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OBJECTIVES: To determine the natural history of pediatric hypertension. METHODS: We conducted a 72-month retrospective cohort study among 165 primary care sites. Blood pressure measurements from two consecutive 36 month periods were compared. RESULTS: Among 398 079 primary care pediatric patients ages 3 to 18, 89 347 had ≥3 blood pressure levels recorded during a 36-month period, and 43 825 children had ≥3 blood pressure levels for 2 consecutive 36-month periods. Among these 43 825 children, 4.3% (1881) met criteria for hypertension (3.5% [1515] stage 1, 0.8% [366] stage 2) and 4.9% (2144) met criteria for elevated blood pressure in the first 36 months. During the second 36 months, 50% (933) of hypertensive patients had no abnormal blood pressure levels, 22% (406) had elevated blood pressure levels or CONCLUSIONS: In a primary care cohort, most children initially meeting criteria for hypertension or elevated blood pressure had subsequent normal blood pressure levels or did not receive recommended follow-up measurements. These results highlight the need for more nuanced initial blood pressure assessment and systems to promote follow-up of abnormal results.

IntroductionPrimary care remains an underused venue for prevention and management of paediatric overweight and obesity. A prior trial demonstrated a significant impact of paediatrician/nurse practitioner (Ped/NP)-and registered dietitian (RD)-delivered motivational interviewing (MI) on child body mass index (BMI). The study described here will test the effectiveness of an enhanced version of this primary care-based MI counselling intervention on child BMI.Methods and analysisThis cluster randomised effectiveness trial includes 24 Ped/NPs from 18 paediatric primary care practices that belong to the American Academy of Pediatrics (AAP) national Pediatric Research in Office Settings (PROS) practice-based research network. To date, practices have been randomised (nine to intervention and nine to usual care). Intervention Ped/NPs have been trained in MI, behavioural therapy, billing/coding for weight management and study procedures. Usual care Ped/NPs received training in billing/coding and study procedures only. Children 3– 11 years old with BMI >the 85th percentile were identified via electronic health records (EHRs). Parents from intervention practices have been recruited and enrolled. Over about 2 years, these parents are offered approximately 10 MI-based counselling sessions (about four in person sessions with their child’s Ped/NP and up to six telephonic sessions with a trained RD). The primary outcome is change in child BMI (defined as per cent from median BMI for age and sex) over the study period. The primary comparison is between eligible children in intervention practices whose parents enrol in the study and all eligible children in usual care practices. Data sources will include EHRs, billing records, surveys and counselling call notes.Ethics and disseminationInstitutional Review Board approval was obtained from the AAP. All Ped/NPs provided written informed consent, and intervention group parents provided consent and Health Insurance Portability and Accountability Act (HIPAA) authorisation. Findings will be disseminated through peer-reviewed publications, conference presentations and appropriate AAP channels.Trial registration numberNCT03177148; Pre-results.

OBJECTIVE: To evaluate the change in the diagnosis of attention-deficit/hyperactivity disorder (ADHD) and prescribing of stimulants to children 4 to 5 years old after release of the 2011 American Academy of Pediatrics guideline. METHODS: Electronic health record data were extracted from 63 primary care practices. We included preventive visits from children 48 to 72 months old receiving care from January 2008 to July 2014. We compared rates of ADHD diagnosis and stimulant prescribing before and after guideline release using logistic regression with a spline and clustering by practice. Patterns of change (increase, decrease, no change) were described for each practice. RESULTS: Among 87 067 children with 118 957 visits before the guideline and 56 814 with 92 601 visits after the guideline, children had an ADHD diagnosis at 0.7% (95% confidence interval [CI], 0.7% to 0.8%) of visits before and 0.9% (95% CI, 0.8% to 0.9%) after guideline release and had stimulant prescriptions at 0.4% (95% CI, 0.4% to 0.4%) of visits in both periods. A significantly increasing preguideline trend in ADHD diagnosis ended after guideline release. The rate of stimulant medication use remained constant before and after guideline release. Patterns of change from before to after the guideline varied significantly across practices. CONCLUSIONS: Release of the 2011 guideline that addressed ADHD in preschoolers was associated with the end of an increasing rate of diagnosis, and the rate of prescribing stimulants remained constant. These are reassuring results given that a standardized approach to diagnosis was recommended and stimulant treatment is not first-line therapy for this age group.

