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Smith HE, Cruz AI, Mistovich RJ, Leska TM, Ganley TJ, Aoyama JT, Ellis HB, Kushare I, Lee RJ, McKay SD, Milbrandt TA, Rhodes JT, Sachleben BC, Schmale GA, Patel NM. What Are the Causes and Consequences of Delayed Surgery for Pediatric Tibial Spine Fractures? A Multicenter Study. Orthop J Sports Med 2022; 10:23259671221078333. [PMID: 35284586 PMCID: PMC8905066 DOI: 10.1177/23259671221078333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 11/30/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The uncommon nature of tibial spine fractures (TSFs) may result in delayed diagnosis and treatment. The outcomes of delayed surgery are unknown. Purpose: To evaluate risk factors for, and outcomes of, delayed surgical treatment of pediatric TSFs. Study Design: Cohort study; Level of evidence, 3. Methods: The authors performed a retrospective cohort study of TSFs treated surgically at 10 institutions between 2000 and 2019. Patient characteristics and preoperative data were collected, as were intraoperative information and postoperative complications. Surgery ≥21 days after injury was considered delayed based on visualized trends in the data. Univariate analysis was followed by purposeful entry multivariate regression to adjust for confounders. Results: A total of 368 patients (mean age, 11.7 ± 2.9 years) were included, 21.2% of whom underwent surgery ≥21 days after injury. Patients who experienced delayed surgery had 3.8 times higher odds of being diagnosed with a TSF at ≥1 weeks after injury (95% CI, 1.1-14.3; P = .04), 2.1 times higher odds of having seen multiple clinicians before the treating surgeon (95% CI, 1.1-4.1; P = .03), 5.8 times higher odds of having magnetic resonance imaging (MRI) ≥1 weeks after injury (95% CI, 1.6-20.8; P < .007), and were 2.2 times more likely to have public insurance (95% CI, 1.3-3.9; P = .005). Meniscal injuries were encountered intraoperatively in 42.3% of patients with delayed surgery versus 21.0% of patients treated without delay (P < .001), resulting in 2.8 times higher odds in multivariate analysis (95% CI, 1.6-5.0; P < .001). Delayed surgery was also a risk factor for procedure duration >2.5 hours (odds ratio, 3.3; 95% CI, 1.4-7.9; P = .006). Patients who experienced delayed surgery and also had an operation >2.5 hours had 3.7 times higher odds of developing arthrofibrosis (95% CI, 1.1-12.5; P = .03). Conclusion: Patients who underwent delayed surgery for TSFs were found to have a higher rate of concomitant meniscal injury, longer procedure duration, and more postoperative arthrofibrosis when the surgery length was >2.5 hours. Those who experienced delays in diagnosis or MRI, saw multiple clinicians, and had public insurance were more likely to have a delay to surgery.
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Affiliation(s)
- Haley E. Smith
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Aristides I. Cruz
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - R. Justin Mistovich
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Tomasina M. Leska
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Theodore J. Ganley
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Julien T. Aoyama
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Henry B. Ellis
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Indranil Kushare
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Rushyuan J. Lee
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Scott D. McKay
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Todd A. Milbrandt
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Jason T. Rhodes
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Brant C. Sachleben
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Gregory A. Schmale
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
| | - Neeraj M. Patel
- All authors are listed in the Authors section at the end of this article
- Investigation performed at Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA
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Nicolet A, Peytremann-Bridevaux I, Bagnoud C, Perraudin C, Wagner J, Marti J. Continuity of care and multimorbidity in the 50+ Swiss population: An analysis of claims data. SSM Popul Health 2022; 17:101063. [PMID: 35308585 PMCID: PMC8928125 DOI: 10.1016/j.ssmph.2022.101063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/01/2022] [Accepted: 03/01/2022] [Indexed: 11/20/2022] Open
Abstract
Objective To assess the relationship between continuity of care (COC) and multimorbidity in the older general population in Switzerland, accounting for relevant determinants of COC, and to apply various expressions of multimorbidity derived from claims data. Methods We used data on 240'000 insured individuals aged 50+ for the period 2015-2018, received from one of the largest Swiss health insurance company. We calculated Bice-Boxerman index based on all doctor visits (overall COC) and visits to the general practitioners (COC GP). We analyzed the relationship between COC and multimorbidity using generalized linear and probit models. To express multimorbidity, we applied three approaches based on pharmacy-cost groups (PCGs) assigned to an individual. First, we used simple PCG counts. Second, we expressed multimorbidity via clinically relevant disease groups derived from PCGs. Finally, a data-driven approach allowed defining distinct clusters representing different patient complexities. Results The association between overall COC and multimorbidity expressed in PCG counts was modest: COC among individuals with 3+ PCGs was 2 percentage points higher than COC among individuals with 0 PCGs. The approach of clinically relevant disease groups showed larger variation in COC and its association with multimorbidity. The data-driven approach showed that most complex ("high-cost high-need") individuals tended to have higher overall COC. Additionally, 70% of the sample visited exclusively one general practitioner (COC GP = 1.0). Other important factors associated with COC in the Swiss context were insurance model with gatekeeping, level of deductibles, and region of residence. Conclusions Multimorbid patients require regular medical attention often involving multiple healthcare providers, which can lead to varying COC, depending on types of doctors seen and specific condition of the patient. Insurance models with gatekeeping may facilitate COC, prompting developments of better-designed models of care. This represents important implications for policymakers, health insurance representatives, medical professionals and hospital managers.
