Miranda Hester

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

In 2013 New York State enacted regulations on sepsis in the hope of improving pediatric sepsis outcomes. An 

 into the effectiveness of the regulations was published in 

Investigators used hospital discharge data from New York and 4 control states (Florida, Massachusetts, Maryland, and New Jersey) from 2011 to 2015. Overall, they looked at 9436 children who were admitted to 237 hospitals.

Unadjusted pediatric sepsis mortality decreased in New York and the control states. Following primary analysis, no significant effect from the regulations was found on mortality trends. However, in a prespecified sensitivity analysis that excluded hospitals in the New York metropolitan area that had been involved in earlier quality improvement programs found that the regulations were associated with improved mortality. Furthermore, regulations were tied to improved mortality trends in certain subgroups such as children who weren’t admitted through the emergency department and children who had previously been healthy.

The researchers concluded that implementing statewide regulations to improve sepsis outcomes were overall linked to improved mortality trends. This was particularly true in subpopulations of patients.

1. Gigli K, Davis B, Yabes J, et al. Pediatric outcomes after regulatory mandates for sepsis care. 

. 2020:145(6):e20193353. doi:10.1542/peds.2019-3353

Articles

Some states have used laws and regulations to help improve health outcomes. An investigation examines whether New York’s sepsis regulations helped.

Did New York sepsis regulations improve outcomes?

By now you are no stranger to telehealth (TH) virtual visits and have likely decided on your TH service provider of choice. Once the COVID-19 pandemic is over, you will, no doubt, continue to provide TH services for patients. Let’s explore several common myths about TH services and see if they need busting!

This is reminiscent of the terminology applied to our digital medical records. At one point these were referred to as “Electronic Medical Records” (EMRs) rather than “Electronic Health care Records” (EHRs) in common use today. Strictly speaking, telemedicine refers to virtual visits between providers and patients. Telehealth includes telemedicine services, but also includes phones calls, reviewing photos and videos sent by patients, call centers, and remote monitoring of patients via mobile applications connected to glucometers, cardiac monitors, and others.

The more you spend on a TH service provider, the better services you can provide patients!

In the case of TH services, the old adage “you get what you pay for” is just not the case. More expensive TH portals include virtual waiting rooms, a section within the TH application to document visits, the ability for patients to pay for visits, screen sharing, and more. These duplicate many of the features included in your EHR and patient portal. In my view you want to communicate with patients quickly and easily from both the provider and patient perspective. That’s why I will recommend Doximity’s Dialer Video as one of best TH services available today. It is free of charge, supports group visits, and “it just works”.

Telehealth video visits provide health care savings for physicians, patients, and insurance companies

During the pandemic, most states have mandated that TH video visits be paid at parity with in-office visits, and many have even mandated that telephone TH visits be paid in this way as well. Telehealth saves parents money in traveling expenses, lost time from work, as well as a multitude of inconveniences (getting kids dressed, arranging a babysitter for the sibling not being seen in the office etc.). At the practice level, for virtual visits, patients do not need to be roomed, have vitals taken, and personal protection equipment isn’t needed, saving overhead expenses. Moreover, if you are proficient at TH video visits you can “see” more video visits per hour than you can in-office visits. Therefore, TH can increase practice productivity at a time when the pandemic has reduced revenue. Lastly, insurance companies will realize reduced payments, as fewer patients will need to be seen in emergency departments, and likely fewer diagnostic tests will be ordered via TH visits compared to in office visits.

You cannot do physical examinations via virtual visits!

As a consequence of the pandemic, parents have avoided bringing children to their routine well visits. This is quite understandable as venturing into the community is considered hazardous, and most parents (and pediatricians) recognize that medical offices are especially risky environments for catching illnesses. The American Academy of Pediatrics (AAP) has given their approval for virtual well visits - “For practices who have successfully implemented telehealth to provide appropriate elements of the well exam virtually, these telehealth visits should continue to be supported, followed by a timely in-person visit.” You can provide important age appropriate advice during these visits and have the parents obtain measurements (baby scales are inexpensive and can be ordered from online vendors for $20-$40). You can also do a cursory physical examination looking for rashes, orthopedic issues, examine the throat, and have the parents palpate the neck, abdomen, etc.

Once the pandemic is over, regulations regarding TH virtual visits will change.