BACKGROUND: Primary care pediatricians increasingly care for children’s mental health problems, but little is known about practice-level variation in diagnosis and psychotropic medication prescribing practices. METHODS: This retrospective review of electronic heath records from 43 US primary care practices included children aged 4 to 18 years with ≥1 office visit from January 1, 2009, to June 30, 2014. We examined variability in diagnosis and psychotropic prescribing across practices using logistic regression with practice fixed effects and evaluated associations of the availability of colocated or community-based mental health providers or the proportion of children in foster care with diagnosis and prescribing using generalized linear mixed models. RESULTS: Among 294 748 children, 40 932 (15%) received a mental health diagnosis and 39 695 (14%) were prescribed psychotropic medication. Attention deficit/hyperactivity disorder was most commonly diagnosed (1%–16% per practice). The proportion of children receiving any psychotropic medication (4%-26%) and the proportion receiving ≥2 medication classes (1%-12%) varied across practices. Prescribing of specific medication classes also varied (stimulants, 3%–18%; antidepressants, 1%–12%; α-agonists, 0%–8%; second-generation antipsychotics, 0%–5%). Variability was partially explained by community availability of psychiatrists (significantly higher odds of a diagnosis or prescription when not available) but not by colocation of mental health professionals or percentage of children in foster care. CONCLUSIONS: The prevalence of mental health diagnosis and psychotropic medication prescribing varies substantially across practices and is only partially explained by psychiatrist availability. Research is needed to better define the causes of variable practice-level diagnosis and prescribing and implications for child mental health outcomes.

Previous research demonstrated that as many as one-half of all clinical decisions are reached without adequate medical evidence to inform choices.1 In contrast to other areas of investigation, comparative effectiveness research (CER) directly addresses this problem. Specifically, CER uses varied study designs to generate and synthesize evidence demonstrating the benefits and harms of alternative methods to prevent, diagnose, treat, and monitor clinical conditions or improve the delivery of care.1,2 The need for CER is especially urgent in pediatrics, a field in which clinicians and families frequently depend on the generalization of medical knowledge from adult trials despite limited evidence to support the use of these treatments.3 To close these knowledge gaps, the American Recovery and Reinvestment Act of 2009 (ARRA) allocated $1.1 billion for CER.4 CER to improve child health must address the needs of families treated by primary care clinicians in the community. After the newborn period, most children are infrequently admitted to hospitals and are only occasionally cared for by pediatric subspecialists.5 To aggregate data from multiple primary care settings and avoid bias from small samples of families or clinicians, pediatric primary care practice-based research networks have increasingly informed how pediatric clinicians understand child health issues.6 However, because of the costs of manually reviewing paper-based records and collecting other data from geographically dispersed sites, the research productivity of these networks could be dramatically increased through access to electronic medical record (EMR) data.7 This potential is enhanced because EMRs are becoming increasingly common in pediatric practices8,9 as a result of ARRA incentives, which devoted $19 billion to promote their adoption.4 Through examples from The Children’s Hospital of Philadelphia (CHOP) Pediatric Research Consortium (PeRC) and the American Academy of Pediatrics (AAP) Electronic Pediatric Research in Office Settings (ePROS) networks, this review highlights the challenges and opportunities in using EMRs to foster CER and improve the delivery and outcomes of pediatric care.

The purpose of this study was to describe rates and patterns of long- and short-acting alpha agonist use for behavioral problems in a primary care population following Food and Drug Administration (FDA) approval of the long-acting alpha agonists guanfacine and clonidine.Children and adolescents 4-18 years of age, who received an alpha agonist prescription between 2009 and 2011, were identified from a sample of 45 United States primary care practices in two electronic health record-based research networks. Alpha agonist receipt was identified using National Drug Codes and medication names. The proportion of subjects receiving long- and short-acting prescriptions in each year was calculated and examined with respect to reported mental health diagnoses, and whether indications for use were on-label, had evidence from clinical trials, or had no trial evidence.In a cohort of 282,875 subjects, 27,671 (10%) received any psychotropic medication and only 4,227 subjects (1.5%) received at least one prescription for an alpha agonist, most commonly a short-acting formulation (83%). Only 20% of alpha agonist use was on-label (use of long-acting formulations for attention-deficit/hyperactivity disorder [ADHD]). Most subjects (68%) received alpha agonists for indications with evidence of efficacy from clinical trials but no FDA approval, primarily short-acting formulations for ADHD and autism; 12% received alpha agonists for diagnoses lacking randomized clinical trial evidence in children, including sleep disorders and anxiety, or for which there was no documented mental health diagnosis. Rates of long-acting alpha agonist use increased more than 20-fold from 0.2% to 4%, whereas rates of short-acting alpha agonist use grew only slightly between 2009 and 2011 from 10.6% to 11.3%.Alpha agonist use was uncommon in this population, and most subjects received short-acting forms for conditions that were off-label, but with clinical trial evidence. The safety and efficacy of use for conditions, including sleep disorders and anxiety, lacking evidence from randomized trials, warrant further investigation.

