“Helping parents cope with adolescent behavior

 provides a comprehensive review of emotional and behavioral changes that occur throughout the adolescent years. The article focuses the role of pediatricians helping parents and adolescents understand the vast array of emotions including promising behaviors as well as at-risk behaviors, eg, substance use, that can lead to troubling consequences for the adolescent and the parents. Jellinek describes the flux of emotions in cycles that occur on a pendulum with behaviors that demonstrate the promise of entering young adulthood with mature cognitive and emotional responses to a more toddler-like behavioral swing that frustrates parents, teachers, coaches, their friends, and perhaps, themselves. I highly recommend reading Jellinek’s article.

Thinking about adolescent emotional/behavioral swings during the COVID-19 pandemic

The normal day-to-day lives of adolescents have changed significantly over the past 18 months during the COVID-19 pandemic. Their routine behaviors, eg, meeting and interacting with friends, participating in sports, the anticipated experience by adolescents of ‘newfound’ freedoms, the excitement of entering high school, preparing to enter schools of higher education, and/or a first job have all been either put on hold or significantly altered during the pandemic.

Most adolescents have experienced at least some form of virtual education throughout the COVID-19 pandemic. For many, their first return to a classroom, either high school or college, will be this Fall 2021 semester. However, for high school students, return to school may be impacted by the current community spread of the Delta variant in areas of the country that have a high number of unvaccinated populations. How has virtual education impacted the totality of adolescent growth and development experiences? We do not have the answer to this question, as yet. Many pediatric providers schedule extra time for the annual adolescent visit. Today, this extended time for the visit is more critical than ever, to allow time to talk with the adolescent, identify real or potential emotional and/or behavioral health problems and make sustainable plans to assure the adolescent is on the path to healthy behaviors.

What about adolescents who lost a parent, sibling, relative, or friend to COVID-19?

On July, 20, 2021, the National Institute of Health published a news release based on a published research studyrevealing that 1.5 million children around the world lost a primary or secondary caregiver due to the COVID-19 pandemic.

 The United States was identified as 1 of 6 countries with the highest numbers of children who lost their parent or primary caregiver during the pandemic. As pediatricians and pediatric nurse practitioners, it is essential to consider the loss of a parent by an adolescent and the influences and possible consequences of this loss on the adolescent emotional and behavioral development. Has the adolescent even had time to grieve the loss of their parent or caregiver? Who is now supporting the adolescent? Has the adolescent received counseling for their loss? How is the adolescent coping with the loss? This is a critical time to administer and interpret validated screening tools, such as the Patient Health Questionnaires (PHQ-2

 or the Screen for Child Anxiety Related Disorders (SCARED) tool,

 during each of the office visits. These tools will help to identify the emotional and behavioral status of adolescents who have lost a parent, and to implement evidence-based treatment plans to help the adolescent cope and emerge mentally and physically healthy. In addition, as Dr. Jellinek discusses, it is also essential to screen for suicide ideation in adolescents and even more so, for adolescents who have lost a parent or primary caregiver during this pandemic. The mental health, emotional and behavioral health of our adolescents must addressed in each primary care encounter.

1. Hillis S, Unwin H, Chen Y et al. Global minimum estimates of children affected by COVID-19-associated orphanhood and deaths of caregivers: a modelling study. 

. July 20, 2021. Epub ahead of print. doi:10.1016/s0140-6736(21)01253-8

2. National Institute of Health. New Release: More than 1.5 million children lost a primary or secondary caregiver due to the COVID-19 pandemic

Published July 20, 2021. Accessed July 20, 2021.

 https://www.nih.gov/news-events/news-releases/more-15-million-children-lost-primary-or-secondary-caregiver-due-covid-19-pandemic

3. American Psychological Association. Patient Health Questionnaire (PHQ-9 & PHQ-2). Accessed July 22, 2021.

 https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/patient-health

4. The CRAFFT Questionnaire (version 2.0). Accessed July 22, 2021.

 https://njaap.org/wp-content/uploads/2018/03/COMBINED-CRAFFT-2.1-Self-Admin_Clinician-Interview_Risk-Assess-Guide.pdf

