Enhancing food insecurity screening in pediatric celiac disease using a quality improvement framework
Telly Cheung1, Mala Setty1, Erica Riray1
1Department of Pediatrics, University of California, San Francisco, San Francisco, California, USA.
Insights
Food insecurity screening improved significantly for children with celiac disease (CeD) by addressing team-identified barriers. This systematic approach enhanced early detection and intervention for at-risk households.
Area of Science:
- Pediatric gastroenterology
- Public health nutrition
- Healthcare quality improvement
Background:
- Food insecurity (FI) impacts millions of US households, disproportionately affecting children.
- Children with celiac disease (CeD) require strict gluten-free diets, making FI screening crucial for their well-being.
- Gaps exist in identifying food-insecure households in pediatric settings, hindering access to vital interventions.
Purpose of the Study:
- To develop and implement a system for identifying and overcoming barriers to FI screening in a pediatric CeD clinic.
- To improve the rate of FI screening among children diagnosed with celiac disease.
- To establish a sustainable process for addressing FI in vulnerable pediatric populations.
Main Methods:
- Utilized the Model for Improvement framework for quality initiatives over 12 months.
- Conducted surveys to identify medical team barriers to FI screening.
- Implemented a validated screening form, clinic flowsheet, educational module, and EHR visual aid.
- Employed plan-do-study-act cycles to refine screening processes.
Main Results:
- Median FI screening rates increased from 0.0% to over 75.0% within 12 months.
- Sustained high screening rates for over 6 months post-implementation.
- Identified key barriers: language, resource availability, provider forgetfulness, and discomfort with screening questions.
- Reported general FI at 19.7% and gluten-free FI at 14.8% among screened children.
Conclusions:
- A systematic framework effectively addressed team-reported barriers, significantly increasing FI screening for children with CeD.
- Interventions targeting FI are essential for improving health outcomes in food-insecure households.
- This quality improvement initiative provides a scalable model for other pediatric clinics.
Objectives:
Food insecurity (FI) affects more than 18 million households in the United States. Children with celiac disease (CeD) depend exclusively on the gluten-free diet, yet gaps persist in screening for food-insecure households who could benefit from interventions. We developed a system to identify and address barriers to FI screening in a pediatric clinic for CeD.
Methods:
Using the Model for Improvement, we conducted quality initiatives for eligible households between January 1, 2024 and January 31, 2025. We surveyed the medical team to identify barriers to FI screening and designed a key driver diagram to inform plan-do-study-act cycles. We implemented a (1) validated screening form, (2) clinic flowsheet, (3) educational module, and (4) visual aid in the electronic health records. We measured the process of FI screening and documentation. We tracked outcomes on positive screens for general and gluten-free FI.
Results:
Among 100 eligible children, the majority were female (63.0%), other race (55.0%), non-Hispanic (66.0%), and primary English-speakers (80.0%); and 66 received FI screening (66.0%). We identified top team-reported barriers to FI screening: language barriers, lack of FI resources, forgetting, and discomfort with asking questions. Applying the model for Improvement, we improved median FI screening from 0.0% to ≥75.0% within 12 months and sustained screening rates for ≥6 months. The average general and gluten-free FI among screened households was 19.7% and 14.8%, respectively.
Conclusions:
We implemented a systematic framework to address team-reported barriers, helping to increase FI screening for children with CeD. Developing interventions to address FI may improve poor outcomes among food-insecure households.
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