The United States lacks a system to use routinely collected electronic health record (EHR) clinical data to conduct comparative effectiveness research (CER) on pediatric drug therapeutics and other child health topics. This Special Article describes the creation and details of a network of EHR networks devised to use clinical data in EHRs for conducting CER, led by the American Academy of Pediatrics Pediatric Research in Office Settings (PROS). To achieve this goal, PROS has linked data from its own EHR-based “ePROS” network with data from independent practices and health systems across the United States. Beginning with 4 of proof-of-concept retrospective CER studies on psychotropic and asthma medication use and side effects with a planned full-scale prospective CER study on treatment of pediatric hypertension, the Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER2) collaborators are developing a platform to advance the methodology of pediatric pharmacoepidemiology. CER2 will provide a resource for future CER studies in pediatric drug therapeutics and other child health topics. This article outlines the vision for and present composition of this network, governance, and challenges and opportunities for using the network to advance child health and health care. The goal of this network is to engage child health researchers from around the United States in participating in collaborative research using the CER2 database.

Creating links to community resources for childhood aggression is one component of office-based violence prevention. Evidence is lacking regarding the effect of training clinicians to make these referrals and families’ responses to them. Clinicians who received training (n=47) and parents (1093) were queried on the provision of referrals immediately after the visit. Fewer than half of clinicians (45%) reported making a community referral. A third of providers (37%) noted difficulty in identifying local resources. Training clinicians to utilize community resources for childhood aggression does not often result in creating community links for this purpose.

OBJECTIVE. The objective of this study was to determine whether patients' families' violence-prevention behaviors would be affected by their primary care practitioner's use of a violence-prevention clinical intervention during the routine well-child examination.METHODS. In this cluster-randomized, controlled trial (2002–2006), 137 Pediatric Research in Office Settings practices were randomly assigned and initiated patient recruitment for either an office-based violence-prevention intervention or a control group (educational handout on literacy promotion provided). Primary caregivers of children who were aged 2 to 11 years and presented for a well-child visit were surveyed at baseline and 1 and 6 months. Practitioners were trained to (1) review a parent previsit summary regarding patient-family behavior and parental concern about media use, discipline strategies, and children's exposure to firearms, (2) counsel using brief principles of motivational interviewing, (3) identify and provide local agency resources for anger and behavior management when indicated, and (4) instruct patient-families on use of tangible tools (minute timers to monitor media time/timeouts and firearm cable locks to store firearms more safely where children live or play). Main outcomes were change over time in self-reported media use RESULTS. Generalized estimating equation analysis revealed a significant effect at 6 months for decreased media use and safer firearm storage. The intervention group compared with the control group showed an increase in limiting media use to CONCLUSIONS. This randomized, controlled trial demonstrated decreased media exposure and increased safe firearm storage as a result of a brief office-based violence-prevention approach.

The feasibility and effectiveness of a distance-based quality improvement model were examined in a cohort of Pediatric Research in Office Settings (PROS) practices, with the goal of improving immunization rates and practitioner behaviors and attitudes. Of an initially assessed 82 practices, 29 with baseline rates of ≤88% for children 8 to 15 months of age were randomized into year-long paper-based education or distance-based quality improvement intervention groups. Outcomes were utility/helpfulness of quality improvement modalities, immunization rate change, and behavior/attitude change. Quality improvement participants attended approximately 75% of monthly conference calls but used the quality improvement Listserv and Web site infrequently (mean 1.09 and 0.92 uses, respectively). Helpfulness ratings of quality improvement modalities mirrored usage. Analyses revealed a 4.9% increase in quality improvement group immunization rates ( P = .061), a 0.8% education group increase ( P = .752), and a 4.1% difference between groups ( P = .261). More quality improvement practices adopted systems identifying children behind in immunizations. A distance-based quality improvement model is feasible and may improve immunization rates.