and instructions to increase knowledge of healthy cooking techniques and consumption of under-utilized food pantry ingredients.

Methods

Four cooking demonstrations were held over an 8-month study period in 2021 designed to educate participants on under-utilized and seasonally available ingredients. Each demonstration was professionally led by a chef who taught cooking skills and the use of different equipment, which were subsequently gifted to the participants. Participants were surveyed before and after each demonstration to assess cooking perceptions and comfort using Likert scales. Final analysis was completed in 2022 using mixed effects models to analyze changes between pre- and post-demonstration.

Results

There were 34 total participants. Statistically significant improvements were seen in confidence in cooking (mean increase=0.5; SD=0.2; p=0.031; 95% CI=0.1, 1.0), preparation of a simple recipe (mean increase=0.6; SD=0.2; p=0.013; 95% CI=0.1, 1.0), and cooking new foods (mean increase=0.6; SD=0.3; p=0.026; 95% CI=0.1, 1.1).

Conclusions

Cooking with the Community provides valuable information on how cooking confidence may be boosted within vulnerable populations by providing cooking equipment and professional instructions on its use.

Evaluating the Impact of Aevidum on Mental Health Knowledge, Attitudes, and Help-Seeking Behaviors in High School Students: A Mixed-Methods Study

PURPOSE

To compare Aevidum's school mental health curriculum vs the curriculum plus Aevidum clubs in a mixed-methods study including pre/post surveys, a randomized clinical trial, and qualitative interviews.

DESIGN

Concurrent mixed-methods: Aim 1) pre-post surveys evaluated curriculum only vs curriculum plus club schools separately regarding changes in knowledge, help-seeking, and school culture; Aim 2) randomized clinical trial compared curriculum only to curriculum plus club schools; Aim 3) qualitative school staff interviews enhanced understanding of school culture changes.

SETTING

Curriculum delivered to 9th graders at ten Pennsylvania high schools; 5 schools randomized to start clubs.

SUBJECTS

Students (surveys), staff (interviews).

INTERVENTION

Aevidum curriculum plus/minus club.

MEASURES

Aim 1, mixed effects linear and logistic regression models for longitudinal data were used to analyze survey items at each time point. Aim 2, the same regression models were used, except models included a fixed-effect for group and group by time interaction effect. Aim 3, interviews were transcribed; a codebook was developed followed by thematic analysis.

RESULTS

Pre-survey 2557 respondents; 49% female, 86% non-Hispanic white. Post-survey 737 (29% response rate). Aim 1, pre-post (Likert responses, larger numbers favorable) demonstrated increased student knowledge to identify depression (4.26 [4.19-4.33] to 4.59 [4.47-4.71], P < .001) and help a friend access support (4.30 [4.21-4.38] to 4.56 [4.40-4.71], P = .001). Help-seeking increased for phone helplines (1.61 [1.57-1.66] to 1.78 [1.70-1.86], P < .001), crisis textlines (1.60 [1.55-1.64] to 1.78 [1.70-1.86], P < .001), internet/websites (1.80 [1.75-1.85] to 1.99 [1.90-2.08], P < .001), school counselors (P = .005) and teachers (.013). Aim 2, no significant differences in knowledge, help-seeking or culture between curriculum only vs curriculum plus club schools. Aim 3, staff (n = 17) interviews supported reduced stigma and increased mental health referrals.

CONCLUSIONS

Aevidum's curriculum improved mental health knowledge and help-seeking; adding the club did not significantly change responses. Staff identified positive school culture impacts. Limitations include the lower post-survey response.

Effects of a Primary Care-Based Engagement Intervention for Improving Use of ADHD Treatments

INTRODUCTION

Uptake of attention deficit hyperactivity disorder (ADHD) treatments is low in primary care. A quasi-experimental study assessed the impact of a primary care-based engagement intervention to improve ADHD treatment use.

METHOD

Families of children with ADHD from four pediatric clinics were invited to participate in a two-stage intervention. The first step was an assessment battery to assess functioning and identify goals, followed by an in-office engagement session run by primary care staff.

RESULTS

Of the 636 invited families, 184 (28.9%) completed ratings, with 95 (51%) families completing the engagement session. ADHD office visits varied based on the number of steps completed (0-2). ADHD prescriptions decreased over time in families completing neither step but increased for children previously unmedicated whose parents completed either step. Families completing both steps had the highest rates of nonmedication ADHD treatments.

DISCUSSION

A brief two-step engagement intervention was associated with increased uptake of ADHD treatments.

A Collaborative Analysis of Trends in Referrals to the Pennsylvania Student Assistance Program from 2013 to 2018

BACKGROUND

The Student Assistance Program (SAP) is mandated kindergarten to 12th grade in Pennsylvania schools to address barriers to student academic success. Following student referral, SAP teams use a systematic process to inform recommendations for school or community-based services. To evaluate program outcomes, a review of student SAP referral trends over a 5-year period was undertaken.

METHODS

The Pennsylvania Network for Student Assistance Services (PNSAS), the state leadership providing oversight of SAP, partnered with Penn State College of Medicine in a retrospective analysis of student referral data from 2013 to 2018. Public school enrollment demographics were used for comparison. Frequencies and percentages were calculated.

RESULTS

Referrals (total n = 352,640) increased by 24% over the 5 years; demographics 55% male, 69% non-Hispanic white, 16% non-Hispanic black, and 10% Hispanic. Referrals were most commonly for behavioral concerns (31%). Discontinued referrals (39%) were primarily for parent refusal/no permission. Trends included rising minority and elementary referrals over the study period.

CONCLUSIONS

SAP referral demographics were consistent with state public school enrollment race/ethnicity breakdown suggesting lack of systematic bias. The proportion of behavioral referrals was consistent with rising youth behavioral health needs. PNSAS must consider strategies to support rising referral numbers and trends.

Evaluation of a stakeholder advisory board for an adolescent mental health randomized clinical trial

INTRODUCTION

Community engagement in research is widely accepted as best practice, despite gaps in existing frameworks to evaluate its process, context, and impact on research. The Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) study evaluated the use of a school-based major depressive disorder screening tool in the identification of symptoms and treatment initiation among adolescents, and was developed, implemented, and disseminated in partnership with a Stakeholder Advisory Board (SAB). We summarize outcomes of the evaluation strategy applied through our partnership with the SAB and explore gaps in the available engagement evaluation tools for mixed stakeholder populations including youth.

