Skip to main content

We use cookies so that we can offer you the best possible website experience. This includes cookies, which are necessary for the operation of the website and to manage our corporate commercial objectives, as well as other cookies which are used solely for anonymous statistical purposes and for more comfortable website settings. You are free to decide which categories you would like to permit. Depending on the settings you choose, the full functionality of the website may no longer be available.

Cookie Policy
×

Abstract

Background

The American Academy of Pediatrics recommends routine screening and resource provision for food insecurity (FI). The authors describe documentation of FI, as well as social, developmental, and health care utilization characteristics, among patients with and without FI in a pediatric clinic.

Methods

This data-only case–control study describes patients with and without FI seen by pediatricians who identified at least 10 patients with FI between January 2019 and January 2020. Controls were seen by the same pediatrician on the same day, matched 2:1 with cases. Chart review identified FI documentation. Bivariate analyses were used to describe demographic, clinical, and health care utilization characteristics.

Results

The authors identified 74 patients with FI (cases) and 144 controls. Pediatricians documented FI in the medical record for 76% of patients identified with FI, although only 43% had FI in the problem list. There were no differences between cases and controls in the distribution of age or sex. A larger proportion of cases used the emergency department (25.7% vs 9.6%; p < 0.05), were Black (36.5% vs 15.3%; p < 0.05) or Hispanic (44.6% vs 18.8%; p < 0.05), utilized Medi-Cal (41.9% vs 16.7%; p < 0.05), had developmental delay (13.5% vs 4.2%; p < 0.05), received speech therapy (20.3% vs 4.9%; p < 0.05), or were referred to a social worker (37.8% vs 3.5%; p < 0.05).

Discussion

Our findings show inconsistent documentation of FI in medical records and that FI is associated with increased social, developmental, and health care utilization needs.

Conclusion

Further research is needed to assess the impact of documenting FI in patient charts.

Background

Food insecurity (FI), the inconsistent access to adequate food due to a lack of money or other resources, impacted approximately 14.8% of US households with children in 2020,1 with a dramatic rise in FI and federal and community assistance program enrollment during the COVID-19 pandemic.2,3 FI is associated with higher rates of attention deficit hyperactivity disorder (ADHD),4,5 anemia,5 emergency department (ED) use,5,6 a higher than optimal body mass index7,8 and multidimensional social- and health-related concerns.9
Health care institutions, medical centers, and clinics have become increasingly aware of their opportunity to support patients with FI. In 2015, the American Academy of Pediatrics shared “Promoting Food Security for All Children,” a policy statement highlighting the need for FI screening and connecting patients and their families with appropriate resources. Several studies have identified the pediatrician’s office as a place that families feel comfortable disclosing FI.10,11 Self-reporting surveys of pediatricians showed that most were willing to screen for FI and saw a benefit but were not consistently screening their patients.12 Although studies have looked at opportunities within health care systems to support families with FI, few studies have assessed chart documentation of FI. Failure to document FI may prevent or delay linking patients with appropriate resources.13,14 Our study, of a contemporary and diverse pediatric patient population receiving care at a community clinic within an integrated health care system, aims to 1) assess the documentation of FI and 2) describe the demographic, clinical, and health care utilization characteristics of pediatric patients facing FI.