5. Generalized anxiety disorder GAD-7. Accessed July 22, 2021. 

http://www.medi-mouse.com/graphics/GAD7.pdf

6 .Screen for child anxiety related disorders (SCARED). Accessed July 21, 2021.

 https://projectteachny.org/wp-content/uploads/2017/09/SCARED_child.pdf

Articles

Adolescence is often a time when a teenager swings between maturity and childish behavior. This already fraught period has been exacerbated by the effects of the pandemic as well.

Understanding the perplexing adolescent years

Ms. Hester is Content Specialist with Contemporary OB/GYN and Contemporary Pediatrics.

Guidelines currently recommend administering intravenous magnesium sulfate for refractory pediatric asthma in the emergency department, but hospitalization rates tied to asthma have been stable. An 

 looked at whether receiving intravenous magnesium sulfate therapy was linked to subsequent hospitalization.

Investigators performed a post hoc secondary analysis of a double-blind randomized clinical trial of children who had acute asthma and were treated from September 2011 to November 2019 in 7 Canadian tertiary care pediatric emergency departments. Children with Pediatric Respiratory Assessment Measure scores that were 5 points or higher following an initial treatment with systemic corticosteroids and inhaled albuterol with ipratropium bromide were randomized to either receive 3 nebulized treatments of albuterol plus intravenous magnesium sulfate (40-75 mg/kg) or 3 nebulized treatments of albuterol plus an intravenous 5.5% saline placebo.

There were 816 children included in the study of which 364 were hospitalized. There were 215 children who were given intravenous magnesium sulfate, of which 190 were hospitalized. By comparison only 174 of the 601 children who did not get intravenous magnesium sulfate were hospitals. Factors linked to hospitalization included an increase in Pediatric Respiratory Assessment Measure score at disposition (per 1-U increase: odds ratio [OR], 2.24; 95% CI, 1.89-2.65; 

 < .001), utilization of additional albuterol (OR, 5.94; 95% CI, 3.52-10.01; 

 < .001), and receiving intravenous magnesium sulfate from 2011 to 2016 (OR, 22.67; 95% CI, 6.26-82.06; 

 < .001) as well as from 2017 to 2019 (OR, 4.19; 95% CI, 1.99-8.86; 

 < .001). Administration of intravenous magnesium sulfate was linked to hospitalization in children who had a disposition Pediatric Respiratory Assessment Measure score of 3 or lower (OR, 8.52; 95% CI, 2.96-24.41; 

The investigators concluded that after adjusting for patient-level characters that receiving intravenous magnesium sulfate therapy after an initial asthma treatment in the emergency department was linked to subsequent hospitalization and existed even among children with mild asthma at emergency department disposition.

1. Schuh S, Freedman S, Zemek R, et al. Association between intravenous magnesium therapy in the emergency department and subsequent hospitalization among pediatric patients with refractory acute asthma. 

. 2021;4(7):e2117542. doi:10.1001/jamanetworkopen.2021.17542

Intravenous (IV) magnesium sulfate is recommended for treating refractory pediatric asthma, but is it linked to consequent hospitalization?

Does IV magnesium treatment for asthma lead to hospitalization?

AAP recommends universal masking in school for kids older than 2 years

The newest guidance from the American Academy of Pediatrics (AAP) says that all students aged older than 2 years should wear masks for in-person learning.

Examining the disparities in school reopening last fall

Much was made about how virtual learning was an imperfect substitute for in-person education that left many sociodemographic groups behind. When schools reopened for in-person education, were those groups left behind again?

Parents and teens want to discuss reproductive health

A report indicates that both parents and teenagers want to have discussions on sexual and reproductive health during preventive visits, but those discussions may not be happening as often as they should be.