METHODS

SHIELD study SAB members (n = 13; adolescents, parents, mental health and primary care providers, and professionals from education and mental health organizations) advised on study design, implementation, and dissemination over a three-year period. Both SAB members and study team members (i.e., clinician researchers, project managers) were invited to quantitatively and qualitatively evaluate stakeholder engagement after each project year. At the conclusion of the study, SAB members and study team members were asked to evaluate the application of engagement principles in overall stakeholder engagement across the study period, using portions of the Research Engagement Survey Tool (REST).

RESULTS

SAB members and study team members responded similarly when evaluating engagement process (i.e., valued on team, voice represented); means ranged from 3.9 to 4.8 out of 5 points across all three project years. Reported engagement within study-specific engagement activities (i.e., meetings, study newsletter) varied from year to year, with some discrepancy between SAB member and study team evaluations. Using REST, SAB members reported the alignment of their experience with key engagement principles the same or higher than study team members. Qualitative feedback at the conclusion of the study generally matched quantitative measures; adolescent SAB members, however, reported disengagement from stakeholder activities that was not accurately or effectively captured in evaluation strategies employed across the study period.

CONCLUSIONS

Challenges exist in effectively engaging stakeholders and evaluating their engagement, particularly among heterogenous groups that include youth. Evaluation gaps should be addressed through the development of validated instruments that quantify the process, context, and impact of stakeholder engagement on study outcomes. Consideration should be given to collecting parallel feedback from stakeholders and study team members to fully understand the application and execution of engagement strategy.

Effects of COVID-19 pandemic on pediatric weight: A retrospective chart review

The COVID-19 pandemic forced United States school closures in March 2020. Students moved to online learning, fostering a sedentary lifestyle. As the pandemic heightened population disparities, the impact on weight gain may also be unequally distributed. This study aimed to evaluate changes in body mass index (BMI) z-scores and weight percentiles of pediatric patients during the pandemic and associated demographics to identify those at risk for weight gain. Methods included a retrospective chart review of patients 5-18 years-old with a well-visit in the three years 2018, 2019 and 2020; first identified with a well-visit in August-September of 2020. BMI z-scores and weight percentiles were analyzed using a correlated errors regression model appropriate for longitudinal data. This longitudinal approach was used to model outcomes by patient demographics. Interaction terms with time were evaluated for each variable. Of 728 patients, mean age was 9.7 years (2018); 47 % female, 70 % white, and 23 % publicly insured. BMI z-score did not increase significantly from 2018-2019 versus 2019-2020. Weight percentile demonstrated a slight trajectory increase over these same time points. Publicly insured patients demonstrated significantly greater increase in BMI z-score versus privately insured patients (p = 0.009). Mean differences between groups increased from 0.26 in 2018 (95 % CI [0.07, 0.45]) to 0.42 in 2020 (95 % CI [0.23, 0.61]). Results were similar for weight percentile. Publicly insured pediatric patients experienced significant increase in BMI-z score and weight percentile, but over time this trajectory remained constant. The results support targeting at risk subgroups in addressing long-term impacts of the pandemic.

Adolescent Suicide Risk Screening: A Secondary Analysis of the SHIELD Randomized Clinical Trial

OBJECTIVE

To evaluate the effectiveness of adolescent suicide risk screening to increase initiation of mental health services via a secondary analysis using data from the SHIELD (Screening in High Schools to Identify, Evaluate and Lower Depression) randomized clinical trial, which evaluated school-based screening for major depressive disorder (MDD).

STUDY DESIGN

Students in 14 Pennsylvania high schools were randomized by grade to either the usual school practice of targeted referral for behavior raising a concern for suicide risk or universal screening using the Patient Health Questionnaire-9 (PHQ-9), with any response >0 to item 9 regarding suicide risk considered positive. Students identified in either arm were referred to the Student Assistance Program (SAP), which is mandated in all Pennsylvania schools. The SAP determined follow-up. Study groups were compared using mixed-effects logistic regression.

RESULTS

The participants comprised 12 909 students, with 6473 (50.1%) randomized to universal screening. The study group was 46% female and 43% Hispanic or non-Hispanic Black. Adolescents in the universal screening arm had 7.1-fold greater odds (95% CI, 5.7-8.8) of being identified as at risk for suicide, 7.8-fold greater odds (95% CI, 4.6-13.1) of follow-up needs, and 4.0-fold greater odds (95% CI, 2.0-7.9) of initiating mental health treatment.

CONCLUSIONS

Although the PHQ-9 is a MDD screening tool, its use in universal screening increased identification and treatment initiation for adolescents at risk for suicide. This confirms the value of universal screening and suggests that a suicide-specific risk assessment would have even greater impact on treatment initiation for identified youth.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03716869.

Insights on COVID-19, School Reopening Procedures, and Mental Wellness: Pilot Interviews With School Employees

BACKGROUND

The COVID-19 pandemic has caused interruptions to the K-12 US school landscape since spring 2020.

METHODS

In summer 2020, we completed a pilot study utilizing interviews (n = 13) with school staff (ie, nurses, educators) from across the United States. We aimed to understand the status of school operation and re-entry plans after the primary period of school closure, along with resources needed for students and staff during the COVID-19 pandemic.

RESULTS

All interviewees described their school's re-entry plan as complete or in-development. Ten plans included strategies to meet students' mental health needs. Only 3 clearly planned for staff mental health resources. Interviews suggest gaps in planning and execution of mental health resources for school staff, a group already vulnerable to stress, anxiety, and burnout.

IMPLICATIONS FOR SCHOOL HEALTH

Several school staff mental health resources were developed as a result of the pandemic, though ongoing impacts necessitate integration of these supports into school operation plans. This is particularly important as schools continue to navigate periods of altered operation in response to elevated community COVID-19 infection rates.

CONCLUSIONS

As schools implement strategies to support students, similar consideration should be given to the adults in the school environment who teach and support school-aged children.

Treatment Engagement Following a Positive Mental Health Screening Questionnaire

INTRODUCTION

Less than half of U.S. adolescents with major depressive disorder receive treatment. Despite the U.S. Preventive Services Task Force 2016 statement supporting primary care major depressive disorder screening, there is limited data examining whether positive screens prompt treatment engagement. This study evaluated treatment engagement following a positive Patient Health Questionnaire-Adolescent Version screen and assessed the impact of demographics, clinical variables, and provider recommendations on treatment engagement.