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Affiliation(s)
- Anna Nicolet
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | | | - Christophe Bagnoud
- Groupe Mutuel, Rue des Cèdres 5, Case Postale, CH-1919, Martigny, Switzerland
| | - Clémence Perraudin
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Joël Wagner
- Department of Actuarial Science, Faculty of Business and Economics (HEC), And Swiss Finance Institute, University of Lausanne, Lausanne, Switzerland
| | - Joachim Marti
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
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3
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Huang J, Liu Y, Zhang T, Wang L, Liu S, Liang H, Zhang Y, Chen G, Liu C. Can family doctor contracted services facilitate orderly visits in the referral system? A frontier policy study from Shanghai, China. Int J Health Plann Manage 2021; 37:403-416. [PMID: 34628680 PMCID: PMC9293337 DOI: 10.1002/hpm.3346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 09/06/2021] [Accepted: 09/20/2021] [Indexed: 11/24/2022] Open
Abstract
Background China committed to establishing a family doctor (FD)‐based referral system following the medical reform in 2009. This paper explored the effect of FD on establishing the anticipated system. Methods Two waves of survey were conducted in Shanghai, China. 2754 and 1995 individuals were sampled in 2013 and 2016 respectively. We compared orderly visiting behaviour between contracted and non‐contracted residents. Logistic regression models were performed to further test the effect of FD on orderly visits. Results More contracted residents first‐contacted community health service centres (CHSCs; 45.48%) than non‐contracted residents (28.93%). Contracted residents were also more likely to refer to specialists via CHSCs than the non‐contracted (9.84% vs. 2.60%). The odds ratio (OR) for first‐contact at CHSCs by contract status was 1.569 in 2013, but increased to 1.675 in 2016. Being contracted with a FD was associated with referral behaviour, but the OR declined from 2.692 to 2.487 over years. Conclusion The survey from Shanghai showed that FD had a significant effect on attracting first‐contact at CHSCs and referral via CHSCs; however, the effect on the latter decreased. The effectiveness of the FD role on referral behaviour requires a well‐established referral system, which has not yet been completely achieved in China.
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Affiliation(s)
- Jiaoling Huang
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Center for HTA, China Hospital Development Institute, Shanghai Jiao Tong University, Shanghai, China
| | - Yan Liu
- School of Public Health, Fudan University, Shanghai, China.,Health Inspection Agency of Shanghai Pudong New Area Health and Family Planning Commission, Shanghai, China
| | - Tao Zhang
- Jinyang Community Health Service Center of Pudong New Area, Shanghai, China
| | - Luan Wang
- Shanghai Sixth People's Hospital East Affiliated to Shanghai University of Medicine & Health Sciences, Shanghai, China
| | - Shanshan Liu
- Pudong Institute for Health Development, Shanghai, China
| | - Hong Liang
- Pudong Institute for Health Development, Shanghai, China.,School of Social Development and Public Policy, Fudan University, Shanghai, China
| | - Yimin Zhang
- Pudong Institute for Health Development, Shanghai, China
| | - Gang Chen
- School of Public Health, Fudan University, Shanghai, China
| | - Chengjun Liu
- School of Social Development and Public Policy, Fudan University, Shanghai, China.,Eye and Dental Diseases Prevention & Treatment of Pudong New Area, Shanghai, China
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4
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Klein JD, Gorzkowski J, Resnick EA, Harris D, Kaseeska K, Pbert L, Prokorov A, Wang T, Davis J, Gotlieb E, Wasserman R. Delivery and Impact of a Motivational Intervention for Smoking Cessation: A PROS Study. Pediatrics 2020; 146:e20200644. [PMID: 32989082 PMCID: PMC7546094 DOI: 10.1542/peds.2020-0644] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We tested a Public Health Service 5As-based clinician-delivered smoking cessation counseling intervention with adolescent smokers in pediatric primary care practice. METHODS We enrolled clinicians from 120 practices and recruited youth (age ≥14) from the American Academy of Pediatrics Pediatric Research in Office Settings practice-based research network. Practices were randomly assigned to training in smoking cessation (intervention) or social media counseling (attentional control). Youth recruited during clinical visits completed confidential screening forms. All self-reported smokers and a random sample of nonsmokers were offered enrollment and interviewed by phone at 4 to 6 weeks, 6 months, and 12 months after visits. Measures included adolescents' report of clinicians' delivery of screening and counseling, current tobacco use, and cessation behaviors and intentions. Analysis assessed receipt of screening and counseling, predictors of receiving 5As counseling, and effects of interventions on smoking behaviors and cessation at 6 and 12 months. RESULTS Clinicians trained in the 5As intervention delivered more screening (β = 1.0605, P < .0001) and counseling (β = 0.4354, P < .0001). In both arms, clinicians more often screened smokers than nonsmokers. At 6 months, study arm was not significantly associated with successful cessation; however, smokers in the 5As group were more likely to have quit at 12 months. Addicted smokers more often were counseled, regardless of study arm, but were less likely to successfully quit smoking. CONCLUSIONS Adolescent smokers whose clinicians were trained in 5As were more likely to receive smoking screening and counseling than controls, but the ability of this intervention to help adolescents quit smoking was limited.
