Literature Collection

BACKGROUND: Pediatric specialist shortages and rapidly rising autism prevalence rates have compelled primary care clinicians to consider playing a greater role in the autism diagnostic process. The ECHO Autism: Early Diagnosis Program (EDx) prepares clinicians to screen, evaluate, differentiate, diagnose, and provide longitudinal care for children with autism in primary care settings. Canvas Dx is a prescription-only Software as a Medical Device designed to support clinical diagnosis or rule out of autism, including in primary care settings. It is authorized by the Food and Drug Administration for use, in conjunction with clinical judgment, in 18- to 72-month-olds with indicators of developmental delay. OBJECTIVE: This study aims to assess the feasibility and impact of integrating the device into the ECHO Autism: EDx workflow. Time from the first clinical question of developmental delay to autism diagnosis is the primary endpoint. Secondary endpoints explore clinician and caregiver experience of device use. METHODS: Children aged 18 to 72 months with concern for developmental delay indicated by either a caregiver or health professionals were eligible to participate in this prospective observational study. Experienced ECHO Autism: EDx clinicians were recruited to evaluate the inclusion of the device as part of their diagnostic evaluations. Outcome data were collected via a combination of electronic questionnaires, standard clinical care record reviews, and analysis of device outputs. Institutional review board approval was provided by the University of Missouri-Columbia (project number 2075722). RESULTS: Eighty children and 7 clinicians completed the study. On average, time from clinical concern at study enrollment to final autism diagnosis was 39.22 days, compared to 180- to 264-day waits at adjacent specialist referral centers. The vast majority (93%, 50/54) of caregivers reported being satisfied with the ECHO Autism: EDx plus device evaluation their child received and endorsed that they would recommend it to others and that they felt comfortable using the device. The device produced determinate autism predictions or rule-outs for 52.5% of participants, and in all cases, these were consistent with the final clinical determination. Participating clinicians reported that device use was feasible and reduced several challenges associated with their previous diagnostic process; however, they noted it did not obviate the need for additional structured observation in every case. CONCLUSIONS: The ECHO Autism: EDx plus device workflow offers considerable time savings compared to specialty center referral and was strongly endorsed by caregiver participants. Embedding the device into the ECHO Autism: EDx workflow was feasible and helped streamline several workflow efficiencies. Clinicians still utilized their training and application and interpretation of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria when formulating the diagnosis for indeterminate cases.

INTRODUCTION: Periprocedural anxiety is common in pediatric patients and is characterized by tension, anxiety, irritability, and autonomic activation. Periprocedural anxiety increases during certain events including admission to the preoperative area, separation from caregivers, induction of anesthesia, and IV placement. A study of children aged 2-12 showed that perioperative anxiety in children may be influenced by high parental anxiety and low sociability of the child. While these are nonmodifiable variables in the perioperative setting, there are numerous ways to ameliorate both parental and patient anxiety including the use of certified child life specialists (CCLSs) to aid in child comfort. In this study, our objective was to evaluate the integration of CCLS in our perioperative setting on the rate of benzodiazepine use. METHODS: We used a prospectively maintained database to identify patients undergoing outpatient elective surgical and radiologic procedures from July 2022 to September 2023 and January 2023 to September 2023 respectively. CCLSs were used to work with appropriately aged children in order to decrease the use of benzodiazepines and reduce possible adverse events associated with their use. RESULTS: A total of 2175 pediatric patients were seen by CCLS in same day surgery from July 2022 to September 2023. During this period, midazolam use decreased by an average of 11.4% (range 6.2%-19.3%). An even greater effect was seen in the radiologic group with 73% reduction. No adverse events were reported during this period. CONCLUSIONS: CCLSs working with age-appropriate patients in the periprocedural setting is a useful adjunct in easing anxiety in pediatric patients, reducing the need for periprocedural benzodiazepine administration and the risk of exposure to unintended side effects.

BACKGROUND: Given the increasing recognition of the value of greater integration of physical and mental health services for children and young people, we aimed to evaluate preferences among parents for the characteristics associated with integrated health service provision for two conditions (eating disorders, functional symptom disorders). METHODS: Two discrete choice experiments (DCEs) were conducted, using electronic surveys. Participants were adult parents of children and young people. Choice scenarios were based on five attributes for the eating disorders study, and four attributes for the functional symptom disorders study. RESULTS: Two hundred parents participated in each DCE. For eating disorders, days missed from school in the last year was the attribute valued most highly, followed by days in hospital in the last year, costs to the NHS, functioning, and interaction with peers with eating disorders. Respondents were willing to trade £531 of costs to the NHS for one less day missed from school. For functional symptom disorders, time to diagnosis was valued most highly, followed by days missed from school while obtaining a diagnosis, reservations about seeing a mental health practitioner, and costs of diagnosis to the NHS. Respondents were willing to trade £4237 of costs to the NHS to wait one month less for a diagnosis. CONCLUSION: Respondents' preferences were largely consistent with the planned goals of integrating physical and mental health services. Our findings show the factors which ought to be considered when designing new integrated pathways and evaluating them.