Often discussed in adult patients, the likelihood of long COVID-19 in children is less well known. A research letter offers insight.

It was a very busy week for the Contemporary Pediatrics team.

 In case you missed it: July 19 to July 23

 AztraZeneca’s BYDUREON BCise (exenatide extended-release) once-weekly injectable suspension for use in children aged 10 to 17 years for the treatment of type 2 diabetes.

 The treatment should be used in addition to a diet and exercise plan.

The approval is passed on a 24-week, randomized, double-blind, placebo-controlled phase III trial, which had a 28-week open-label extension. The 82 participants who were treated with diet and exercise alone or in combination with oral antidiabetic agents and/or insulin were randomly placed into a treatment arm where they received exenatide extended-release 2 mg on into the control arm where they received a placebo. The primary endpoint for efficacy was change in glycated hemoglobin A1c (HbA1c) from baseline to the 24th week. The investigators found that children in the treatment arm had a significantly larger mean change in HbA1c when compared to the placebo group (-0.25%, n=58, baseline A1c 8.13% vs + 0.45%, n = 24, baseline A1c 8.28%, respectively; 

The adverse events noted in the trial were similar to those seen in the adult population. The most common events were an injection site nodule and nausea. It’s not recommended for use a first-line therapy in children who are inadequately controlled on diet and exercise and should not be use with other exenatide-containing products. For patients with a history of pancreatitis, other therapies should be considered first.

1. AstraZeneca. BYDUREON BCise (exenatide extended-release) approved in the US for the treatment of type 2 diabetes in pediatric patients ages 10 years and older. Published July 23, 2021. Accessed July 23, 2021. 

https://www.astrazeneca-us.com/content/az-us/media/press-releases/2021/bydureon-bcise-exenatide-extended-release-approved-in-the-us-for-the-treatment-of-type-2-diabetes.html

The US Food and Drug Administration (FDA) has approved the AstraZeneca once-weekly injectable therapy for use in children aged 10 to 17 years.

FDA approves BYDUREON BCise for treatment of type 2 diabetes

Preventive oral health services are a cornerstone of a child having good oral health. However, as with other health services, these preventive services may require extra care for children with special health care needs. A 

 looked into the prevalence or oral health concerns as well as receiving preventive oral health care.

The investigators used pooled data from the 2016-2018 National Survey of Children’s Health. The sample included 23,099 children with special health care needs and 75,612 children who did not have special health care needs. Caregivers were asked about toothaches, bleeding gums, delayed teeth, cavities, and fair or poor teeth conditions. Preventive dental visits, cleanings, tooth brushing as well as oral health care instructions, fluoride, and sealants were defined as preventive oral health services.

When looking at the past year, investigators found that a higher proportion of children with special health care needs than those with no special needs had received preventive dental care (84% vs 78%, 

 < .0001). An analysis of specific preventive services showed similar patterns. However, there were higher rates of oral health problems seen in children with special health care needs than their peers with no needs. Decayed teeth and cavities occurred in 16% of children with special health care needs and only 11% in their peers. Through an adjusted analysis, investigators found that several factors had a significant link to a decreased prevalence of receiving preventive oral services in a subset of children with special health care needs, which included lower household education, non-English language, younger or older age, and worse condition of teeth, and lack of health insurance, lack of a medical home.

The investigators concluded that although children with special health care needs receive a higher rate of preventive oral health services than their peers without those needs, they also have worse oral health status. Making sure that appropriate use of preventive oral services is important to reducing oral health problems in children with special health care needs.

1. Lebrun-Harris L, Canto M, Vodicka P, Mann M, Kinsman S. Oral health among children and youth with special health care needs. 

. July 21, 2021. Epub ahead of print. doi:10.1542/peds.2020-025700

A study looks at the prevalence of preventive oral care and overall oral health in children who have special health care needs.

Considering oral care in children with special health care needs

 that AZSTARYS (serdexmethylphenidate and dexmethylphenidate) is now available for treatment of attention-deficit/hyperactivity disorder (ADHD) in children aged 6 years and older.