Hopefully, in the not too distant future, the pandemic will be over! Realistically, it is likely to linger for months to come. Emergency mandates at the federal and state levels have facilitated the performance of TH virtual and telephone visits by medical professionals. Eventually we can expect that these mandates will be lifted, the status quo will be state policies that were in place 

 the COVID-19 pandemic crippled our health care system. Many states, such as my state of New Hampshire, have mandates in place to assure that insurance companies and Medicaid pay for TH virtual visits at parity with office visits. You can check the status of your state by visiting the Center for Connected Health Policy’s webpage at 

. Many forward-thinking insurance plans may continue to cover TH virtual visits, realizing it is to their advantage to do so. It would also be prudent to ask your AAP state chapter to petition your state legislature to consider changing state laws, if needed, to continue full payment for virtual TH visits.

By the way, as of this writing, several US senators are collaborating on a bill to make current guidelines for TH care permanent – so stay tuned!

That’s it. Hope your experience providing TH services to patients is a positive one. Please send your comments and questions to me at 

What's telehealth fact and what's telehealth fiction? Dr. Schuman explores common assumptions regarding telehealth.

Telehealth myths: True or not true?

With children being exposed to media via television, smartphones, and tablets, there’s also exposure to advertising. The industry has taken notice and spent $3.2 billion on nondigital advertising and $900 million for digital advertising in the United States in just 2018. The American Academy of Pediatrics has issued a

The statement discusses how children aged 7 years and younger have difficulty understanding when someone is trying to persuade them, but this doesn’t mean that children can resist advertising, as children aged as young as 2 years can identify characters and connect them with a product that the characters have endorsed.

The statement offered the following recommendations for parents:

1. Know what the child is accessing and downloading.

2. Monitor privacy settings on all digital devices.

3. Create a family media plan that mostly includes media content with as few ads as possible.

4. Educate the child on how to analyze ads, understand what personal information may be collected, and to be aware of persuasive content.

5. Talk about digital privacy tools used in the child’s school with administrators and teachers.

1. Knowing how children are being targeted and assist parents in understanding how targeting may work.

2. Ask families if they have media use concerns during well-visits.

3. Give families resources that can help them build digital literacy.

4. Encourage parents to consider themselves as digital role models for their children.

5. Advocate for regulations that limit advertising and data collection for children and teenagers.

1. Radesky J, Chassiakos Y, Ameenuddin N, Navsaria D. Digital advertising to children. 

. 2020: 145(6):e20201681. doi:10.1542/peds.2020-1681

The American Academy of Pediatrics (AAP) has issued a statement on keeping children safe from the potential harms of advertising.

AAP issues guidance on advertising to children

Obesity can be related to certain psychological and behavioral attributes. A recent report in 

 compared those attributes between children and adolescents who were overweight or non-severe obese with those who had severe obesity.

The investigators invited children and adolescents with a body mass index ≥ 85th percentile to engage in a prospective research registry. The participants were asked about their family characteristics, dietary intake, physical activity, cardiometabolic parameters, perception of health and mental well-being, and eating behaviors.

A racially/ethnically diverse cohort of 105 participants were included in the study. In this cohort, 51% of the participants had severe obesity. With higher levels of obesity the percentage of body fat percentage increased. No difference was seen in the self-reported frequency of consumption of intake of sugar sweetened beverages and fresh produce across all of the weight categories. Among the participants with severe obesity, higher levels of emotional eating and eating were reported (

 = 0.022) as well as higher levels of stress (

 = 0.013). They also reported engaging in fewer sports or organized activities (

 = 0.044) and had a suboptimal perception of their health (p = 0.053). Participants with severe obesity reported asthma, depression and obstructive sleep apnea more frequently as well.

The investigators concluded that children and adolescents who have severe obesity have noticeable differences in both behavioral and psychosocial attributes. These differences can be used to create targeted intervention to improve health.

1. Thaker VV, Osganian SK, deFerranti SD, et al. Psychosocial, behavioral and clinical correlates of children with overweight and obesity. 

. 2020;20(1). doi:10.1186/s12887-020-02145-2

A report examines whether children and adolescents who have severe obesity have differences in certain psychological and behavioral attributes than their peers.

Author | Miranda Hester

Articles

Did New York sepsis regulations improve outcomes?

Telehealth myths: True or not true?

AAP issues guidance on advertising to children

Looking at the mental health of severely obese children