BACKGROUND: Evidence suggests that centralising specialist healthcare services can improve outcomes for patients but increase travel distances and times. Traditionally, people requiring specialist health care were cared for by a single specialist, with mental and physical health care delivered by separate services. Recent trends involve greater collaboration between specialists. Integrated care is the highest level of collaboration, including shared access to medical records and multidisciplinary care. OBJECTIVES: To investigate how centralisation of specialised healthcare services can be characterised. To examine the proposed integration between physical and mental health services in the care of children and young people with eating disorders and functional symptom disorders in one region of England. DESIGN: Mixed-methods study comprising: a scoping review (conducted in November 2020) of four databases to characterise centralisation of specialised healthcare services; a systematic literature review (conducted in August 2022, updated in July 2024) of three databases to evaluate integration of physical and mental health services for children and young people with eating disorders and functional symptom disorders; an interview study of parents (n = 10 participants), healthcare professionals (n = 14 participants) and a project lead (n = 1 participants) to understand perspectives on integration, which analysed data in themes organised within the Consolidated Framework for Implementation Research; and two discrete choice experiments of preferences using online surveys (n = 400 participants). RESULTS: The scoping review (n = 93 studies) found that definitions of centralisation commonly lacked detail but, where available, covered centralisation's form, objectives, mechanisms and drivers. Limited evidence suggests centralisation could be linked to better outcomes, but many important outcomes were rarely examined. The systematic review of integration found one low-quality (uncontrolled) pre-post study of eating disorders in Australia. Findings from the interviews suggest that service redesign should ensure the concept of 'integration' has shared meaning among professionals, and that agreement is reached over roles and responsibilities. From the discrete choice experiments, the main things that mattered to parents when thinking about integration were days missed from school in the case of eating disorders and time to diagnosis for functional symptom disorders. LIMITATIONS: Limited, poor-quality literature in the reviews; small numbers of interview participants; difficulties engaging parents, carers and healthcare professionals for the discrete choice experiment. CONCLUSIONS: There is a lack of evidence around integrated care for children and young people affected by eating disorders and functional symptom disorders. Implementation of integrated services needs to address concerns regarding roles, responsibilities and leadership. Future evaluations should measure impact in terms of the factors found to matter most to participants in this study. FUTURE WORK: Mixed-methods studies to evaluate integrated pathways. FUNDING: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR133613.; ‘Specialised healthcare services’ are teams who are expert in treating people with certain kinds of health problem. Sometimes, they are joined up into a smaller number of larger services, so that they can treat more patients with the same condition: this is called ‘centralisation’. Previous evidence suggests that centralising specialist healthcare services can improve outcomes for patients, but it can also increase travel distances and times for patients and families. We reviewed the evidence on centralisation of specialised services. The evidence was limited, but said that centralisation was linked with better care or outcomes. We also did a more focused study looking at integration between physical and mental health services for children and young people, to inform the development of a new children’s hospital. Traditionally, people requiring specialised health care were cared for by a single specialist, with mental and physical health care delivered by separate services. More recent trends involve greater collaboration between specialists. Integrated care is the highest level of collaboration, involving shared access to medical records and multidisciplinary care. We focused on two health conditions, eating disorders and functional symptom disorders (experiencing physical symptoms, for which there is no clear explanation). We looked for research to find out what is known about integrating services for these conditions and found little evidence. We also conducted interviews with healthcare professionals, and interviews and a survey of parents to find out their views. These found broad support for integrating services for children and young people affected by these conditions. There were several concerns about integration, mostly around clearly defining roles and responsibilities of staff. The main things that mattered to parents when thinking about integration were days missed from school in the case of eating disorders, and time to diagnosis in the case of functional symptom disorders.; eng