Methods

In 2016 the Kaiser Permanente Pediatric Clinic in Oakland, California, began screening every patient for social determinants of health (SDOH). FI was included on the screener using the Hunger Vital Signs (HVS), a 2-question validated survey with high sensitivity and specificity for identifying families with young children at risk for FI.15 Upon registration for a medical appointment, every patient or family was given multiple questionnaires about their health and well-being, including the HVS,a series of images to circle relating to SDOH, and an opportunity to request more support. Medical assistants performed patient vital signs and entered findings from questionnaires into patient charts. If the questionnaire was interpreted as negative, the medical assistant entered the following into a note: “Screening for Social Determinants of Health: (including safety/violence, clean environment and play spaces, education, community/social support, income/employment, housing, legal support, and transportation) completed and revealed no areas of concern and no food insecurity.” If the questionnaire was positive, the medical assistant gave the positive screener form to the physician. A family was considered to have FI if they answered “yes” to either of the following questions: 1) “We worried whether our food would run out before we got money to buy more,” or 2) “The food we bought just didn’t last and we didn’t have money to get more,” or if they answered affirmatively if asked by the physician about SDOH or HVS during their appointment.
Starting in November 2017, patients identified as having FI were provided with a bag of resources, and a sticker from the appointment was placed onto a paper registry. The use of the paper registry was voluntary, and became more standard over time, so the authors narrowed our study dates to be from January 2019 to January 2020 to capture the largest number of patients seen by the same set of practitioners. The sticker on the paper registry documented the appointment date, pediatrician name, and patient medical record number. These sheets were kept in a locked office by the pediatrician heading the initiative. The resource bags, which were created by a local food bank, contained nonperishable food items and information on how to enroll in state and federal subsidized food assistance programs and local food bank resources.
Inclusion criteria for this study involved having at least 6 months of health insurance membership within our medical system at the time of the index appointment and being seen by 1 of 7 practitioners who documented FI in at least 10 patients during the study period. This ensured that the authors selected practitioners who were aware of and actively distributing the food bags and who were using the FI paper registry. Cases were eligible patients who were given a food bag and were included on the registry. The authors narrowed the cases to those seen between January 2019 and January 2020 because this was the densest period of patient identification by a group of pediatricians. Up to 2 controls were selected retrospectively for each case. Controls were selected from patients who had medical appointments on the same day as cases and were seen by the same practitioner. This was done to increase the internal validity of individual practitioners screening for FI among patients. A 1:2 case-to-control ratio was chosen rather than the inclusion of every patient seen on the same day based on the time demands of individual chart review. Without consistent documentation, population-level chart extrapolation was not feasible. Controls met the following criteria for being food secure: They were not on the FI paper registry, had documentation in their chart that they screened negative for FI, or had no documentation of FI in their chart. After the controls were selected, 4 were excluded during the chart review because they were found to have FI documented in their medical record.
The chart review identified all forms of documentation of FI among participants beyond the paper registry documentation. This included documentation in the problem list, appointment diagnosis, appointment note, and notes by medical assistants. The authors also reviewed the documented problem list diagnoses for cases and controls, guided by findings in the literature of more common illnesses and conditions among patients with FI. They limited the list to those identified in 10 or more participants, ie, slightly less than 5% for the study population. The chart review was used to identify provision of the Ages and Stages Questionnaire at any point in a patient’s history, a questionnaire that is given to pediatric patients to assess for multiple areas of development at discrete ages and is typically provided to parents for children 12–24 months of age during their routine well-check appointments to assess for language and gross and fine motor and behavior skills and includes an autism spectrum assessment. Social work consults, which are provided to patients by their pediatrician if there is any concern of undue stress from family, job, housing, or multidimensional social concerns, were also identified. Speech therapist appointments and referrals to a social worker were noted if they were ever recorded in a patient’s chart or medical record.
Electronic medical record data extraction identified the demographic (age at index appointment, sex, race/ethnicity, health insurance data), clinical (ADHD, asthma, atopic dermatitis, obesity, developmental delay), and health care utilization (ED use, speech therapist appointments, referral to a social worker) characteristics of the cases and controls. ED use was captured within 6 months before and/or after the index appointment.
Bivariate analyses report the significance of demographic, clinical, and health care utilization differences between cases and controls based on the χ2 statistic for an unmatched case–control design, and descriptive statistics were used to describe the different methods of FI documentation. A p value of < 0.05 was used for our significance threshold (Table 1). The authors chose to represent significance using 3 levels of significance, ie, < 0.05, < 0.01, < 0.001, rather than using exact p values, as a way of acknowledging the small sample size impact on data precision. This study was reviewed by the Kaiser Permanente Northern California institutional review board, and patient consent was waived. Analysis was conducted using SAS (version 9.4; SAS Institute Inc.).
Table 1: Demographic and clinical characteristics of cases and controls
Characteristics, n (%)Cases (N = 74)Controls (N = 144)p valuea
Demographic characteristics   
Age, y  > 0.05
 < 528 (37.8)58 (39.7) 
 5–1222 (29.7)33 (22.9) 
 > 1224 (32.4)53 (36.8) 
Race/ethnicity  < 0.001
 Black27 (36.5)22 (15.3) 
 White, non-Hispanic2 (2.7)49 (34.0) 
 Asian1 (1.4)23 (15.8) 
 Hispanic33 (44.6)27 (18.8) 
 Other11 14.9)23 (15.8) 
Female sex36 (48.7)67 (46.5)> 0.05
Enrolled in subsidized insurance (eg, Affordable Care Act, Medi-Cal)31 (41.9)24 (16.7)< 0.001
Enrolled in Kaiser insurance for at least 6 months from index appointment65 (87.8)126 (87.5)> 0.05
Clinical characteristics (problem list diagnosis)   
 Attention deficit hyperactivity disorder6 (8.1)6 (4.2)> 0.05
 Asthma15 (20.3)18 (12.5)> 0.05
 Atopic dermatitis7 (9.5)12 (8.3)> 0.05
 Obesity6 (8.1)5 (3.5)> 0.05
 Developmental delay10 (13.5)6 (4.2)< 0.05
Health care utilization (clinical care referrals and follow-up)   
 Used emergency department within 6 months before and/or after index appointment19 (25.7)14 (9.7)< 0.01
 Ages and Stages Questionnaire ever given to parent10 (13.5)5 (3.5)< 0.01
 Ages and Stages Questionnaire ever received by developmental pediatrics5 (50.0)3 (60.0)> 0.05
 Ever received speech therapy15 (20.3)7 (4.9)< 0.001
 Ever had a social work referral28 (37.8)5 (3.5)< 0.001
 Social worker ever connected with family16 (57.1)5 (100)< 0.05
a
Based on likelihood ratio χ2.
Medi-Cal, California Medical Assistance Program (California's Medicaid program).