 The therapy is 70% extended-release serdexmethylphenidate and dexmethylphenidate with 30% immediate release dexmethylphenidate. The therapy is available in 3 once-daily dosages: 26.1/5.2mg, 39.2/7.8mg, and 52.3/10.4 mg.

The therapy was approved by the US Food and Drug Administration in March 2021. The approval was based on a multicenter, double-blind, randomized, placebo-controlled, phase 3 study of 150 children aged 6 to 12 years who had been diagnosed with ADHD. The study found that there were significant improvements in the group treated with the therapy. No serious adverse events were noted in the study, but headache, upper abdominal pain, insomnia, and pharyngitis were more notable in the group receiving the treatment than the placebo group.

The therapy should not be used children who are allergic to serdexmethylphenidate, methylphenidate, or other ingredients in AZSTARYS as well as children who have taken or stopped taking within 2 weeks monoamine oxidase inhibitor. AZSTARYS is a controlled substance with the potential for abuse that may lead to dependence. Caregivers should put the drug in a safe place to prevent misuse.

1. Corium, Inc. Corium launches innovative ADHD treatment AZSTARYS (serdexmethylphenidate and dexmethylphenidate) in the US for patients age 6 years and older. Published July 21, 2021. Accessed July 22, 2021. 

https://www.corium.com/pdf/Corium_AZSTARYS_Now_Available_Press_Release_7-21-21.pdf

AZSTARYS (serdexmethylphenidate and dexmethylphenidate) is available for prescription to help provide rapid and extended duration of attention-deficit/hyperactivity disorder (ADHD) symptoms.

AZSTARYS is now available for treating ADHD

We know a lot more about COVID-19 than we did when the pandemic started, but there are still aspects of the infection that are unknown. One is the neurologic and psychiatric complications related to infection. An 

 analyzed these issues in children and teenagers who had been hospitalized.

Investigators used an online network of secure rapid-response portals to run a prospective cohort study. They asked pediatric neurologists to note any pediatric patient admitted to the hospital with neurological or psychiatry disorders that they considered COVID-19 relevant to the presentation. The patients were divided into primary neurological disorder associated with COVID-19 (COVID-19 neurology group) or pediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS) with neurological features (PIMS-TS neurology group).

There were 52 cases among 1334 children and teenagers who had been hospitalized with COVID-19, for an estimated prevalence of 3.8 cases per 100 pediatric patients. There were 27 patients in the COVID-19 neurology group and 25 were in the PIMS-TS neurology group. In the COVID-19 neurology group, the diagnoses included status epilepticus (n=7), encephalitis (n=5), Guillain-Barré syndrome (n=5), acute demyelinating syndrome (n=3), chorea (n=2), psychosis (n=2), isolated encephalopathy (n=2), and transient ischaemic attack (n=1). Patients in the PIMS-S neurology group were found to more often have multiple features, including encephalopathy (n=22 [88%]), peripheral nervous system involvement (n=10 [40%]), behavioral change (n=9 [36%]), and hallucinations at presentation (n=6 [24%]). Neuroimmune disorders were more common in the COVID-19 neurology group. More children in the PIMS-TS neurology group went to intensive care and were given immunomodulatory treatment. Seventeen patients (10 in the COVID-19 neurology group and 7 in the PIMS-TS neurology group) were discharged from the hospital with disability and 1 participant in the PIMS-TS neurology group died.

The investigators concluded that although patients in the PIMS-TS neurology group were more likely to need intensive care, overall the outcomes were similar across both groups. They urged further study of the mechanisms for neurological involvement in COVID-19 as well as understanding the longer-term outcomes.

1. Ray S, Abdel-Mannan O, Sa M, et al. Neurological manifestations of SARS-CoV-2 infection in hospitalised children and adolescents in the UK: a prospective national cohort study. 