BACKGROUND: There is a high prevalence of health problems among single people who are homeless. Specialist primary health care services for this population have been developed in several locations across England; however, there have been very few evaluations of these services. OBJECTIVES: This study evaluated the work of different models of primary health care provision in England to determine their effectiveness in engaging people who are homeless in health care and in providing continuity of care for long-term conditions. It concerned single people (not families or couples with dependent children) staying in hostels, other temporary accommodation or on the streets. The influence on outcomes of contextual factors and mechanisms (service delivery factors), including integration with other services, were examined. Data from medical records were collated on participants' use of health care and social care services over 12 months, and costs were calculated. DESIGN AND SETTING: The evaluation involved four existing Health Service Models: (1) health centres primarily for people who are homeless (Dedicated Centres), (2) Mobile Teams providing health care in hostels and day centres, (3) Specialist GPs providing some services exclusively for patients who are homeless and (4) Usual Care GPs providing no special services for people who are homeless (as a comparison). Two Case Study Sites were recruited for each of the specialist models, and four for the Usual Care GP model. PARTICIPANTS: People who had been homeless during the previous 12 months were recruited as 'case study participants'; they were interviewed at baseline and at 4 and 8 months, and information was collected about their circumstances and their health and service use in the preceding 4 months. Overall, 363 participants were recruited; medical records were obtained for 349 participants. Interviews were conducted with 65 Case Study Site staff and sessional workers, and 81 service providers and stakeholders. RESULTS: The primary outcome was the extent of health screening for body mass index, mental health, alcohol use, tuberculosis, smoking and hepatitis A among participants, and evidence of an intervention if a problem was identified. There were no overall differences in screening between the models apart from Mobile Teams, which scored considerably lower. Dedicated Centres and Specialist GPs were more successful in providing continuity of care for participants with depression and alcohol and drug problems. Service use and costs were significantly higher for Dedicated Centre participants and lower for Usual Care GP participants. Participants and staff welcomed flexible and tailored approaches to care, and related services being available in the same building. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services. LIMITATIONS: There were difficulties recruiting mainstream general practices for the Usual Care GP model. Medical records could not be accessed for 14 participants of this model. CONCLUSIONS: Participant characteristics, contextual factors and mechanisms were influential in determining outcomes. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were relatively favourable. They had dedicated staff for patients who were homeless, 'drop-in' services, on-site mental health and substance misuse services, and worked closely with hospitals and homelessness sector services. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (HSDR 13/156/03) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 16. See the NIHR Journals Library website for further project information.; Health problems are common among single people who are homeless, but there is little evidence of the best ways to deliver primary health care to them. This study evaluated four types of services (models) that are in existence: (1) health centres primarily for people who are homeless (Dedicated Centres); (2) Mobile Teams that provide health care in hostels and day centres; (3) Specialist GPs that have some services exclusively for patients who are homeless; and (4) Usual Care GPs providing health care to all patients, with no special services for people who are homeless. The study concentrated on single people (not homeless families or couples with dependent children) staying in hostels, other temporary accommodation and on the streets. Overall, 363 patients at these practices who had been homeless in the previous 12 months participated, and information was collected from them over a 12-month period. We examined the extent to which screening for different health conditions was undertaken, and to which treatment and follow-up care were provided for participants with chronic respiratory problems, depression, alcohol problems and drug problems. Information was gathered from their medical records about use of health and social care services over 12 months. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were more favourable. They had staff working specifically with patients who were homeless; provided flexible ‘drop-in’ services instead of requiring patients to book appointments; and worked closely with mental health, alcohol and drug services, and with hostels, day centres and street outreach teams. Participants were also more satisfied with the health care they received from the specialist models, and were more likely to say that they had confidence and trust in doctors and nurses at these sites. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services.; eng

BACKGROUND: Perinatal mental illnesses (PMI) affect up to 20% of women and 10% of men during pregnancy and in the first year after the birth of the child. Perinatal mental illness contributes significantly to maternal mortality and adverse neonatal, infant, and child outcomes. Because of the high prevalence and the impact of PMI on both the parents and the infant, there is an urgent need for rapid and effective care. The aim of this scoping review was to identify comprehensive evidence-based guidelines and care models for the prevention and treatment of PMI and summarize their common characteristics. METHODS: We searched manually in several databases and on websites of relevant institutions and contacted experts. We included guidelines and guidance documents based on pre-defined inclusion criteria. RESULTS: We identified six relevant guidelines and care models from four countries (United Kingdom, Ireland, Canada, Australia). The identified documents highlight the need for integrated care models (including prevention, early identification, counseling, treatment), clear referral pathways, stepped-care approaches and multi-professional, coordinated networks. CONCLUSIONS: The 'ideal' care model should consider not only the mental health of the mother, but also that of the father/co-parent and the children, as well as the parent-infant relationship. The results from this scoping review can be used for further discussion and as decision support for designing, developing, and implementing perinatal and infant mental health (PIMH) care.