Results

FI Documentation

Of the 74 patient cases given food bags, 56 (76%) had FI documented in their chart (Table 2). Of those with FI in their chart, 24 (43%) had it in their problem list either at the time of chart review or within 30 days of the appointment, allowing pediatricians time to complete charting after the appointment. Thirty-eight (67%) had FI in their appointment diagnosis, which is uniquely assigned to each appointment. Fifty-three (95%) had FI documented in a note; 49% of these notes included an SDOH screener, 16% used the 2-question HVS, and the rest were unstructured notations of providing a food bag.
Table 2: Food insecurity documentation characteristics of cases
Food insecurity documentation characteristicsn (%)
FI documented by practitioner in paper registry74 (100)
FI documented by practitioner in patient chart56 (76)
Medical assistant note documenting no concerns for social determinants of healtha18 (24)
Food/resource bag provision documented by practitioner in patient chart42 (57)
Type of documentation for 56 cases with FI documented in patient chart 
 In problem list24 (43)
 In appointment diagnosis38 (67)
 In note53 (95)
 Documented via Hunger Vital Sign12 (16)
 Documented via Social Determinants of Health Screen36 (49)
 No documentation in note5 (9)
a
Medical assistant documented that patient was not facing any social determinants of health, including FI, among 18 (24%) cases and 62 (43.1%) controls (p < 0.01).
FI, food insecurity.
Among the 56 cases with FI documented in their charts, 24% had a note by a medical assistant documenting no concerns for SDOH, and 76% had no medical assistant note. In the control group, 43% had a note by a medical assistant documenting no concerns for SDOH, leaving 57% of the controls without a screening note from a medical assistant.

Demographics

For the study dates (January 2019–January 2020), the authors identified 218 patients: 74 who met study criteria for the cases and 144 controls. All were insured members within our health care system, 0–17 years of age. There were no significant differences between cases and controls regarding the distribution of age or sex (Table 1). A larger proportion of cases were Black (37% vs 15%) or Hispanic (45% vs 20%) compared with controls (p < 0.05). Although the proportion with established Kaiser Permanente membership was similar for cases and controls, insurance type differed, with a much larger proportion of cases (42%) relying on subsidized insurance, either through the Affordable Care Act, California Medical Assistance Program (Medi-Cal; California’s Medicaid program), or other, compared with controls (17%; p < 0.05).