METHODS

This was a retrospective cohort study (analysis November 2021) of adolescents aged 11-18 years seen at a primary care clinic of an academic medical center from July 2017 to December 2018 and identified with a positive Patient Health Questionnaire-Adolescent Version (broadest definition score ≥10; ≥1 for Item 9 regarding suicidal thoughts; yes for unscored Items 1, 3, or 4; or very or extremely difficult for unscored Item 2). Positive screen by score ≥10 alone was also considered. The primary outcome was treatment engagement, defined as initiation of a psychotropic medication, or a behavioral health treatment session within 1 year of symptom identification.

RESULTS

Of the 1,315 eligible adolescents, 23.0% had a positive Patient Health Questionnaire-Adolescent Version (n=302) by the broadest criteria; 92/302 (30.5%) engaged in treatment. Patients whose providers recommended treatment had 7.32 times the odds (95% CI=3.76, 14.2, p<0.001) of treatment engagement. For those positive by Patient Health Questionnaire-Adolescent Version ≥10 (85/302, 28.1%), 37/85 (43.5%) engaged in treatment. The influence of provider recommendations was comparable (OR=6.96, 95% CI=3.56, 13.6, p<0.001).

CONCLUSIONS

Less than half of adolescents with a positive Patient Health Questionnaire-Adolescent Version at an academic primary care clinic engaged with treatment. Provider recommendation was an impactful intervention to improve mental healthcare treatment engagement.

Leveraging Community-Engaged Research to Address Adolescent Depression with Pennsylvania Public Schools and Communities

BACKGROUND

The prevalence of adolescent major depressive disorder increased from 8.3% in 2008 to 14.4% in 2018, and suicide is now the second leading cause of death among U.S. adolescents.

OBJECTIVE

Describe the process of community-engaged research methods used to develop a randomized clinical trial (RCT) comparing the effectiveness of school-based universal depression screening on depression identification and treatment engagement, compared with standard symptom-based depression recognition.

METHODS

We engaged stakeholders with personal or professional expertise and schools enrolled in the study. Qualitative methods aimed to elucidate barriers and opportunities during RCT development.

RESULTS

Stakeholders were instrumental in all phases of RCT development. Qualitative feedback from participating schools, students, and parents informed RCT development and implementation.

CONCLUSIONS

The inclusion of community-engaged research methods provided opportunities to collaboratively address barriers to RCT design and implementation with school communities. This dialogue was invaluable in establishing relationships to further address mental health and other controversial adolescent health topics in future research.

"I wouldn't even know what to do," Adolescent and Parent Perspectives on Identifying, Understanding, and Seeking Help for Adolescent Depression

Within the context of a randomized clinical trial (RCT) of school-based depression screening, the study objective was to understand parent and adolescent perspectives on school-based depression screening and barriers to help-seeking for adolescent depression. From May-Nov. 2019, separate focus groups were held with adolescents (8 groups, n = 52) and parents (6 groups, n = 36). Two coders individually coded 20% of transcripts to establish interrater reliability (adolescent k = 0.76 and parent k = 0.80). Remaining transcripts were then separately coded and reviewed to develop three themes: (1) Both recognized depression as a serious issue that needed to be addressed in schools, but had confidentiality and communication concerns; (2) Both parents and adolescents believed the majority of adolescents would seek help with depression from friends more than any other source; and (3) Neither adolescents nor parents could clearly describe steps to take if their peers (adolescents) or adolescents (parents) were depressed. We intend to address identified barriers and concerns in the context of the larger RCT.

Screening in High Schools to Identify, Evaluate, and Lower Depression Among Adolescents: A Randomized Clinical Trial

IMPORTANCE

Adolescent major depressive disorder (MDD) prevalence has nearly doubled in the past decade. The US Preventive Services Task Force endorses universal adolescent MDD screening in primary care; however, most adolescents lack preventive health care, resulting in worsening disparities in MDD screening and treatment.

OBJECTIVE

To evaluate the effectiveness of universal adolescent MDD screening in the school setting in an effort to reduce disparities and improve MDD identification and treatment initiation.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial, conducted from November 6, 2018, to November 20, 2020, compared the usual school practice of targeted or selected screening based on observable behaviors of concern with universal MDD screening. Students within an identified school were randomized by grade to 1 of the 2 study groups. Study groups were compared using mixed-effects logistic regression. Participants included students in grades 9 through 12 enrolled at 1 of the 14 participating Pennsylvania public high schools.

INTERVENTIONS

In targeted screening, students with behaviors prompting concern for MDD were referred to the Student Assistance Program (SAP), mandated in all Pennsylvania schools. The SAP determined follow-up recommendations. In universal screening, all students completed the Patient Health Questionnaire-9 (PHQ-9); students with positive scores proceeded to SAP. The universal screening group could also have targeted referral to SAP for concerning behavior independent of the PHQ-9.

MAIN OUTCOMES AND MEASURES

The primary outcome was initiation of MDD treatment or services based on data collected by school SAP teams during the academic year.

RESULTS

A total of 12 909 students were included (median age, 16 years [range, 13-21 years]; 6963 male [53.9%]), of whom 2687 (20.8%) were Hispanic, 2891 (22.4%) were non-Hispanic Black, 5842 (45.3%) were non-Hispanic White, and 1489 (11.5%) were multiracial or of other race or ethnicity. A total of 6473 students (50.1%) were randomized to universal screening, and 6436 (49.9%) were randomized to targeted screening. Adolescents in the universal screening group had 5.92 times higher odds (95% CI, 5.07-6.93) of being identified with MDD symptoms, 3.30 times higher odds (95% CI, 2.49-4.38) of SAP confirming follow-up needs, and 2.07 times higher odds (95% CI, 1.39-3.10) of initiating MDD treatment. No differences were identified in initiation for planned subgroup analyses by sex or race and ethnicity.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, universal school-based MDD screening successfully increased identification of MDD symptoms and treatment initiation among adolescents, confirming the value of this approach to address this rising public health concern.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03716869.

National Survey of School Employees: COVID-19, School Reopening, and Student Wellness

BACKGROUND

During spring 2020, COVID-19 forced widespread United States school building closures in an unprecedented disruption for K-12 students and staff. Partnering with the American School Health Association (ASHA), we sought to identify areas of concern among school staff planning for school reopening with the goal of addressing gaps in resources and education.

METHODS

This 16-item web-based survey was distributed via email to 7467 ASHA members from May to June 2020. Topics focused on 3 Whole School, Whole Community, Whole Child components: physical environment, health services, and mental health. Chi-square tests were used to identify differences in responses by school characteristics and school role on each survey item.