. July 14, 2021. Epub ahead of print. doi:10.1016/s2352-4642(21)00193-0

A study looks into the neurological and psychiatric aspects of COVID-19 infections.

Examining the neurological and psychiatric complications of COVID-19

AbbVie announced the US Food and Drug Administration has approved dalbavancin (Dalvance) for treatment of acute bacterial skin and skin structure infection (ABSSSI) in pediatric patients.1 It is the first single-dose treatment option administered as a 30-minute intravenous (IV) infusion for ABSSSI caused by susceptible Gram-positive bacteria in pediatric patients which includes infections caused by methicillin-resistant 

"Serious infections in children can be difficult to treat and the impact of ABSSSI among children is significant, as these infections often require IV antibiotics, resulting in hospitalization," said Margaret Burroughs, medical director, infectious diseases, AbbVie, Libertyville, Illinois. "This pediatric approval for Dalvance as a single-dose provides a meaningful contribution to the treatment of children and infants with ABSSSI."

This approval is based on results from a multicenter, open-label, actively controlled clinical trial (NCT02814916) evaluating dalbavancin as treatment in pediatric patients from 0 to 18 years diagnosed with ABSSI and 3 pharmacokinetic trials (NCT01946568, NCT02688790, and NCT00678106).

In NCT02814916, the safety and efficacy of dalbavancin was compared to vancomycin, intravenous oxacillin, and flucloxacillin. Patients were randomized 3:3:1 to be treated with single-dose dalbavancin, 2-dose dalbavancin, or comparator.

The primary endpoint of the study was to evaluate the safety and tolerability of dalbavancin. The trial was not powered for comparative inferential efficacy analysis. There was an analysis of 183 patients with ABSSI in a modified intent-to-treat (mITT) population, which included all randomized patients who received any dose of study drug and had a diagnosis of ABSSI by gram-positive organisms, to evaluate the treatment efficacy.

The analysis evaluated patient response at 48 to 72 hours on a 20% or greater reduction in lesion size compared to baseline and no past of rescue antibacterial therapy for pediatric patients 3 months and older. Of the 75 patients analyzed, 73 achieved an early clinical response (97.3%) in the single-dose arm, 73 out of 78 (93.6%) of the double-dose arm, and 26 of 30 (86.7%) patients in the comparator arm.

These results were similar to those observed in adults. The approved recommended dosage for dalbavancin in pediatric patients with a creatinine clearance of 30 mL/min/1.73m2 and above is a single-dose regimen based on the age and weight of the pediatric patient.

This article was originally published by Dermatology Times.

1. Dalvance® (Dalbavancin) receives FDA approval to treat acute bacterial skin and skin structure infections in pediatric patients | Abbvie news center. Accessed July 27, 2021. 

https://news.abbvie.com/news/press-releases/dalvance-dalbavancin-receives-fda-approval-to-treat-acute-bacterial-skin-and-skin-structure-infections-in-pediatric-patients.htm?view_id=5591

Dalbavancin has received US Food and Drug Administration (FDA) approval to treat acute bacterial skin and skin structure infections in pediatric patients.

FDA approval given to dalbavancin for acute skin infections 

In a hospital setting, awareness of medical conditions that are most prevalent, have the highest costs, or greatest variations in costs can be helpful in determining which could most benefit from research funding. A 

Investigators performed a retrospective cohort study of children who had hospital encounters at 45 tertiary care US children’s hospitals. The Pediatric Clinical Classification System was used to classify the primary diagnosis discharge code. The Cost Master Index was used to determine the standard cost of hospital goods and services used for care, in order to eliminate the high variation in those costs across hospitals.