Clinical Characteristics

A larger proportion of cases compared with controls had a diagnosis of developmental delay (p < 0.05; Table 1). Other diagnoses, including ADHD, asthma, obesity, and eczema, did not differ significantly (p > 0.05) between cases and controls.

Health Care Utilization

Utilization of the ED in the 6 months before and/or after the index appointment differed significantly between cases and controls, with a greater proportion of cases than controls using the ED (p < 0.05; Table 1). A larger proportion of cases were given an Ages and Stages Questionnaire (p < 0.01) at any time by any practitioner, speech therapy (p < 0.001) at any time, and a social work consult (p < 0.001). Among patients with a social work consult, those without FI were substantially more likely to have social work notes (100% of patients without FI vs 57% of patients with FI), an indication that the social worker and parent or patient were able to connect.

Discussion

The authors found that documentation of FI was high (76%) for patients who had been given a food bag, and some form of documentation in the note was present for the majority of these patients. However, documentation of FI in the problem list, which is visible to all health care practitioners at all appointments, was present in less than half of these patients’ charts (43%). The current study captured patients who were identified as being food insecure by practitioners who were consistently identifying FI among their patients, suggesting that such practitioners may be more likely to document FI than other practitioners. By not documenting FI in the problem list, other practitioners’ ability to know this important piece of health information is limited, as is our integrated health care system’s ability to capture the breadth of FI across our Northern California patient population. The lack of consistent documentation in the problem list is a subject for further study. In our integrated health care system, there is no financial incentive to add more items to the problem list, which could reduce incentives for documentation. Periods of FI tend to be recurrent, instead of constant,1 which may discourage practitioners from putting FI in the problem list, which is considered a place to log chronic conditions that remain unchanged over time. Practitioners may also be hesitant to label their patient as food insecure for fear that it will cause them to feel shame or stigma after the appointment. One consideration for future screening programs would be to counsel the team of practitioners on the dramatic and lasting impacts of FI on their patients and why it is important to document it in the patient chart. This very point is highlighted in the 2021 American Academy of Pediatrics toolkit for Pediatricians to Address Food Insecurity.16 Although other studies have shown that patients are comfortable disclosing FI to their pediatrician10,11 and that pediatricians are willing to screen for this in their office,12 disclosure and documentation remains challenging.
Through the universal screener and use of ancillary health care practitioners, the authors found that 18 of these patients (24%) had an inappropriate note in the chart indicating that there were no concerns for SDOH, which raises concerns about the validity of the paper screener and how the results are entered into the chart.
Our retrospective study of a private health care system where patients with public insurance theoretically have the same access to health care resources—including telehealth, in-person appointments, and secure messages to practitioners—found that patients identified as having FI by their pediatricians, compared with their control counterparts seen on the same day by the same set of pediatricians, were more likely to be Black or Hispanic, have public or subsidized insurance, have developmental delay, and use the ED within the 6 months before and/or after the index appointment. These findings in a private practice setting are consistent with associations seen in prior studies primarily conducted in other settings.4–6,17,18 The authors did not have a sufficient sample size to determine whether FI was an independent predictor of adverse clinical outcomes. Interestingly, we found that this group of patients were more likely to have social work referrals and to be given an Ages and Stages Questionnaire but less likely to connect with a social worker or to have their developmental assessment reviewed by a developmental pediatrician, indicating that they were identified as needing additional resources but were not able to access them. This finding suggests that although these families are undergoing increased stress from FI, they are not being connected with the resources that could help them with multiple aspects of health and development.
Through this universal screening process for SDOH, multiple patients were identified as having FI and given a food bag. The total number of patients identified as having FI was below the national average of children with FI, which is likely multifactorial. For example, this population is universally insured. Moreover, there are known barriers to identifying patients with FI, including the stigma of being labeled as food insecure, concern that FI would be interpreted as abuse, and privacy concerns.19 Further, although there is evidence that using a paper screener is more effective than asking people to divulge FI to a practitioner,19 the authors found some discordance in the information from the paper screen and the documentation from the pediatrician. In this integrated health care system where patients often see the same practitioner for many years, it is possible that patients were more willing to discuss FI with their practitioner than to divulge it on a screening form. Thus, adequately capturing the extent of this problem is challenging. The benefits of increasing resources for consistent screening and documentation of FI among pediatric patients include adequately capturing the extent of FI, facilitating screening patients for other related outcomes, and connecting patients with appropriate resources.
Further research is needed to identify ways to improve documentation of FI in patient charts, as well as ways to assess the impact of this documentation on patients and their care. For example, a future study could look at granting access for ancillary health care practitioners, such as medical assistants and social workers, to enter FI into a patient’s problem list.