OBJECTIVE: The Children's Depression Rating Scale-Revised (CDRS-R) is widely used in clinical research to assess depression in adolescents; however, limited research explores its measurement properties. This study aimed to test the interrater reliability of the CDRS-R and describe the corresponding measurement error. METHOD: A cross-sectional design was used in the context of a controlled clinical trial. The sample consisted of help-seeking adolescents (N = 55, ages 13-18 years, inclusive) experiencing depressive symptoms. A research analyst administered and coded the CDRS-R to adolescents through a virtual video-based platform with audio and video recordings. A second research analyst independently watched and coded recordings. The lower bound of the 95% CI of the intraclass correlation coefficient with respect to absolute agreement between 2 independent raters was hypothesized to be ≥0.70. RESULTS: The reliability of CDRS-R was calculated as an intraclass correlation coefficient of 0.84 (95% CI 0.71 to 0.91), indicating acceptable reliability. The associated standard error of measurement was 4.67, and the mean difference in scores between raters was 1.13. The limits of agreement were -11.59 to 13.84. CONCLUSION: The findings provide support for the CDRS-R as a tool with adequate interrater reliability to assess depressive symptoms in adolescents. The measurement error parameters can assist in clinical interpretation of differences in scores when adolescents are assessed by multiple raters. CLINICAL TRIAL REGISTRATION INFORMATION: Effectiveness of an Integrated Care Pathway for Depression: Cluster Randomized Controlled Trial (CARIBOU-2); https://clinicaltrials.gov/study/NCT05142683.; This study evaluated the reliability of the Childhood Depression Rating Scale-Revised (CDRS-R), a common interview tool used to assess depression among youth. Researchers found strong agreement among different raters, with a high statistical reliability score of 0.84. These results suggest that the CDRS-R is a consistently reliable assessment tool.; eng

BACKGROUND: A U.S. Preventive Services Task Force (USPSTF) report found no consistent evidence that counseling interventions are effective at reducing drug use or improving other health outcomes in populations whose drug use was identified through primary care-based screening with questions about drug use or drug-related risks (i.e., “screen-detected populations”). Evidence from studies of persons seeking or referred for treatment for substance use or with clinical signs or symptoms of substance use (i.e., “treatment-seeking populations”) might also be useful for informing assessments regarding screening in primary care settings. PURPOSE: This report updates a 2008 USPSTF report on screening for illicit drug use and supplements an updated USPSTF report on screening for any drug use, focusing on the benefits and harms of pharmacotherapy and psychosocial interventions for persons whose drug use was identified when seeking substance use treatment, when presenting with signs or symptoms of drug use, when screened for drug use in primary care or other settings with questions about drug use or drug-related risks, or other means. DATA SOURCES: The Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Ovid MEDLINE, Embase, and PsycINFO from inception to September 2018; surveillance for new literature was conducted through November 22, 2019. STUDY SELECTION: We included trials of Food and Drug Administration (FDA)-approved pharmacotherapies for opioid use disorder (methadone, buprenorphine, and naltrexone) and trials of psychosocial interventions for persons engaging in opioid, stimulant, cannabis, and mixed drug or polysubstance use. We also included trials of preemptive prescribing of naloxone in primary care settings as a rescue medication for opioid-related overdose. Trials compared included interventions against placebo, a minimal intervention, waitlist control, or usual care, and evaluated outcomes at ≥3 months for drug use or other risky behaviors; health, social, and legal consequences of drug use; or harms of treatment. DATA EXTRACTION: One investigator abstracted data and a second investigator checked data abstraction for accuracy. Two investigators independently assessed study quality using methods developed by the USPSTF. DATA SYNTHESIS (RESULTS): We included a total of 71 trials, with 19 trials of pharmacotherapies and 52 trials of psychosocial interventions. All trials of pharmacotherapies and 25 trials of psychosocial interventions were conducted in treatment-seeking populations. Psychosocial interventions commonly incorporated cognitive-behavioral or motivational interventions and ranged from brief interventions consisting of one or two sessions of no more than one hour to multiple treatment sessions over weeks or months. In most pharmacotherapy trials, drug use counseling was provided to all patients. No study evaluated benefits or harms of preemptive naloxone prescribed in primary care settings versus placebo or no naloxone as a rescue medication for opioid-related overdose. In treatment-seeking populations with opioid use disorder, naltrexone (12 trials; relative risk [RR] 0.73, 95% confidence interval [CI] 0.62 to 0.85; number needed to treat [NNT] 5.3) and opioid agonist therapy with methadone or buprenorphine (4 trials; RR 0.75, 95% CI 0.59 to 0.82; NNT 2.9) were associated with decreased risk of drug use relapse compared with placebo or no pharmacotherapy. Naltrexone and methadone/buprenorphine therapy were also associated with increased likelihood of retention in substance use treatment (9 trials; RR 1.71, 95% CI 1.13 to 2.49; NNT 6.7 and 7 trials; RR 2.58, 95% CI 1.78 to 4.59; NNT 2.6; respectively). Evidence on harms of pharmacotherapies was limited, but indicated no increased risk of serious adverse events. Psychosocial interventions were associated with increased likelihood of abstinence from drug use versus control conditions at 3 to 4 months (15 trials, RR 1.60, 95% CI 1.24 to 2.13; NNT 11) and at 6 to 12 months (14 trials; RR 1.25, 95% CI 1.11 to 1.52; NNT 17), based on trials primarily conducted in treatment-seeking populations. Psychosocial interventions were also associated with a greater decrease versus control conditions in the number of drug use days (19 trials; mean difference −0.49 day in the last 7 days, 95% CI −0.85 to −0.13) and a small but statistically significant greater decrease in drug use severity (16 trials; standard mean difference −0.18, 95% CI −0.32 to −0.05) at 3- to 4-month followup. There was no difference between psychosocial interventions versus controls on drug use days or severity at longer (6 to 12 month) followup. Effects of psychosocial interventions were generally stronger in trials of treatment-seeking than screen-detected populations, trials that evaluated cannabis use than other types of drug use, and trials of more intensive than brief interventions. Few trials evaluated effects of psychosocial interventions for opioid or stimulant use, and estimates were imprecise. LIMITATIONS: Limitations included restriction to English-language articles, statistical heterogeneity in pooled analyses, and little evidence on drug-related health, social, or legal outcomes; most trials had methodological limitations. Evidence was lacking on effectiveness of treatments for opioid use disorder related to prescription drug use or stimulant use and evidence was limited for adolescents or pregnant persons. CONCLUSIONS: Pharmacotherapy and psychosocial interventions are effective at improving drug use outcomes, but evidence of effectiveness remains primarily derived from trials conducted in treatment-seeking populations. Although the applicability of data from such trials to persons whose drug use is identified through primary care-based screening is uncertain, intervention trials that enrolled patients based on screening identified a spectrum of drug use, ranging from mild drug use to more severe, untreated disease. The applicability of current evidence on drug use interventions to screening might be greater for the subset of patients screened in primary care settings with severe, untreated drug use who could utilize pharmacotherapies or more intensive psychosocial interventions.