RESULTS

A total of 375 respondents representing 45 states completed the survey. The majority were female (91.7%), white (83.4%) and non-Hispanic (92.2%), and school nurses (58.7%). Priority concerns were feasibility of social distancing (93.6%), resurgence of COVID-19 (92.8%), and the availability of health supplies (88.8%).

CONCLUSION

Understanding staff concerns in the context of the Whole School, Whole Community, Whole Child model better positions the school community to address ongoing gaps and changing needs as schools continue to address COVID-19 complications.

School Nurse Perspectives on COVID-19

Pennsylvania responded to the COVID-19 pandemic by closing schools and moving to online instruction in March 2020. We surveyed Pennsylvania school nurses (N = 350) in May 2020 to assess the impact of COVID-19 on nurses' concerns about returning to school and impact on practice. Data were analyzed using χ² tests and regression analyses. Urban school nurses were more concerned about returning to the school building without a COVID-19 vaccine than rural nurses (OR = 1.58, 95% CI [1.05, 2.38]). Nurses in urban locales were more likely to report being asked for guidance on COVID-19 (OR = 1.69, 95% CI [1.06, 2.68]), modify communication practices (OR = 2.33, 95% CI [1.42, 3.82]), and be "very/extremely concerned" about their safety (OR = 2.16, 95% CI [1.35, 3.44]). Locale and student density are important factors to consider when resuming in-person instruction; however, schools should recognize school nurses for their vital role in health communication to assist in pandemic preparedness and response.

Parent Views on School-Based Depression Screening: Findings From a National Survey

PURPOSE

This study explored parent views on school involvement in screening and identification of adolescent depression.

METHODS

This was a cross-sectional Internet-based survey with the C.S. Mott Children's Hospital National Poll on Children's Health. Of 2,004 parents (63.4% response rate), 770 had a middle/high school student and were eligible for this module. Poststratification weights were generated by survey vendor Ipsos. Descriptive and bivariate results were calculated; multinomial logistic regression models controlled for parent sex, race/ethnicity, education, employment status, and school level.

RESULTS

Parent respondents were 54.8% female, 57.5% white, 64.3% above a high school education, and 79.7% employed; 76.2% were answering based on a high school student. Most parents supported school-based depression screens starting in sixth (46.7%) or seventh (15.1%) grades, although 15.9% responded no screening should be done. Among parent respondents, 93.2% wished to be informed of a positive screen. Regression analysis found parents of middle school students were 4.18 times more likely to prefer sixth versus 9th to 12th grade to start screening.

CONCLUSIONS

Most parents support middle school depression screening but overwhelmingly wished to be informed of a positive result. Guidelines for maintaining adolescent confidentiality in a school-based depression screening program will require careful consideration.

Effectiveness of Universal School-Based Screening vs Targeted Screening for Major Depressive Disorder Among Adolescents: A Trial Protocol for the Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) Randomized Clinical Trial

Importance

The prevalence of annual major depressive disorder (MDD) episodes among adolescents in the United States rose from 8.3% in 2008 to 12.8% in 2016. Despite the US Preventive Services Task Force 2009 endorsement and 2016 reaffirmation of universal adolescent MDD screening in primary care, many adolescents are missed, as more than 60% lack annual preventive health visits and MDD screening remains inconsistent.

Objective

To compare the effectiveness of universal school-based screening for adolescent MDD vs the existing process of targeted screening based on observable behavior.

Design, Setting, and Participants

Screening in High Schools to Identify, Evaluate, and Lower Depression (SHIELD) is a randomized clinical trial that will take place in at least 8 Pennsylvania public high schools among at least 9650 students enrolled in 9th through 12th grade. Students will be randomized by grade to either targeted screening (current process) or universal screening (intervention). Students in the targeted screening arm will complete mandated school health screenings, which do not include an MDD screening. These students will be observed through the academic year for referral to the Student Assistance Program (SAP), required in all Pennsylvania schools. If a student exhibits behavior concerning for MDD raised by any contact (eg, teacher, parent, peer, or self-referral), SAP will triage the student and provide follow-up recommendations. Students in the universal screening arm will complete the validated Patient Health Questionnaire-9 (PHQ-9) from September through December of the academic year. The PHQ-9 includes 9 close-ended questions and is scored from 0 to 27. Students with a positive result (ie, score >10) will proceed to SAP triage. Students in the intervention arm will also be observed for behavior concerning for MDD during the school year, potentially prompting SAP triage referral. The primary outcome will be the proportion of adolescents referred to SAP triage who are recommended for additional MDD-related services and successfully engage with at least 1 SAP recommendation. Observers will not be blinded to patient groups, and an intention-to-treat analysis will be used.

Discussion

The SHIELD trial began with 3 schools during the 2018-2019 academic year. Screening in the intervention arm with the PHQ-9 is currently underway for the remaining schools, with a goal of completion of all PHQ-9 screenings by December 2019. This trial addresses the US Preventive Services Task Force call for large, high-quality randomized clinical trials to better understand the effects of MDD screening and quantify the proportion of adolescents with screen-detected MDD successfully referred and treated.

Trial Registration

ClinicalTrials.gov identifier: NCT03716869.

The Possibility of Early Discharge for Newborns Being Monitored for Neonatal Abstinence Syndrome Based on Modified Finnegan Score Distributions

We tested the hypothesis that Modified Finnegan Neonatal Scoring System (MFNSS) scores can guide early discharge at 72 hours for newborns at risk for neonatal abstinence syndrome (NAS). A retrospective cohort study with a primary outcome of early discharge of newborns at risk for NAS using mean MFNSS scores recorded before pharmacologic treatment was performed. Quantile regression was used to develop percentile curves of mean MFNSS scores. A total of 202 term newborns at risk for NAS with 5066 mean MFNSS scores recorded before pharmacologic treatment were studied. Sixty-eight of 121 (56%) newborns not treated at 72 hours had mean MFNSS scores <50th percentile and only 1 was ultimately treated (1.5%, 95% confidence interval: 0% to 8%). No newborns with mean MFNSS scores <25th percentile at 72 hours were treated. Newborns at risk for NAS with mean MFNSS scores <50th percentile can be safely discharged by 72 hours if families can assure close outpatient follow-up.