Limitations

This was a small, retrospective, exploratory study providing novel research on the chart documentation, demographics, and clinical characteristics of a patient population enrolled in a private health care system. The cases were identified through a paper registry and may have been underrepresentative of the total population of food insecure patients utilizing this health system. Multiple factors contribute to this underreporting, including stigma and fear of reporting, as well as practitioner hesitancy in documenting FI. This specific data set was also limited by the additional barrier of practitioners having to place a sticker onto a registry, an additional step that takes extra time and effort.

Conclusions

FI, a key SDOH, is increasingly impacting households across the United States and the globe, particularly in the wake of the COVID-19 pandemic. The authors found that documentation of FI was high (76%) for patients who had been given a food bag, although the documentation was inconsistently placed across elements of the chart, and that pediatric patients with FI were more likely to use the ED and to have developmental delay. Routine screening for and documentation of FI among pediatric patients is critical for providing patients with appropriate and timely resources to address not only calorie and energy needs through nutrition bags and information on local and federal nutrition assistance programs but also to refer patients for specialized care, counseling, and additional screening. FI screening and documentation, while posing challenges, should be integrated into clinical practice and inform pediatric practitioner practice.

Acknowledgments

The authors would like to acknowledge patient contributions to the research findings, including use of data from their electronic medical records.

Footnote

Author Contributions
Victoria Fort, MD, MPH, participated in the study design, acquisition and analysis of data, critical review, drafting, and submission of the final manuscript. Miranda Ritterman Weintraub, PhD, MPH, participated in the study design, data analysis, critical review and drafting of the final manuscript. Carol Conell, PhD, participated in the study design, analysis of data, critical review and drafting of the final manuscript. Abhay Dandekar, MD, participated in the study design, acquisition of data and critical review of the final manuscript. Elizabeth Hayes, MD, participated in data analysis, critical review and drafting of the final manuscript. All authors have given final approval to the manuscript.