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Affiliation(s)
- Jonathan D Klein
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois;
- Julius B. Richmond Center of Excellence, American Academy of Pediatrics, Itasca, Illinois
| | - Julie Gorzkowski
- Julius B. Richmond Center of Excellence, American Academy of Pediatrics, Itasca, Illinois
| | - Elissa A Resnick
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois
| | - Donna Harris
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois
| | - Kristen Kaseeska
- Julius B. Richmond Center of Excellence, American Academy of Pediatrics, Itasca, Illinois
| | - Lori Pbert
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | | | - Tianxiu Wang
- Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois
| | - James Davis
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois
| | - Edward Gotlieb
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois
| | - Richard Wasserman
- Primary Care Research, American Academy of Pediatrics, Itasca, Illinois
- Department of Pediatrics, Larner College of Medicine, University of Vermont, Burlington, Vermont; and
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5
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Drivers of referrals to a children's hospital neonatal-infant intensive care unit. J Perinatol 2019; 39:295-299. [PMID: 30573751 DOI: 10.1038/s41372-018-0297-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 10/01/2018] [Accepted: 11/27/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Evaluate the outreach program of a regional NICU for referral satisfaction, drivers and barriers, preferences for service methods, outreach communication, and education. STUDY DESIGN To point out prevalence assessment of preferences, referral reasons, satisfaction and general feedback by regional neonatologists implemented by electronic survey using either multiple-choice or Likert scale questions. Survey questions were derived via consensus of the outreach program team. RESULTS A 100% response rate was achieved from 136 neonatologists. Over 90% of the respondents indicated either increased or unchanged referral rates and answered "maybe" or "definitely satisfied" with the outreach program. Insurance, bed availability, excellence in subspecialty support, and communication from neonatologists were important referral factors. Research reputation was not a significant driver. Case conferences at referral hospitals and program newsletters were the preferred education methods. CONCLUSIONS Advanced subspecialty services, communication with referring neonatologists, and access to the referral system are important drivers of satisfaction for referrals to our quaternary NICU.
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6
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Smith P, Nicaise P, Giacco D, Bird VJ, Bauer M, Ruggeri M, Welbel M, Pfennig A, Lasalvia A, Moskalewicz J, Priebe S, Lorant V. Predictors of personal continuity of care of patients with severe mental illness: A comparison across five European countries. Eur Psychiatry 2018; 56:69-74. [PMID: 30583254 DOI: 10.1016/j.eurpsy.2018.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/05/2018] [Accepted: 12/08/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In Europe, at discharge from a psychiatric hospital, patients with severe mental illness may be exposed to one of two main care approaches: personal continuity, where one clinician is responsible for in- and outpatient care, and specialisation, where various clinicians are. Such exposure is decided through patient-clinician agreement or at the organisational level, depending on the country's health system. Since personal continuity would be more suitable for patients with complex psychosocial needs, the aim of this study was to identify predictors of patients' exposure to care approaches in different European countries. METHODS Data were collected on 7302 psychiatric hospitalised patients in 2015 in Germany, Poland, and Belgium (patient-level exposure); and in the UK and Italy (organisational-level exposure). At discharge, patients were exposed to one of the care approaches according to usual practice. Putative predictors of exposure at patients' discharge were assessed in both groups of countries. RESULTS Socially disadvantaged patients were significantly more exposed to personal continuity. In all countries, the main predictor of exposure was the admission hospital, except in Germany, where having a diagnosis of psychosis and a higher education status were predictors of exposure to personal continuity. In the UK, hospitals practising personal continuity had a more socially disadvantaged patient population. CONCLUSION Even in countries where exposure is decided through patient-clinician agreement, it was the admission hospital, not patient characteristics, that predicted exposure to care approaches. Nevertheless, organisational decisions in hospitals tend to expose socially disadvantaged patients to personal continuity.
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Affiliation(s)
- Pierre Smith
- Institute of Health and Society IRSS, Université catholique de Louvain, Brussels, Belgium.