IMPORTANCE: Emerging evidence suggests that integrated care models are associated with improved mental health care access and outcomes for youths (children ≤12 years and adolescents 12-21 years) served in pediatric primary care settings. However, the key components of these complex models remain unexamined. OBJECTIVE: To identify and describe the key components of effective pediatric integrated mental health care models. EVIDENCE REVIEW: The PubMed, Embase, PsycINFO, and Cochrane Controlled Register of Trials electronic databases were searched for relevant peer-reviewed articles published between January 1, 1985, and April 30, 2019. Articles were restricted to those published in the English language. Eligible articles reported original data on youths 17 years or younger, implemented an integrated mental health care model in a pediatric primary care setting, and assessed the model's association with primary outcomes (eg, mental health symptom severity) and secondary outcomes (eg, functional impairment and patient satisfaction). Articles that specified some degree of systematic coordination or collaboration between primary care and mental health professionals were included in the final review. Two independent reviewers extracted data on study design, model type, model components, level of integration, and outcomes. Study quality was assessed using the Jadad scale. Data were analyzed between January 1, 2018, and May 31, 2019. FINDINGS: Eleven randomized clinical trials involving 2190 participants were included. Three studies focused on youths with depression, 3 on youths with attention-deficit/hyperactivity disorder, and 5 on youths with behavioral disorders. Most studies (9 of 11) implemented either the collaborative care model (n = 3), a slightly modified version of the collaborative care model (n = 2), or colocated care (n = 4). The most commonly reported components of effective pediatric integrated mental health care models were population-based care, measurement-based care, and delivery of evidence-based mental health services; all 3 components were present in studies reporting clinical improvement of mental health symptoms. Other model components, such as treatment-to-target or team-based care, were common in studies reporting specific outcomes, such as functional impairment. CONCLUSIONS AND RELEVANCE: This review is the first to date to systematically search and qualitatively synthesize information on the key components of effective pediatric integrated mental health care models. This knowledge may be especially useful for pediatric primary care administrators in the selection of an integrated care model for their setting.