There were 2,882,490 inpatient hospital encounters included in the report. From a list of 50 most prevalent and 50 most costly conditions, there were 74 total conditions, of which 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 costly conditions made up $12.4 billon of $33.4 billon total costs and 33.8% of all of the conditions. The highest cost per encounter was seen with extreme immaturity conditions (ie, birth weight 500-749 g) at $382,910 (95% CI, $368,084-$397,736). The highest degree of interhospital variability in cost was seen with major depressive disorder, type 1 diabetes with complications, diabetic ketoacidosis, and acute appendicitis without peritonitis. Conditions that had high prevalence, variation in cost, and overall cost were major depressive disorder (cost rank, 19; prevalence rank, 10), scoliosis (cost rank, 6; prevalence rank, 38), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11), asthma (cost rank, 10; prevalence rank, 2), and dehydration (cost rank, 24; prevalence rank, 8).

Those in charge of determining where to allocate research funding for improved care and outcomes should keep in mind the conditions that were found to be most common and costly.

1. Gill P, Anwar M, Thavam T, et al. Identifying conditions with high prevalence, cost, and variation in cost in US children’s hospitals. 

. 2021;4(7):e2117816. doi:10.1001/jamanetworkopen.2021.17816

Knowing what conditions are the most prevalent and costly in hospitals can help determine the focus of future research, which can ensure better care. A report sheds some light.

What are the common but costly conditions treated at hospitals?

In only a matter of weeks, children and teenagers will be back at school. Many schools will be dropping virtual only or hybrid model learning at the start of the year. With so many children returning to the classroom as well as the rise of the delta variant of COVID-19, there are many questions that parents and older patients may have about returning. To address these concerns, the Infectious Disease Society of America held a briefing this morning to tackle the biggest questions in both K-12 and higher education and the delta variant.

editor-in-chief Tina Q. Tan, MD, FAAP, FIDSA, FPIDS, stressed that COVID-19 was definitely a cause for concern in children with 41 million infected with the disease, 18,000 requiring hospitalization, and 350 deaths. In addition, over 4000 of those children also developed multisystem inflammatory syndrome in children. Tan said that all who are eligible to be vaccinated should do so, nothing that only 30% of children aged 12 to 17 years are fully vaccinated. She affirmed her support of the American Academy of Pediatrics universal masking recommendations, in addition to maintaining social distancing of at least 3 feet, creating small cohorts of students and staff, and ensuring good hand hygiene as well as good ventilation. Due to the difficulty in implementing a protocol, testing in K-12 is likely not going to be common. Tan did address the fact that a number of states and cities have indicated that they will not require masking in schools. In those cases, she recommended that parents still send children to school with a mask as well as encouraging the child to maintain distance when possible.

Higher education offers a much different scenario said Preeti Malani, MD, MS, MSJ, FIDSA, FSHEA, professor of medicine in the division of infectious diseases, University of Michigan in Ann Arbor. Some institutions of higher education have mandated the vaccination for all students returning to campus, with a judge upholding one at Indiana University in Bloomington and some are setting additional fees for students who choose to go unvaccinated. Malani did note the institutions should be prepared to provide the vaccine for international students, as many may be unable to get the vaccine in their home country or the vaccine they did receive may not be one of those approved in the United States. She emphasized that even with the vaccine that the return to campus is not free of risk, but students who are vaccinated and are returning to campuses in communities with a high vaccination rate and low spread of the disease should feel comfortable with their risk level.

The Infectious Disease Society of America discussed keeping children and teenagers safe in the upcoming school year.

What the school year may hold

In response to the devastating COVID-19 pandemic in 2020, the federal government and state governments took a number of overlapping actions to promote telehealth as an alternative method for effectively delivering patient care while lowering risk of transmission – passing laws, updating regulations, issuing waivers and executive and agency orders, and releasing sub-regulatory guidance. Insurance companies and providers took corresponding steps to embrace telehealth, standing up new telehealth platforms and processes almost overnight. The result was a significant expansion of telehealth services, programs, and technologies that enabled patients to access critical care from the comfort of their homes, reduce the risk of transmission, and enable providers to reserve in-person care for higher acuity conditions.