| | - Pablo Nicaise
- Institute of Health and Society IRSS, Université catholique de Louvain, Brussels, Belgium
| | - Domenico Giacco
- Unit for Social and Community Psychiatry (World Health Organisation Collaborating Centre for Mental Health Services Development), Queen Mary University of London, London, UK
| | - Victoria Jane Bird
- Unit for Social and Community Psychiatry (World Health Organisation Collaborating Centre for Mental Health Services Development), Queen Mary University of London, London, UK
| | - Michael Bauer
- Department of Psychiatry and Psychotherapy, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Mirella Ruggeri
- Section of Psychiatry, Department of Public Health and Community Medicine, University of Verona, Verona, Italy
| | - Marta Welbel
- Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Andrea Pfennig
- Department of Psychiatry and Psychotherapy, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Antonio Lasalvia
- UOC di Psichiatria, Azienda Ospedaliera Universitaria Intergrata (AOUI) di Verona, Verona, Italy
| | | | - Stefan Priebe
- Unit for Social and Community Psychiatry (World Health Organisation Collaborating Centre for Mental Health Services Development), Queen Mary University of London, London, UK
| | - Vincent Lorant
- Institute of Health and Society IRSS, Université catholique de Louvain, Brussels, Belgium
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7
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Chang AY, Askari M, Fan J, Heidenreich PA, Michael Ho P, Mahaffey KW, Ullal AJ, Perino AC, Turakhia MP. Association of Healthcare Plan with atrial fibrillation prescription patterns. Clin Cardiol 2018; 41:1136-1143. [PMID: 30098034 DOI: 10.1002/clc.23042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/08/2018] [Accepted: 08/08/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is treated by many types of physician specialists, including primary care physicians (PCPs). Health plans have different policies for how patients encounter these providers, and these may affect selection of AF treatment strategy. HYPOTHESIS We hypothesized that healthcare plans with PCP-gatekeeping to specialist access may be associated with different pharmacologic treatments for AF. METHODS We performed a retrospective cohort study using a commercial pharmaceutical claims database. We utilized logistic regression models to compare odds of prescription of oral anticoagulant (OAC), non-vitamin K-dependent oral anticoagulant (NOAC), rate control, and rhythm control medications used to treat AF between patients with PCP-gated healthcare plans (eg, HMO, EPO, POS) and patients with non-PCP-gated healthcare plans (eg, PPO, CHDP, HDHP, comprehensive) between 2007 and 2012. We also calculated median time to receipt of therapy within 90 days of index AF diagnosis. RESULTS We found similar odds of OAC prescription at 90 days following new AF diagnosis in patients with PCP-gated plans compared to those with non-PCP-gated plans (OR: OAC 1.01, P = 0.84; warfarin 1.05, P = 0.08). Relative odds were similar for rate control (1.17, P < 0.01) and rhythm control agents (0.93, P = 0.03). However, PCP-gated plan patients had slightly lower likelihood of being prescribed NOACs (0.82, P = 0.001) than non-gated plan patients. Elapsed time until receipt of medication was similar between PCP-gated and non-gated groups across drug classes. CONCLUSIONS Pharmaceutical claims data do not suggest that PCP-gatekeeping by healthcare plans is a structural barrier to AF therapy, although it was associated with lower use of NOACs.
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Affiliation(s)
- Andrew Young Chang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Mariam Askari
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Paul A Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - P Michael Ho
- Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado.,Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Kenneth W Mahaffey
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Aditya Jathin Ullal
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | | | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, Stanford, California.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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8
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Gorzkowski JA, Klein JD, Harris DL, Kaseeska KR, Whitmore Shaefer RM, Bocian AB, Davis JB, Gotlieb EM, Wasserman RC. Maintenance of Certification Part 4 Credit and recruitment for practice-based research. Pediatrics 2014; 134:747-53. [PMID: 25180282 PMCID: PMC4179094 DOI: 10.1542/peds.2014-0316] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Competing priorities in pediatric practice have created challenges for practice-based research. To increase recruitment success, researchers must design studies that provide added value to participants. This study evaluates recruitment of pediatricians into a study, before and after the development and addition of a quality improvement (QI) curriculum approved for American Board of Pediatrics Maintenance of Certification (MOC) Part 4 Credit as an enrollment incentive. METHODS Researchers implemented multiple outreach methods to enroll pediatric practices over 28 months. Field note review revealed that many physicians declined enrollment, stating that they prioritized MOC Part 4 projects over research studies. A QI curriculum meeting standards for MOC Part 4 Credit was developed and added to the study protocol as an enrollment incentive. Enrollment rates and characteristics of practitioners enrolled pre- and post-MOC were compared. RESULTS Pre-MOC enrollment contributed 48% of practices in 22 months; post-MOC enrollment contributed 49% of practices in 6 months. An average of 3.5 practices enrolled per month pre-MOC, compared with 13.1 per month post-MOC (P < .001). Clinicians in pre- and post-MOC groups were similar in age, gender, race, and time spent on patient care; practices enrolled post-MOC were more likely to be located in federally designated Medically Underserved Areas than those enrolled pre-MOC (28.6% vs 12%, P = .03). CONCLUSIONS Addition of MOC Part 4 Credit increased recruitment success and increased enrollment of pediatricians working in underserved areas. Including QI initiatives meeting MOC Part 4 criteria in practice-based research protocols may enhance participation and aid in recruiting diverse practice and patient populations.
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Affiliation(s)
| | | | - Donna L. Harris
- Pediatric Research in Office Settings, Department of Research, American Academy of Pediatrics, Elk Grove Village, IL; and
| | | | | | - Alison B. Bocian
- Pediatric Research in Office Settings, Department of Research, American Academy of Pediatrics, Elk Grove Village, IL; and
| | - James B. Davis
- Pediatric Research in Office Settings, Department of Research, American Academy of Pediatrics, Elk Grove Village, IL; and
| | - Edward M. Gotlieb
- Pediatric Research in Office Settings, Department of Research, American Academy of Pediatrics, Elk Grove Village, IL; and
| | - Richard C. Wasserman
- Pediatric Research in Office Settings, Department of Research, American Academy of Pediatrics, Elk Grove Village, IL; and,Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont
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9
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Wendland J, Danet M, Gacoin E, Didane N, Bodeau N, Saïas T, Le Bail M, Cazenave MT, Molina T, Puccinelli O, Chirac O, Medeiros M, Gérardin P, Cohen D, Guédeney A. French version of the Brief Infant-Toddler Social and Emotional Assessment questionnaire-BITSEA. J Pediatr Psychol 2014; 39:562-75. [PMID: 24719240 DOI: 10.1093/jpepsy/jsu016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The aim of the present study was to examine the psychometric properties of the French version of the Brief Infant-Toddler Social and Emotional Assessment (BITSEA). METHODS The sample consisted of 589 low-risk infants aged 12-36 months and their parents. Parents completed the BITSEA, the Child Behavior Checklist 1½-5 (CBCL - 18 months to 5 years version), and the Parenting Stress Index - Short Form (PSI-SF). RESULTS Multitrait-multimethod and confirmatory factor analyses revealed adequate psychometric properties for the French version of the BITSEA. Scores on the BITSEA Problem scale were positively correlated to all CBCL and PSI-SF subscales, whereas negative correlations were found between BITSEA Competence scale and CBCL and PSI-SF subscales. The BITSEA Problem score significantly increased with level of parental worry, examined through a single-item question that is part of the BITSEA. CONCLUSION Findings support the validity of the French version of the BITSEA. However, additional work on the clinical validity of the BITSEA, including with at-risk children, is warranted.