Opportunities and challenges in screening for childhood sexual abuse

Retrospective studies suggest 1 in 4 girls and 1 in 6 boys will experience sexual abuse before 18 years of age, resulting in future morbidity. Successful interventions exist, however, victims are reluctant to disclose. Screening for childhood sexual abuse (CSA) may provide an opportunity to overcome this barrier, yet no current model for universal CSA screening exists. We sought to understand the perspective of key stakeholders on CSA screening through qualitative research. Eight focus groups of 7-10 participants each (n=62) were conducted from April-September 2016. Stakeholders included school nurses, school teachers, counselors and administrators, pediatric providers, and parents. The interview guide focused on reporting suspected CSA and impressions of a CSA screening tool. Sessions were audiotaped and transcribed. Researchers used qualitative content analysis to develop conceptual categories that related to CSA screening and reporting. Two research team members independently open-coded 20% of the data for interrater reliability (kappa=0.98) prior to completing the coding process. Three major categories emerged to inform CSA screening. First, early screening (e.g. kindergarten) was preferred. Confidentiality was a concern, specifically privacy in the school-setting. As CSA perpetrators are often known to the child, parental presence in the medical office was also a concern. Finally, refinement of the screening process was discussed starting with routine education on safe touch and defining "normal." Rather than direct questioning, consistent and repeated offering of opportunities to disclose CSA and identification of a trusted adult were suggested. Next steps should involve partnering with evidence-based CSA prevention programs to incorporate and evaluate the aforementioned elements.

Variability in State-Based Recommendations for Management of Alpha Thalassemia Trait and Silent Carrier Detected on the Newborn Screen

We conducted an inventory of state-based recommendations for follow-up of alpha thalassemia silent carrier and trait identified on newborn screen. We found wide variability in the nature and timing of these recommendations. We recommend a standardized recommendation to guide pediatricians in evidenced-based care for this population.

Risk-Based Questionnaires Fail to Detect Adolescent Iron Deficiency and Anemia

OBJECTIVE

To evaluate the predictive ability of screening questionnaires to identify adolescent women at high-risk for iron deficiency or iron deficiency anemia who warrant objective laboratory testing.

STUDY DESIGN

Cross-sectional study of 96 female individuals 12-21 years old seen at an academic medical center. Participants completed an iron deficiency risk assessment questionnaire including the 4 Bright Futures Adolescent Previsit Questionnaire anemia questions, along with depression, attention, food insecurity, and daytime sleepiness screens. Multiple linear regression controlling for age, race, and hormonal contraception use compared the predictive ability of 2 models for adolescent iron deficiency (defined as ferritin <12 mcg/L) and anemia (hemoglobin <12 g/dL). Model 1, the Bright Futures questions, was compared with model 2, which included the 4 aforementioned screens and body mass index percentile.

RESULTS

Among participants, 18% (17/96) had iron deficiency and 5% (5/96) had iron deficiency anemia. Model 1 (Bright Futures) poorly predicted ferritin and hemoglobin values (R² = 0.03 and 0.08, respectively). Model 2 demonstrated similarly poor predictive ability (R² = 0.05 and 0.06, respectively). Mean differences for depressive symptoms (0.3, 95% CI -0.2, 0.8), attention difficulty (-0.1, 95% CI -0.5, 0.4), food insecurity (0.04, 95% CI -0.5, 0.6), daytime sleepiness (0.1, 95% CI -0.1, 0.3), and body mass index percentile (-0.04, 95% CI -0.3, 0.2) were not significantly associated with ferritin in model 2. Mean differences for hemoglobin were also nonsignificant.

CONCLUSIONS

Risk-based surveys poorly predict objective measures of iron status using ferritin and hemoglobin. Next steps are to establish the optimal timing for objective assessment of adolescent iron deficiency and anemia.

Association of Iron Deficiency Anemia With Hearing Loss in US Adults

Importance

Hearing loss in the US adult population is linked to hospitalization, poorer self-reported health, hypertension, diabetes, and tobacco use. Because iron deficiency anemia (IDA) is a common and easily correctable condition, further understanding of the association between IDA and all types of hearing loss in a population of US adults may help to open new possibilities for early identification and appropriate treatment.

Objective

To evaluate the association between sensorineural hearing loss (SNHL) and conductive hearing loss and IDA in adults aged 21 to 90 years in the United States.

Design, Setting, and Participants

The prevalence of IDA and hearing loss (International Classification of Diseases, Ninth Revision codes 389.1 [SNHL], 389.0 [conductive hearing loss], and 389 [combined hearing loss]) was identified in this retrospective cohort study at the Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania. Iron deficiency anemia was determined by low hemoglobin and ferritin levels for age and sex in 305 339 adults aged 21 to 90 years. Associations between hearing loss and IDA were evaluated using χ2 testing, and logistic regression was used to model the risk of hearing loss among those with IDA. The study was conducted from January 1, 2011, to October 1, 2015.

Main Outcomes and Measures

Hearing loss.

Results

Of 305 339 patients in the study population, 132 551 were men (43.4%); mean (SD) age was 50.1 (18.5) years. There was a 1.6% (n = 4807) prevalence of combined hearing loss and 0.7% (n = 2274) prevalence of IDA. Both SNHL (present in 26 of 2274 individuals [1.1%] with IDA; P = .005) and combined hearing loss (present in 77 [3.4%]; P < .001) were significantly associated with IDA. Logistic regression analysis confirmed increased odds of SNHL (adjusted odds ratio [OR], 1.82; 95% CI, 1.18-2.66) and combined hearing loss (adjusted OR, 2.41; 95% CI, 1.90-3.01) among adults with IDA, after adjusting for sex.

Conclusions and Relevance

Iron deficiency anemia was associated with SNHL and combined hearing loss in a population of adult patients. Further research is needed to better understand the potential links between IDA and hearing loss and whether screening and treatment of IDA in adults could have clinical implications in patients with hearing loss.

The Relationship Between Iron Deficiency Anemia and Sensorineural Hearing Loss in the Pediatric and Adolescent Population

PURPOSE

A correlation between iron deficiency anemia (IDA) and sudden sensorineural hearing loss (SNHL) was described in adults. In this study, we examined if there is a relationship between IDA and hearing loss in the pediatric population.

METHOD

This was a retrospective cohort study of data collected from the Informatics for Integrating Biology and the Bedside database from 2011 to 2016. Children and adolescents 4-21 years old seen at Penn State Milton S. Hershey Medical Center, Hershey, PA, were examined for hearing loss and IDA status. Hearing loss was determined by International Classification of Disease-9 and -10 codes, and IDA was determined by both low hemoglobin and serum ferritin levels for age and sex.