These changes were crucial because regulatory and payment restrictions on telehealth limited its utility prior to the pandemic, except in certain situations and for specialized care for specific conditions. The COVID-19 expansion of telehealth resulted from a joint federal-state effort to waive, amend, and remove those restrictions. Importantly, inconsistencies in the approaches taken by states and the federal government, and inconsistent messaging from regulators, resulted in differing regulatory regimes for providers, particularly those who sought to provide care to patients across state lines, which was necessary as patients and providers scattered throughout the country in response to the pandemic. As a result, health care providers have raised questions regarding the permissibility of telehealth practice across state lines, and of potential exposure to audits for providers who have been reimbursed for telehealth services delivered to patients in states where providers may not be licensed. These questions – and the differences in approach taken between states – are becoming more acute as states terminate or allow state-level emergency declarations to expire, which in many cases end waivers that have enabled telehealth services during the pandemic.

Differences in telehealth regulation among New England states highlight the challenges for providers, and regulatory risks for practice across state lines. In response to the pandemic, Connecticut Governor Ned Lamont suspended state licensure requirements for telehealth services to facilitate the provision of telehealth services to patients in Connecticut by providers licensed in good standing in other states. Notably, out-of-state providers who met the minimum criteria under Governor Lamont’s order (and corresponding state Department of Public Health (DPH) orders available here and here) were authorized to provide telehealth services to individuals in Connecticut without completing any Connecticut registration or receiving a specific emergency license. The Connecticut legislature codified this approach with emergency legislation in July 2020 that was subsequently extended by Governor Lamont via executive order, and then superseded by follow-up legislation in 2021. As a result, out-of-state providers that maintain sufficient malpractice insurance are allowed to continue providing telehealth services to patients in Connecticut until DPH orders otherwise.

By contrast, Massachusetts Governor Baker’s order expanding access to telehealth services allowed for emergency licensure of physicians licensed in another state in good standing, but such out-of-state physicians were required to present a license verification to the Massachusetts Board of Registration in Medicine (BoRM) in order to be issued an emergency Massachusetts license. The Massachusetts Bureau of Health Professions Licensure then issued an order on licensure noting that BoRM “shall refrain from taking disciplinary action or other enforcement action solely upon the basis of providing telemedicine services to a patient in Massachusetts provided that the person providing such telemedicine services holds a valid Massachusetts license at the time the service is provided, including” an emergency license issued in response to COVID-19. Accordingly, to be able to provide telehealth services to a patient located in Massachusetts at the time of the visit, a physician would need to have obtained an emergency license from BoRM or other applicable licensure. Unlike in Connecticut, simply being licensed in good standing in another state was not sufficient to be licensed to provide telehealth services to individuals in Massachusetts.

Rhode Island took a third approach, in which the Department of Health’s (DOH) Board of Medical Licensure and Discipline (BMLD) issued guidance stating that although under normal circumstances “a physician not licensed to practice in Rhode Island cannot . . . treat a patient physically located in Rhode Island” due to the COVID-19 pandemic, the BMLD encouraged “all physicians to use telemedicine to deliver care to their patients” and would “not take action against physicians not licensed to practice in Rhode Island who, during the state of emergency, use telemedicine to deliver care to their established Rhode Island patients.” Interestingly, this guidance does not appear to have been accompanied by licensure waivers issued via executive order, but DOH did establish an emergency licensure approval process for out-of-state physicians who sought to obtain a license. Additionally, in early July 2021, the Rhode Island legislature codified modifications to the Rhode Island telemedicine parity law that had been included in Governor Raimondo’s executive order 20-06, which are intended to expand access and improve telehealth technologies in Rhode Island. Ultimately, however, out-of-state physicians could seek to obtain an emergency license from DOH (which are no longer being issued), or could rely on the BMLD guidance, which is limited by the duration of the state of emergency.