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Affiliation(s)
- Jaqueline Wendland
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, ParisParis Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - Marie Danet
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - Estelle Gacoin
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - Nadia Didane
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - Nicolas Bodeau
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - Thomas Saïas
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - Morgane Le Bail
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - Marie-Thérèse Cazenave
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - Thais Molina
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - Ophélie Puccinelli
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - Olivia Chirac
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - Melania Medeiros
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - Priscille Gérardin
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - David Cohen
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
| | - Antoine Guédeney
- Paris Descartes University, Psychopathology and Health Processes Laboratory, Department of Child and Adolescent Psychiatry, Pitié-Salpêtrière University Hospital, Department of Medical Pediatrics and Child and Adolescent Psychiatry, Rouen University Hospital, Rouen, and Department of Child and Adolescent Psychiatry, Bichat University Hospital, Paris
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10
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Toomey SL, Chien AT, Elliott MN, Ratner J, Schuster MA. Disparities in unmet need for care coordination: the national survey of children's health. Pediatrics 2013; 131:217-24. [PMID: 23339228 DOI: 10.1542/peds.2012-1535] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To determine (1) the proportion of parents who report a need for and receipt of effective care coordination for their child, (2) whether unmet care coordination needs differ by children with special health care needs (CSHCN) status and sociodemographic characteristics, and (3) whether having a personal provider or family-centered care mitigates disparities. METHODS This study was a cross-sectional analysis of the 2007 National Survey for Children's Health, a nationally representative survey of 91 642 parents. Outcome measures were parent report of need for and lack of effective care coordination. We also examined the effect of parent report of having a personal provider and family-centered care. We conducted weighted bivariate and multivariate analyses. RESULTS Forty-one percent of parents reported that their child needed care coordination. Among those who needed care coordination, 31% did not receive effective coordination. CSHCN (41%) were more likely than children without special health care needs (26%; P < .001) to have unmet care coordination needs. Latino (40%) and black (37%) children were more likely to have unmet needs than white (27%; P < .001) children. These patterns remained in multivariate analysis. Having a personal provider decreased the odds of having unmet need for care coordination but did not attenuate disparities. Receiving family-centered care mitigated disparities associated with race/ethnicity but not with health status or health insurance. CONCLUSIONS A considerable proportion of parents reported their child needed more care coordination than they received. This was especially true for parents of CSHCN and parents of black and Latino children. Interventions that enhance family-centered care might particularly contribute to reducing racial/ethnic disparities.
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Affiliation(s)
- Sara L Toomey
- MPhil, MSc, Division of General Pediatrics, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.
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11
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Vernacchio L, Muto JM, Young G, Risko W. Ambulatory subspecialty visits in a large pediatric primary care network. Health Serv Res 2012; 47:1755-69. [PMID: 22375886 DOI: 10.1111/j.1475-6773.2012.01391.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine patterns of subspecialty utilization within a pediatric primary care network. DATA SOURCES/STUDY SETTING Paid claims from a large not-for-profit health plan for patients of The Pediatric Physicians' Organization at Children's, a network of private pediatric practices affiliated with Children's Hospital Boston. PRINCIPAL FINDINGS The subspecialty visit rate was 1.01 visits per subject-year. In 2007, 56.8 percent of subjects had no subspecialty visits, whereas 4.2 percent had ≥ 5 visits; the corresponding figures in 2008 were 54.1 and 4.5 percent, respectively. The most frequently visited subspecialties were Ophthalmology, Orthopedics, Dermatology, Otorhinolaryngology, and Allergy/Immunology. Visit rates varied sevenfold by practice. CONCLUSIONS Wide practice variability in pediatric subspecialty utilization suggests an opportunity for reducing unnecessary visits. Better integration between primary care and the most commonly used subspecialties will be needed to meaningfully reduce unnecessary visits and enhance value.
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Affiliation(s)
- Louis Vernacchio
- The Pediatric Physicians' Organization at Children's, Brookline, MA 02445, USA.