References

1.
Coleman-Jensen A, Rabbitt M, Gregory C, Singh A. Household Food Security in the United States in 2020, ERR-298, U.S Department of Agriculture [Economic Research Service]. 2021. Accessed 3 May 2022. https://www.ers.usda.gov/webdocs/publications/102076/err-298.pdf?v=8329.3
2.
Schanzenbach D, Pitts A. Estimates of Food Insecurity During the COVID-19 Crisis: Results from the COVID Impact Survey, Week 1 (April 20–26, 2020) [Institute for Policy Research Rapid Research Report. 2020]. Accessed 3 May 2022. https://www.ipr.northwestern.edu/news/2020/food-insecurity-triples-for-families-during-covid.html
3.
Fang D, Thomsen MR, Nayga RM, Yang W. Food insecurity during the COVID-19 pandemic: Evidence from a survey of low-income Americans [published online ahead of print, July 7, 2021]. Food Secur. 2021:1–19.
4.
Lu S, Perez L, Leslein A, Hatsu I. The relationship between food insecurity and symptoms of attention-deficit hyperactivity disorder in children: A summary of the literature. Nutrients. 2019;11(3):659.
5.
Peltz A, Garg A. Food insecurity and health care use. Pediatrics. 2019;144(4):e20190347.
6.
Thomas MMC, Miller DP, Morrissey TW. Food insecurity and child health. Pediatrics. 2019;144(4):e20190397.
7.
Papas MA, Trabulsi JC, Dahl A, Dominick G. Food insecurity increases the odds of obesity among young hispanic children. J Immigr Minor Health. 2016;18(5):1046–1052.
8.
Lee AM, Scharf RJ, DeBoer MD. Association between kindergarten and first-grade food insecurity and weight status in U.S. children. Nutrition. 2018;51–52:1–5.
9.
Baer TE, Scherer EA, Fleegler EW, Hassan A. Food insecurity and the burden of health-related social problems in an urban youth population. J Adolesc Health. 2015;57(6):601–607.
10.
Orr CJ, Chauvenet C, Ozgun H, Pamanes-Duran C, Flower KB. Caregivers’ experiences with food insecurity screening and impact of food insecurity resources. Clin Pediatr (Phila). 2019;58(14):1484–1492.
11.
Adams E, Hargunani D, Hoffmann L, Blaschke G, Helm J, Koehler A. Screening for food insecurity in pediatric primary care: A clinic’s positive implementation experiences. J Health Care Poor Underserved. 2017;28(1):24–29.
12.
Barnidge E, LaBarge G, Krupsky K, Arthur J. Screening for food insecurity in pediatric clinical settings: Opportunities and barriers. J Community Health. 2017;42(1):51–57.
13.
Arons A, DeSilvey S, Fichtenberg C, Gottlieb L. Documenting social determinants of health-related clinical activities using standardized medical vocabularies. JAMIA Open. 2019;2(1):81–88.
14.
Cohen GR, Friedman CP, Ryan AM, Richardson CR, Adler-Milstein J. Variation in physicians’ electronic health record documentation and potential patient harm from that variation. J Gen Intern Med. 2019;34(11):2355–2367.
15.
Hager ER, Quigg AM, Black MM, et al. Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics. 2010;126(1):e26–e32.
16.
Ashbrook A, Essel K, Montez K, Bennett-Tejes D. Screen and intervene: A toolkit for pediatricians to address food insecurity 2021. Accessed 3 May 2022. https://frac.org/wp-content/uploads/FRAC_AAP_Toolkit_2021.pdf
17.
Rongstad R, Neuman M, Pillai P, Birstler J, Hanrahan L. Screening pediatric patients for food insecurity: A retrospective cross-sectional study of comorbidities and demographic characteristics. WMJ. 2018;117(3):122–125.
18.
Shankar P, Chung R, Frank DA. Association of food insecurity with children’s behavioral, emotional, and academic outcomes: A systematic review. J Dev Behav Pediatr. 2017;38(2):135–150.
19.
Knowles M, Khan S, Palakshappa D, et al. Successes, challenges, and considerations for integrating referral into food insecurity screening in pediatric settings. J Health Care Poor Underserved. 2018;29(1):181–191.

Information & Authors

Information

Published In

cover image The Permanente Journal
The Permanente Journal
Preprint • August 2022
Pages: 1 - 7

Keywords

  1. Food insecurity
  2. pediatrics
  3. social determinants of health
  4. community

Authors

Affiliations

Victoria Fort, MD, MPH Victoria.x.fort@kp.org
Kaiser Permanente Pediatric Residency Program, Oakland, CA, USA
Miranda Ritterman Weintraub, PhD, MPH
Kaiser Permanente Graduate Medical Education Department, Oakland, CA, USA
Carol Conell, PhD
Kaiser Permanente Northern California, Oakland, CA, USA
Abhay Dandekar, MD
Kaiser Permanente Pediatric Residency Program, Oakland, CA, USA
Elizabeth Hayes, MD
Kaiser Permanente Pediatric Residency Program, Oakland, CA, USA

Notes

Victoria Fort, MD, MPH Victoria.x.fort@kp.org

Conflicts of Interest

None declared

Funding

None declared

Metrics & Citations

Metrics

Downloaded 275 times

Citations

Export citation

Select the format you want to export the citation of this publication.

View Options

View options

PDF

View PDF

Get Access

Restore your content access

Enter your email address to restore your content access:

Note: This functionality works only for purchases done as a guest. If you already have an account, log in to access the content to which you are entitled.

Login options

Check if you have access through your login credentials or your institution to get full access on this article

Media

Figures

Other

Tables

Share

Share

Copy the content Link

Share on social media