RESULTS

We identified 20,113 patients. Prevalence of hearing loss and IDA was 1.7% and 2.3%, respectively. The prevalence of all hearing loss was 3.0% in the IDA cohort and 1.7% in those without IDA. Children and adolescents with IDA are at increased odds of developing SNHL (adjusted odds ratio: 3.67, 95% CI [1.60-7.30]).

CONCLUSIONS

Children with IDA demonstrate increased likelihood of SNHL. Although correction of IDA in those with hearing loss has yet to be linked to improvements in hearing outcomes, screening for and correcting IDA among pediatric patients will positively affect overall health status.

Supplemental Material: https://doi.org/10.23641/asha.5087071.

Association between menarche and iron deficiency in non-anemic young women

Background

The prevalence of iron deficiency (ID) among non-pregnant, reproductive-age US women significantly exceeds rates among males. In clinical practice ID screening relies on hemoglobin, a late-stage indicator of ID. As a single, low-cost laboratory test to diagnose ID before anemia develops is lacking, the study objective was to improve ID screening by identifying risk factors among non-anemic, iron-deficient reproductive age women.

Methods

Cross-sectional data were from the National Health and Nutrition Examination Survey (NHANES) 2003–2010. Hemoglobin identified non-anemic women. ID was defined using the body iron formula, requiring ferritin and transferrin receptor values. Logistic regression assessed the association of sociodemographic, behavioral, and reproductive risk factors in an anemia-based conceptual framework with non-anemic reproductive age women (12–49 years) with ID, as well as subsets of younger (12–21 years) and older (22–49 years) women, recognizing that risks may differ by age.

Results

Among 6216 women, 494 had ID (prevalence was 8.0%, 95% CI 7.3%, 8.6%). Among non-anemic younger women, 250 (8.7%, 95% CI 7.7%, 9.8%) had ID, compared to 244 (7.3%, 95% CI 6.4%, 8.2%) older women. Among younger women, menstruation for over 3 years was the only variable significantly associated with non-anemic ID (risk ratio 3.18, 95% CI 2.03, 4.96). No other significant risk factors were identified.

Conclusion

Menstrual years was the only risk factor significantly associated with ID among non-anemic younger women. The negative results suggest ID risk factors among non-anemic women may need to be considered separately from those associated with ID anemia.

Optimizing hemoglobin thresholds for detection of iron deficiency among reproductive-age women in the United States

Iron deficiency (ID) affects 9%-16% of US women with well-documented morbidity in academic performance, mood, and concentration. Current ID screening depends on the detection of low hemoglobin (ie, anemia, <12.0 g/dL). However, anemia is a late-stage indicator of ID. The study hypothesis was that using higher hemoglobin thresholds would optimize ID screening. The objective was to assess the sensitivity and specificity of hemoglobin to detect ID among nonpregnant, reproductive-age women of 12-49 years and to determine if psychometric characteristics varied by age and race. This cross-sectional study used National Health and Nutrition Examination Survey 2003-2010 data. ID was defined as body iron, calculated using ferritin and transferrin receptors. Logistic regression and receiver operating characteristic (ROC) curves were used to model the predictive probability of ID by hemoglobin values. ID prevalence by body iron was 11.5% (n = 6602). Using <12.0 g/dL, hemoglobin had a sensitivity of 42.9% (95% confidence interval [CI] = 39.4%, 46.4%) and specificity of 95.5% (95% CI = 95.0%, 96.0%) for ID. The ROC curve was optimized at the hemoglobin threshold of <12.8 g/dL with the sensitivity and specificity of 71.3% (95% CI = 68.0%, 74.5%) and 79.3% (95% CI = 78.2%, 80.3%), respectively. The probability of ID at this threshold was 13.5% (95% CI = 11.3%, 15.9%). Hemoglobin better predicted ID among older (22-49 years) vs younger (12-21 years) women (c-index 0.87 vs 0.77, P < 0.001). Among nonpregnant, reproductive-age women, current hemoglobin thresholds are insufficient to exclude ID. A threshold of <12.8 g/dL improves the detection of ID.

The Sensitivity of Adolescent School-Based Hearing Screens Is Significantly Improved by Adding High Frequencies

High frequency hearing loss (HFHL), often related to hazardous noise, affects one in six U.S. adolescents. Yet, only 20 states include school-based hearing screens for adolescents. Only six states test multiple high frequencies. Study objectives were to (1) compare the sensitivity of state school-based hearing screens for adolescents to gold standard sound-treated booth testing and (2) consider the effect of adding multiple high frequencies and two-step screening on sensitivity/specificity. Of 134 eleventh-grade participants (2013-2014), 43 of the 134 (32%) did not pass sound-treated booth testing, and 27 of the 43 (63%) had HFHL. Sensitivity/specificity of the most common protocol (1,000, 2,000, 4,000 Hz at 20 dB HL) for these hearing losses was 25.6% (95% confidence interval [CI] = [13.5, 41.2]) and 85.7% (95% CI [76.8, 92.2]), respectively. A protocol including 500, 1,000, 2,000, 4,000, 6,000 Hz at 20 dB HL significantly improved sensitivity to 76.7% (95% CI [61.4, 88.2]), p < .001. Two-step screening maintained specificity (84.6%, 95% CI [75.5, 91.3]). Adolescent school-based hearing screen sensitivity improves with high frequencies.

The Sensitivity of Adolescent Hearing Screens Significantly Improves by Adding High Frequencies

PURPOSE

One in 6 US adolescents has high-frequency hearing loss, often related to hazardous noise. Yet, the American Academy of Pediatrics (AAP) hearing screen (500, 1,000, 2,000, 4,000 Hertz) primarily includes low frequencies (<3,000 Hertz). Study objectives were to determine (1) sensitivity and specificity of the AAP hearing screen for adolescent hearing loss and (2) if adding high frequencies increases sensitivity, while repeat screening of initial referrals reduces false positive results (maintaining acceptable specificity).

METHODS

Eleventh graders (n = 134) participated in hearing screening (2013-2014) including "gold-standard" sound-treated booth testing to calculate sensitivity and specificity.

RESULTS

Of the 43 referrals, 27 (63%) had high-frequency hearing loss. AAP screen sensitivity and specificity were 58.1% (95% confidence interval 42.1%-73.0%) and 91.2% (95% confidence interval 83.4-96.1), respectively. Adding high frequencies (6,000, 8,000 Hertz) significantly increased sensitivity to 79.1% (64.0%-90.0%; p = .003). Specificity with repeat screening was 81.3% (71.8%-88.7%; p = .003).