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12
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Resnicow K, Mcmaster F, Woolford S, Slora E, Bocian A, Harris D, Drehmer J, Wasserman R, Schwartz R, Myers E, Foster J, Snetselaar L, Hollinger D, Smith K. Study design and baseline description of the BMI2 trial: reducing paediatric obesity in primary care practices. Pediatr Obes 2012; 7:3-15. [PMID: 22434735 PMCID: PMC5427511 DOI: 10.1111/j.2047-6310.2011.00001.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Revised: 08/01/2011] [Accepted: 08/29/2011] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study will test the efficacy of motivational interviewing (MI) conducted by primary care providers and dieticians among children ages 2-8 years old with a body mass index (BMI) ≥ 85th and ≤ 97th percentile. METHODS Forty-two practices from the American Academy of Pediatrics, Pediatric Research in Office Settings Network were assigned to one of three groups. Group 1 (usual care) measures BMI percentile at baseline, and at 1- and 2-year follow-ups and receives standard health education materials. Group 2 providers deliver three proactive MI counselling sessions with a parent of the index child in Year 1 and one additional 'booster' visit in Year 2. Group 3 adds six MI counselling sessions from a trained dietician. The primary outcome is the child's BMI percentile at 2-year follow-up. Secondary outcomes include parent report of the child's screen time, physical activity, intake of fruits and vegetables, and sugar-sweetened beverages. RESULTS We enrolled 633 eligible children whose mean BMI percentile was 92.0 and mean age of 5.1. The cohort was 57% female. Almost 70% of parents reported a household income of ≥ $40,000 per year, and 39% had at least a college education. The cohort was 63% white, 23% Hispanic, 7% black and 7% Asian. Parent self-reported confidence that their child will achieve a healthy weight was on average an 8 (out of 10). CONCLUSION To date, several aspects of the study can inform similar efforts including our ability to use volunteer clinicians to recruit participants and their willingness to dedicate their time, without pay, to receive training in MI.
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Affiliation(s)
- K. Resnicow
- Department of Health Behavior & Health Education, University of Michigan, Ann Arbor, MI, USA
| | - F. Mcmaster
- Department of Health Behavior & Health Education, University of Michigan, Ann Arbor, MI, USA
| | - S. Woolford
- Child Health Evaluation and Research Unit (CHEAR), University of Michigan, Ann Arbor, MI, USA
| | - E. Slora
- Pediatric Research in Office Settings (PROS), American Academy of Pediatrics, Elk Grove Village, IL, USA
| | - A. Bocian
- Pediatric Research in Office Settings (PROS), American Academy of Pediatrics, Elk Grove Village, IL, USA
| | - D. Harris
- Pediatric Research in Office Settings (PROS), American Academy of Pediatrics, Elk Grove Village, IL, USA
| | - J. Drehmer
- Pediatric Research in Office Settings (PROS), American Academy of Pediatrics, Elk Grove Village, IL, USA
| | - R. Wasserman
- Pediatric Research in Office Settings (PROS), American Academy of Pediatrics, Elk Grove Village, IL, USA
,Department of Pediatrics, University of Vermont, Burlington, VA, USA
| | - R. Schwartz
- Department of Pediatrics, Wake Forest University, Winston-Salem, NC, USA
| | - E. Myers
- American Dietetic Association, Chicago, IL, USA
| | - J. Foster
- American Dietetic Association, Chicago, IL, USA
| | - L. Snetselaar
- College of Public Health, University of Iowa, Iowa City, IA, USA
| | - D. Hollinger
- College of Public Health, University of Iowa, Iowa City, IA, USA
| | - K. Smith
- College of Public Health, University of Iowa, Iowa City, IA, USA
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13
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Abstract
OBJECTIVE To assess the effects of physician-centred gatekeeping on health, health care utilization, and costs by conducting a systematic review of the literature. METHODS Systematic search in PubMed (MEDLINE and Pre-MEDLINE), EMBASE, and the Cochrane Library, from the databases' respective inception dates up to January 2010, using the search words "gatekeeping", "gatekeeper*", "first contact", and "self-referral". We included RCTs, CCTs, cohort studies, CBAs, and interrupted time-series. We included only studies in which the gatekeeper function was exercised by a physician and that reported health and patient-related outcomes including quality of life and satisfaction, quality of care, health care utilization, and/or economic outcomes (e.g. expenditures or efficiency). Selection was made independently by two reviewers and discrepancies were solved by consensus after discussion. Data on target population, intervention, additional interventions, study results, and methodological quality were extracted. Methodological quality was assessed independently by two reviewers following the previously defined criteria. Discrepancies were solved by consensus after discussion. RESULTS This review includes 26 studies in 32 publications. The majority of studies (62%) reported data from the United States and in most gatekeeping was associated with lower utilization of health services (up to -78%) and lower expenditures (up to -80%). However, there was great variability in the magnitude and direction of the differences. CONCLUSION Overall, the evidence regarding the effects of gatekeeping is of limited quality. Many studies are available regarding the effects on health care utilisation and expenditures, whereas effects on health and patient-related outcomes have been studied only exceptionally and are inconclusive.
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14
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Zuckerman KE, Cai X, Perrin JM, Donelan K. Incomplete specialty referral among children in community health centers. J Pediatr 2011; 158:24-30. [PMID: 20801461 DOI: 10.1016/j.jpeds.2010.07.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Revised: 05/19/2010] [Accepted: 07/09/2010] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess rates of incomplete specialty referral (referral not resulting in a specialist visit) and risk factors for incomplete referral in pediatric community health care centers. STUDY DESIGN In this cross-sectional study, we used referral records and electronic health records to calculate rate of incomplete referral in 577 children referred from two health care centers in underserved communities to any of 19 pediatric specialties at an affiliated tertiary care center, over 7 months in 2008-2009. We used logistic regression to test the association of incomplete referral with child/family sociodemographic and health care system factors. RESULTS Of the children, 30.2% had an incomplete referral. Incomplete referral rates were similar at the two health care centers, but varied from 10% to 73% according to specialty clinic type. In multivariate analysis, sociodemographic factors of older child age, public insurance status, and no chronic health conditions correlated with incomplete referral, as did health care system factors of surgical specialty clinic type, low patient volume, longer wait for visit, and appointment rescheduling. CONCLUSION Almost one-third of children referred to specialists were unable to complete the referral in a timely manner. To improve specialty access, health care organizations and policymakers should target support to families with high-risk children and remediate problematic health care system features.