The different approaches among states, coupled with uncertainty regarding licensure rules applicable to telehealth encounters, almost certainly resulted in cases of non-compliance with various emergency orders, waivers, processes, and legislation. For example, although the location of the patient during the encounter generally governs licensure, providers may not have always be in a position to determine the patient’s location at the time of the encounter, thereby inadvertently running afoul of a state’s medical practice and licensure regulations. Whether such encounters are billable, or if already billed, could be subject to recoupment efforts, is an open question as payors and the government initiate audits and weigh the impact of the sudden expansion of telehealth on the health care system. Given the varying, and at times conflicting, guidance and requirements from regulators and executive orders, any out-of-state telehealth noncompliance may be immaterial from a reimbursement perspective as long as the service was provided in accordance with the standard of care. The government and payors will likely focus audit and recoupment efforts on bad actors who took advantage of COVID-19 programs for personal gain, and not to expand access to necessary care. However, the Office of the Inspector General has announced a more general approach as part of its work plan, and will review the use of Medicare telehealth services during the COVID-19 pandemic, and audit Medicare Part B telehealth services specifically. Accordingly, even providers who acted in good faith may be subject to such reviews and to heightened scrutiny of their telehealth activities. Therefore, prudent providers will assess their current compliance with licensure requirements, and plans for continued telehealth services in-state and across state lines, as COVID-19 waivers end and states determine how to move forward with telehealth services. Providers who received emergency licenses or similar in-state authorizations may want to follow up with state boards to determine options for maintaining licensure (e.g., by applying for a full license). It may also be advisable for providers to integrate processes into telehealth platforms that allow for documentation of patient location, and to implement restrictions on the provision of telehealth services to patients located in a state where the provider is not licensed. Finally, providers would also be well advised to advocate for the passing of legislation to maintain current telehealth flexibilities beyond the COVID-19 pandemic in order to maintain increased access to care for their patients.

This article was originally published by Medical Economics.

How a hodgepodge of federal and state telehealth waivers creates compliance concerns for providers practicing across state lines.

Confusion with telehealth could create issues

Despite its efficacy, the flu shot rates are still relatively low in children with only 63% of US children receiving it for the 2018-2019 influenza season. Children who are hospitalized often have conditions that may predispose them to influenza morbidity and mortality, but coverage rates are frequently lower than the national average. An 

 examined whether a clinical decision support strategy could improve influenza vaccination rates before discharge from the hospital.

Investigators conducted this quality improvement study in children who were eligible for the season influenza vaccine and were hospitalized in a tertiary pediatric health system that provides care to more than half a million patients every year in 3 hospitals. The intervention included putting a default flu short order into admission sets for eligible patients, providing a script to offer the flu shot that uses the presumptive strategy, and just-in-time education for clinicians that addressed vaccine eligibility.

There were 17,740 hospitalizations, mostly among Black (n = 8943) and White (n = 7559) patients with many using public insurance (n = 11,724). Of those hospitalizations, 10,997 were eligible for the influenza vaccine in the 2019-2020 influenza season, which were split evenly into the intervention group and concurrent controls. A pool of 6743 hospitalizations from 2018-2019 served as historical controls. Vaccine administration rates were 31% in the intervention group, 19% in the concurrent control group, and 14% in the historical control group. Following adjustment, investigators found that the odds of being administered an influenza vaccine was 3.25 (95% CI, 2.94 – 3.59) times higher in the intervention group and 1.28 (95% CI, 1.15-1.42) times higher in the concurrent controls than in the historical controls.

The investigators concluded that the program appeared to be linked to a definite improvement in vaccination rates among children who are hospitalized. Further study should see whether the benefits are sustained across seasons and whether the model would have similar results at other institutions.

1. Orenstein E, El Sayed-Ali O, Kandaswamy S, et al. Evaluation of a clinical decision support strategy to increase influenza vaccination among hospitalized children before inpatient discharge. 

. 2021;4(7):e2117809. doi: 10.1001/jamanetworkopen.2021.17809

Hospitalized children are often at risk of influenza morbidity and mortality, which means that influenza vaccination before discharge can help mitigate those risks. A study discusses how a quality improvement program could make a difference.