Study NJ AAP Chapter Webinar January 2020 Howard Dubowitz MD MS FAAP Professor of Pediatrics SEEK and Primary Prevention of Child Abuse and Neglect Primary Care An Opportunity to Promote Childrens Health Development and Safety ID: 1042991
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1. National Safe Environment for Every Kid (SEEK) StudyNJ AAP Chapter WebinarJanuary 2020Howard Dubowitz, MD, MS, FAAPProfessor of Pediatrics
2. SEEK and Primary Prevention of Child Abuse and Neglect
3. Primary Care: An Opportunity to Promote Children’s Health, Development and SafetyWell accepted, institutionalizedMultiple visits (1st few yrs.)Goal of preventionConcern with child, familySpecial relationship with familyNo stigmaAn opportunity and a responsibility
4. The SEEK ModelSEEK trained primary care professionals (PCPs)SEEK Parent Questionnaire-RBrief assessment of identified problemsMotivational Interviewing principlesInitially help address problemsPCP + behavioral health/SW/case manager/navigator Knowledge of community resourcesSEEK Parent Handouts - customized
5. Targeted Psychosocial ProblemsDepressionMajor parental stressSubstance abuseIntimate partner (domestic) violenceHarsh punishmentFood insecurity
6. SEEK Parent Questionnaire - R Evidence-based Brief Easy to read Answer yes/no ConvenientVoluntaryConfidentialFlexibility – content, timing
7. SEEK PQ-R IntroEmpathic: “Being a parent is not always easy”Universal: “We’re asking everyone …”Provide context: “We want to help families have a safe environment for kids.”Builds on what’s accepted: injury prevention, safetyVoluntaryConfidential
8. How SEEK WorksAt start of visit, parent given SEEK PQ-RParent completes PQ-R while waitingParent gives PQ-R to PCPIdentified problems addressed by PCP + SW/case manager/navigatorSEEK Parent HandoutReferral to community agenciesFollow up – by child’s or parent’s PCP
9. Some of the Evidence
10. Two Randomized Controlled TrialsSEEK I Pediatric resident continuity clinicInner city, low income558 African American familiesSEEK II18 private practicesSuburban, middle income1119 mostly white families
11. Hypothesis I Training PCPs to address targeted problems will significantly improve their:AttitudesKnowledgeComfort levelPerceived competencePractice Dubowitz et al, Pediatrics, 2011 Feigelman et al, Acad Peds, 2011
12. Summary of FindingsImproved PCP attitudes and behavior regarding the targeted problems, based on: Self-report Medical recordsDirect observationIn SEEK I and IISustained for up to 36 months
13. Study Hypothesis II SEEK will help prevent maltreatment, measured by:Parent self-reportMedical record dataChild protective services (CPS) reports Dubowitz et al, Pediatrics, 2009 Dubowitz et al, Acad. Peds, 2012
14. SEEK II: Conflict Tactics Scale: Parent-ChildMinor Physical AssaultP values based on a mixed effects regression model, including random effects for family and practice, controlling for child’s race, age, family income, mother’s education and marital status. Std. Bs represent differences between SEEK and control in SD units. * P < .05 B = -0.08 B = -0.14*
15. Medical Neglect: Non-compliance1from chart review (SEEK I)* P < 0.051MD documented “non-compliance”Percent
16. Medical Neglect: Delayed Immunizations1 from chart review (SEEK I)1 MD documented * P = 0.002Percent
17. Child Protective Services (CPS) Reports for Abuse or Neglect (SEEK I)* P = 0.04* One-tailed t-testPercent
18. Time PCPs Spent on Psychosocial Issues Average time during SEEK II
19. Cost AnalysisSEEK: cost $210 per case prevented Compare to $14,520 ($1,993 – $21,400) for medical & mental health for one physically abused or psychologically maltreated childSEEK is cost saving Lane WG, Frick K, Dubowitz H, et al American Public Health Association 139th Annual Meeting and Exposition. Washington, DC. Nov. 2011.
20. SEEK Studies: Summary of FindingsPediatric primary care offers a good opportunity to address major psychosocial problems facing many children & familiesSEEK offers a practical model to improve primary careEvidence that SEEK can reduce child abuse & neglect and harsh parenting, and help promote children’s health, development and safetySEEK appears cost savingSEEK does not significantly increase time addressing psychosocial problemsNeed for further evaluation
21. Recommended PaperSokol et al. Screening Children for Social Determinants of Health: A Systematic Review. Pediatrics. 2019;144(4):e20191622
22. The National SEEK Study5-years, funded by NICHDPediatric and family medicine primary care practices in the USA
23. Study Goals and AimsOverall goals To learn what facilitates or impedes SEEK’s adoption, implementation, sustainability, and its effectiveness preventing child maltreatment (CM).Improve primary careHelp develop the field of implementation scienceSpecific aimsCompare two approaches to medical education (MOC 4/PI vs. Independent)Examine SEEK in pediatric and family medicine primary care practicesExamine SEEK’s effectiveness in preventing CMExamine the economic costs of implementing SEEK
24. What Do Practices Receive for Participating in the Study?Improving your practiceNeeds assessmentTraining of PCPs: CME, MOC 2 and/or MOC 4/PI credits - for freeAccess to all SEEK materialsAccess to the social work staffed SEEK HelplineHelps you qualify as a “Patient Centered Medical Home” $2000/practice/year to help cover research related admin costsPossibly increased revenues – CPT code 96161Waiving of the license fee for implementing SEEKAn opportunity to advance practice and knowledge of primary care
25. Participation of PCPs Involves:Four 30-minute online surveys - initially and after 8, 16 and 24 monthsPossibly, three 30-min. phone interviews – initially, after 8 and 24 months Accepting randomization to one of two training approaches:Independent: 2-3 hours online SEEK videosMOC 4/PI: 2-3 hours online videos, three 1-hour webinars over a 2-month period, Quality Improvement (QI) project – e.g. reviewing ~12 records x 3Implementing SEEK Administer the PQ-R for selected checkupsBriefly assess and initially help address targeted problemsPCP + behavioral health professional/SW/case manager/navigatorUsing the SEEK Parent Handouts, or use similar handouts
26. Next StepsIf you’re interested, please explore interest in the practice Let us know within ~10 days if you’d like a webinar with your practice If not interested now, may we contact you re. possible future participation?If not interested at all, may we contact you re. limited participation in the study?
27. Thank You!hdubowitz@som.umaryland.edu410.706.6144