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Affiliation(s)
- Katharine E Zuckerman
- Child and Adolescent Health Measurement Initiative, Oregon Health and Sciences University, Portland, OR 97239-2998, USA.
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15
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Abstract
The pediatric hospitalist program at the Children's Hospital of Pittsburgh (CHP)-the Diagnostic Referral Service (DRS)-was first described in the pediatric literature in 1988. At that time, the group consisted of 5 members with a variety of inpatient and outpatient responsibilities. Since then, there has been a significant nationwide growth in pediatric hospital medicine. In the same time frame, the DRS has also grown significantly, with new and enhanced responsibilities in both the inpatient and outpatient settings. This work reflects on the recent trends in pediatrics that resulted in the growth of specialists in hospital medicine and in the evolution of the DRS responsibilities. A detailed description of the unique changes in the DRS is provided as a model for effective care of children in the modern era.
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Affiliation(s)
- Kishore Vellody
- Paul C. Gaffney Diagnostic Referral Service, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15201, USA.
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16
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Skinner AC, Mayer ML. Effects of insurance status on children's access to specialty care: a systematic review of the literature. BMC Health Serv Res 2007; 7:194. [PMID: 18045482 PMCID: PMC2222624 DOI: 10.1186/1472-6963-7-194] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Accepted: 11/28/2007] [Indexed: 11/23/2022] Open
Abstract
Background The current climate of rising health care costs has led many health insurance programs to limit benefits, which may be problematic for children needing specialty care. Findings from pediatric primary care may not transfer to pediatric specialty care because pediatric specialists are often located in academic medical centers where institutional rules determine accepted insurance. Furthermore, coverage for pediatric specialty care may vary more widely due to systematic differences in inclusion on preferred provider lists, lack of availability in staff model HMOs, and requirements for referral. Our objective was to review the literature on the effects of insurance status on children's access to specialty care. Methods We conducted a systematic review of original research published between January 1, 1992 and July 31, 2006. Searches were performed using Pubmed. Results Of 30 articles identified, the majority use number of specialty visits or referrals to measure access. Uninsured children have poorer access to specialty care than insured children. Children with public coverage have better access to specialty care than uninsured children, but poorer access compared to privately insured children. Findings on the effects of managed care are mixed. Conclusion Insurance coverage is clearly an important factor in children's access to specialty care. However, we cannot determine the structure of insurance that leads to the best use of appropriate, quality care by children. Research about specific characteristics of health plans and effects on health outcomes is needed to determine a structure of insurance coverage that provides optimal access to specialty care for children.
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Affiliation(s)
- Asheley Cockrell Skinner
- Department of Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
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17
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Einhorn R, Eekhof JAH, Engelberts AC, Groeneveld Y, Verkerk PH, Wit JM. Referral patterns between the child health service, general practitioners, and secondary healthcare: A prospective descriptive study in the Netherlands. Eur J Gen Pract 2007; 13:225-30. [DOI: 10.1080/13814780701814853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Rubin Einhorn
- Department of Public Health and Primary Care, , Leiden, the Netherlands
| | - Just A. H. Eekhof
- Department of Public Health and Primary Care, , Leiden, the Netherlands
| | - Adele C. Engelberts
- Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
| | - Ymte Groeneveld
- Department of Public Health and Primary Care, , Leiden, the Netherlands
| | | | - Jan M. Wit
- Department of Paediatrics, Leiden University Medical Centre, Leiden, the Netherlands
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18
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Jaruseviciene L, Levasseur G. The appropriateness of gatekeeping in the provision of reproductive health care for adolescents in Lithuania:the general practice perspective. BMC FAMILY PRACTICE 2006; 7:16. [PMID: 16536876 PMCID: PMC1431546 DOI: 10.1186/1471-2296-7-16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2005] [Accepted: 03/14/2006] [Indexed: 11/18/2022]
Abstract
Background Adolescents' consultation of primary health care services remains problematic despite their accessibility. The reproductive health service seeking behavior of adolescents is the object of much research but little is known about how this behavior is influenced by the gatekeeping system. This study aimed to explore general practitioners' perceptions of the appropriateness of gatekeeping in adolescent reproductive health care. Methods Twenty in-depth interviews regarding factors affecting adolescent reproductive health care were carried out on a diverse sample of general practitioners and analyzed using grounded theory. Results The analysis identified several factors that shaped GPs' negative attitude to gatekeeping in adolescent reproductive health care. Its appropriateness in this field was questionable due to a lack of willingness on the part of GPs to provide reproductive health services for teenagers, their insufficient training, inadequately equipped surgeries and low perceived support for reproductive health service provision. Conclusion Since factors for improving adolescent reproductive health concern not only physicians but also the health system and policy levels, complex measures should be designed to overcome these barriers. Discussion of a flexible model of gatekeeping, encompassing both co-ordination of care provided by GPs and the possibility of patients' self-referral, should be included in the political agenda. Adolescents tend to under-use rather than over-use reproductive health services and every effort should be made to facilitate the accessibility of such services.