CONCLUSIONS

Adolescent hearing screen sensitivity improves with high frequencies. Repeat testing maintains acceptable specificity.

Poor Concordance Between Elevated Blood Pressures in the Preschool Years

The 2013 US Preventive Services Task Force report found insufficient evidence for pediatric blood pressure screening. This retrospective study evaluated the reliability of successive annual blood pressure screening of children for hypertension at the 3-, 4-, and 5-year-old health maintenance visits (January 1, 2010 to June 18, 2014). Of 328 patients, 290 (88%) were normotensive at all 3 visits. All elevated blood pressures (≥95th percentile) were stage 1. No patient was hypertensive (3 elevated measures). The extended concordance correlation coefficient indicated poor agreement for systolic (0.19, 95% CI -0.49 to 0.72) and diastolic (0.11, 95% CI -0.39 to 0.56) measurements. Blood pressure at the 3-year (κ -0.008, 95% CI -0.11 to 0.09), 4-year (κ 0.09, 95% CI -0.06 to 0.24), or 5-year (κ 0.08, 95% CI -0.05 to 0.20) visit was not associated with elevated blood pressures at the other 2 time points. In the preschool years, stage 1 elevated blood pressures do not correlate with hypertension and may be better managed by watchful waiting and parental reassurance.

Certified School Nurse Perspectives on State-Mandated Hearing Screens

BACKGROUND

Approximately 15% of children in the United States 6-19 years of age have hearing loss. Even mild, unilateral hearing loss may adversely affect educational success. In 2014, the Pennsylvania Department of Health (PA DOH) began updating the 2001 regulations on state-mandated school hearing screens. To inform the updates, a needs assessment was conducted with PA-certified school nurses (CSNs) regarding current screening practice and potential barriers to making changes.

METHODS

A 42-item electronic survey of CSNs developed with pediatricians, audiologists, nurses, and the PA DOH was administered in October 2014.

RESULTS

There were 536 completed surveys. Most CSNs (50.8%) screened 251-500 students annually. Only 35.8% strictly followed PA DOH protocol, while 51.6% followed protocol and added nonguideline frequencies. Over half of screens (60.2%) were conducted in places where other people were present. Most CSNs (82.5%) reported annual audiometer calibration, but 92.4% were unsure whether the calibration was exhaustive or limited. Reported barriers to change included time, cost, and staffing.

CONCLUSIONS

As most CSNs added frequencies to the PA DOH hearing screen, an update with added frequencies should be well accepted. Clarification regarding test environment and exhaustive audiometer calibration is needed. Adherence to best practice may be optimized by addressing CSN reported barriers to change.

Report of Sugar-Sweetened Beverages Offered in Pennsylvania Childcare Centers

The study objective was to quantify sugar-sweetened beverage (SSB) offerings to children in Pennsylvania (PA) childcare centers and determine whether this information is communicated to parents. In October 2014, a SurveyMonkey link was sent to 4461 PA childcare centers. The 518 respondents represented 88% of PA counties. 279 centers (54%) serve SSBs. 330 (65%) of childcare centers provide parents a report of their child's daily intake. Of 185 centers serving SSBs and providing a daily intake report, 91% include SSB consumption. In total, 38% of centers (103/272) offer but do not report SSB consumption. In 96% of centers, parents may request their child not receive SSBs. In conclusion, though more than half of PA childcare centers surveyed offer SSBs, those providing daily intake reports usually include SSB consumption. Requiring daily intake reports may be a strategy to increase parental awareness of items consumed outside the home.

Differences in Risk Factors for Anemia Between Adolescent and Adult Women

BACKGROUND

Iron deficiency anemia (IDA) affects 2%-5% of reproductive-age women. Screening is based on risk factors, such as a low-iron diet and menstruation. However, published IDA risk factors fail to consider age-related risks specific to adolescent women, potentially limiting identification of high-risk adolescents for objective testing. The goal of the study was to examine IDA risk factors in a nationally representative sample of younger (12-21 years) and older (22-49 years) reproductive-age women.

MATERIALS AND METHODS

Data were obtained from the National Health and Nutrition Examination Survey (NHANES) 2003-2010. IDA was defined using hemoglobin, ferritin, soluble transferrin receptor, standard NHANES laboratory measures. Sex-, age-, and race-specific hemoglobin values defined anemia. Iron deficiency was calculated using ferritin and soluble transferrin receptor in the body iron formula. Logistic regression assessed the association of potential risk factors (race, body mass index, poverty, iron intake, tobacco/nicotine exposure, physical activity, menses, and contraceptive use) with IDA in younger and older women.

RESULTS

The prevalence of IDA was 2.4% and 5.5% among younger and older women, respectively. Among younger women, contraceptive use was marginally protective from IDA (risk ratio 0.50, 95% confidence interval [CI] 0.25-1.00). Among older women, significant variables included Black race (risk ratio 2.31, 95% CI 1.33-4.02) and increased years menstruating (≥25 years vs. <25 years; risk ratio 1.93, 95% CI 0.99-3.76).

CONCLUSIONS

Risk factors for IDA among older reproductive-age women do not apply to adolescent women. To better inform the timing and frequency of screening recommendations, further research must identify adolescent-specific IDA risk factors.

Identifying factors predicting iron deficiency in United States adolescent females using the ferritin and the body iron models

BACKGROUND & AIMS

Iron deficiency is the most prevalent nutritional deficiency in the United States affecting 9-16% of female adolescents. With the primary purpose of detecting iron deficiency, primary care screening consists of a hemoglobin or hematocrit laboratory test. This method is simple and inexpensive, but tests for anemia, and is neither sensitive nor specific for iron deficiency. Alternate methods for diagnosing iron deficiency using the ferritin and body iron models are not widely utilized. The study objective was to compare iron deficiency risk factors among adolescent females defined by the ferritin and body iron models to better characterize those who may benefit from iron deficiency testing as opposed to the current anemia-based screen.

METHODS

This cross-sectional study of female adolescents aged 12-21 years utilized National Health and Nutrition Examination Survey 2003-2006 data. Anemia was defined by standard hemoglobin cutoffs. The ferritin model defines iron deficiency through transferrin saturation, ferritin and erythrocyte protoporphyrin laboratory testing. Body iron calculates iron status with a formula involving transferrin receptor and ferritin. Bivariate and multivariable analyses examined associations between questionnaire responses and iron deficiency defined by each model.

RESULTS

Among 1765 participants, 2.7% were anemic. Iron deficiency prevalence was 13.1% and 9.1% by the ferritin and body iron models, respectively. Based on the model, anemia-based screening had a sensitivity of 15.6-18.8% for iron deficiency. Multivariable associations for ferritin model iron deficiency included age, race/ethnicity, activity level and medroxyprogresterone acetate injection. Age and food insecurity were significant using the body iron model.

CONCLUSIONS

Universal anemia-based screening misses the majority of iron-deficient adolescent females. The common risk factor identified here, adolescent age, may both inform preventive care guidelines on age-based screenings and prospective studies of adolescent iron deficiency risk factors.

Current office-based hearing screening questions fail to identify adolescents at risk for hearing loss

OBJECTIVE

There is a rising prevalence of hearing loss among adolescents in the United States. Current paediatric preventive care recommendations by the Bright Futures guidelines and the American Academy of Pediatrics suggest that clinicians should ask adolescents ten hearing screening questions to identify those who are at high risk of hearing loss for further objective hearing testing. We assessed the utility of these subjective risk assessment questions to distinguish those adolescents with objectively documented hearing loss.

SETTING

A single public high school in Pennsylvania.

METHODS

We compared results from a prospective study evaluating objective hearing assessments with the use of the ten Bright Futures hearing screening questions plus additional adolescent-specific questions to predict adolescent hearing loss.

RESULTS

In relation to the questions used in this study, adolescents who were referred following objective hearing screens were more likely to report "trouble following the conversation when two or more people are talking at the same time" and a "past experience of slight hearing loss". Referrals from sound treated booth testing were more likely to report "trouble hearing over the phone" and have a diagnosis or history of hearing loss.

CONCLUSIONS

Most Bright Futures questions were not associated with adolescent hearing loss. An objective adolescent hearing screen should be considered in the recommended schedule of preventive care, instead of the current risk-based subjective assessment.

Pilot study of a high-frequency school-based hearing screen to detect adolescent hearing loss

OBJECTIVE

Like most of the United States, school-based hearing screening in Pennsylvania focuses on low-frequency, conductive hearing losses typical for young children, rather than the high-frequency, noise-induced hearing loss more prevalent among adolescents. The objective of this study was to compare the sensitivity and specificity of current school hearing screening in Pennsylvania with hearing screening including high frequencies, designed to detect adolescent hearing loss.

SETTING

A single public high school.

METHODS

In the Autumn of 2011 the high-frequency screen was delivered alongside the Pennsylvania school screen for students in the 11(th) grade. Screening referrals and a subset of passes returned for "gold standard" testing with audiology in a sound treated booth, in order to determine the sensitivity and specificity of the screening tests.

RESULTS

Of 282 participants, five (2%) were referred on the Pennsylvania school screen, and 85 (30%) were referred on the high-frequency screen. Of the 48 who returned for gold standard testing with audiology, hearing loss was diagnosed in 9/48 (19%). Sensitivity of the Pennsylvania and high-frequency screens were 13% (95% confidence interval [CI] 0-53%) and 100% (95% CI 66-100%) respectively. Specificity of the Pennsylvania and high-frequency screens were 97% (95% CI 87-100%) and 49% (95% CI 32-65%) respectively.

CONCLUSIONS

Current school hearing screens have low sensitivity for detection of adolescent hearing loss. Modifying school-based protocols may be warranted to best screen adolescents, and make optimal use of school nurse time and effort.

Does trainee involvement affect anticipatory guidance in well-child care?

BACKGROUND

Studies demonstrate gaps in anticipatory guidance during well-child visits, but none consider academic teaching hospitals where physician trainees also provide counseling. We prospectively assessed parental perception of anticipatory guidance at the outpatient clinic of an academic teaching hospital.

METHODS

Parents of patients newborn to <60 months old completed questionnaires regarding providers seen and anticipatory guidance preferences.

RESULTS

Of 204 parents, 40% saw the child's primary attending alone. There was no association between providers seen and the number of topics covered. Seeing the child's primary attending alone increased the odds that parents' priority topics were covered compared with another attending (odds ratio [OR] = 0.31; 95% confidence interval [CI] = 0.11-0.90) or the addition of a resident (OR = 0.35; 95% CI = 0.16-0.77) or medical student (OR = 0.33; 95% CI = 0.12-0.90).

CONCLUSIONS

Priority anticipatory guidance is covered only one third as often when the well-child visit is not conducted by the primary attending. When involving trainees, continuity of care and parental concerns must be emphasized.

A cost-effectiveness analysis of screening urine dipsticks in well-child care

OBJECTIVE

Despite data suggesting that routine urine screening for chronic kidney disease (CKD) has low diagnostic yield and the American Academy of Pediatrics 2007 recommendation to discontinue this screening, pediatricians may not have recognized this change. Because the new recommendation marks a major alteration in the practice guidelines, we sought to evaluate the cost-effectiveness of dipstick urinalysis for detection of CKD from the primary care practitioner's perspective.

METHODS

Decision analysis was used to model a screening dipstick urinalysis strategy relative to a no-screening strategy. Data on the incidence of hematuria and proteinuria in children were derived from published reports of large cohorts of school-aged children. Direct costs were estimated from the perspective of the primary care practitioner. The measure of effectiveness was the rate of diagnoses of CKD. Cost-effectiveness was evaluated by using an incremental cost-effectiveness ratio.

RESULTS

Expected costs and effectiveness for the no-screening strategy were 0 dollars because no resources were used and no cases of CKD were diagnosed. The screening strategy involved a cost per dipstick of 3.05 dollars. Accounting for both true-positive and false-positive initial screens, 14.2% of the patients required a second dipstick as per typical clinical care, bringing the expected cost of the screening strategy to 3.47 dollars per patient. In the screening strategy, 1 case of CKD was diagnosed per 800 screened, and the incremental cost-effectiveness ratio was 2779.50 dollars per case diagnosed.

CONCLUSIONS

Urine dipstick is inexpensive, but it is a poor screening test for CKD and a cost-ineffective procedure for the primary care provider. These data support the change in the American Academy of Pediatrics guidelines on the use of screening dipstick urinalysis. Clinicians must consider the cost-effectiveness of preventive care procedures to make better use of available resources.