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Affiliation(s)
- Lina Jaruseviciene
- The Department of Family Medicine, Kaunas University of Medicine, Lithuania
| | - Gwenola Levasseur
- The Department of General Practice, University of Rennes, France
- National School of Public Health, Rennes, France
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19
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Kogan MD, Newacheck PW, Honberg L, Strickland B. Association between underinsurance and access to care among children with special health care needs in the United States. Pediatrics 2005; 116:1162-9. [PMID: 16264004 DOI: 10.1542/peds.2004-2432] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To examine the impact of underinsurance on access to care among children with special health care needs (CSHCN) in the United States. METHODS Interviews were conducted by telephone with the families of 38866 CSHCN who were younger than 18 years using the 2001 National Survey of Children With Special Health Care Needs. The prevalence of underinsurance and its relationship to access to care and family financial problems was examined in this cross-sectional analysis. CSHCN were classified as underinsured when coverage was deemed inadequate to meet the child's needs. RESULTS An estimated 12.8% of US children experienced a special health care need in 2001. Although 95% of CSHCN had some type of insurance coverage at the time of the interview, 32% were classified as underinsured. Underinsured CSHCN were disproportionately represented in low-income families and were significantly more likely than fully insured children to have unmet health needs, and their families were more likely to report difficulty in obtaining specialty referrals, experience financial problems, and report that the child's condition caused family members to reduce or stop work. Underinsured CSHCN seemed to be somewhat better off than CSHCN with no insurance coverage on these measures. CONCLUSIONS Underinsured CSHCN represent an important and largely hidden underserved population.
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Affiliation(s)
- Michael D Kogan
- Maternal and Child Health Bureau, Health Resources and Services Administration, Rockville, MD 20857, USA.
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20
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Shenkman E, Tian L, Nackashi J, Schatz D. Managed care organization characteristics and outpatient specialty care use among children with chronic illness. Pediatrics 2005; 115:1547-54. [PMID: 15930215 DOI: 10.1542/peds.2004-1496] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Limited information is available about managed care organization (MCO) characteristics that influence outpatient physician specialist use among children with chronic conditions. OBJECTIVE To examine the association between MCO characteristics and outpatient physician specialist use among children with chronic conditions who were receiving care in MCOs in which primary care providers (PCPs) served as gatekeepers for referrals and who were publicly insured. DESIGN AND METHODS A total of 2333 children who had been diagnosed with a chronic condition and had functional limitations, an increased need for or use of health care services beyond what children normally use, and/or dependence on medications or home medical equipment were included in the study. The odds of an outpatient physician specialist visit 1 year after study entry were examined as a function of child health and sociodemographic characteristics, MCO characteristics, the child's prior specialty care use, and provider availability in the MCO service delivery area. RESULTS Children cared for in MCOs with lower percentages of PCPs paid on a fee-for-service basis (odds ratio: 0.95; 95% confidence interval: 0.92-0.98), with higher percentages of pediatricians in the PCP network (odds ratio: 1.17; 95% confidence interval: 1.07-1.29), and offering financial incentives for meeting quality of care standards (odds ratio: 1.71; 95% confidence interval: 1.28-2.29) had greater odds of outpatient physician specialist visits. Black children had odds of specialty care that were approximately one half those of white children. Children with prior physician specialist use were 52% more likely to have a physician specialist visit in the year after study entry. The children's diagnoses and condition consequences were not related significantly to the odds of a specialty visit. CONCLUSIONS Specific MCO characteristics were associated with greater specialty care use among a group of low-income children with chronic conditions. Such information should be used to improve the structure of managed care arrangements for these vulnerable children.
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Affiliation(s)
- Elizabeth Shenkman
- Department of Epidemiology and Health Policy Research, Institute for Child Health Policy, University of Florida, 1329 SW 16th St, Room 5130, Gainesville, FL 32608, USA.
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21
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Redlener I, Grant R, Krol DM. Beyond primary care: Ensuring access to subspecialists, special services, and health care systems for medically underserved children. Adv Pediatr 2005; 52:9-22. [PMID: 16124334 DOI: 10.1016/j.yapd.2005.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Irwin Redlener
- Mailman School of Public Health, Columbia University, New York, New York, USA
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22
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Abstract
OBJECTIVE This study examines patterns of specialist use among children and adolescents by presence of a chronic condition or disability, insurance, and sociodemographic characteristics. DESIGN Cross-sectional analysis of national survey data, describing rates of specialist use, with logistic regressions to examine associations with having a chronic condition or disability, insurance status, and sociodemographic variables. SETTING The 1999 National Health Interview Survey, a nationally representative household survey. PARTICIPANTS Children and adolescents 2 to 17 years old. OUTCOME Parental/respondent reports of specialist visits based on reports of the child having seen or talked to a medical doctor who specializes in a particular medical disease or problem about the child's health during the last 12 months. RESULTS Thirteen percent of US children were reported as seeing a specialist in the past year. Specialist-visit rates were twice as high for children with a chronic condition or disability (26% vs 10.2%). The specialist utilization rates for children without insurance were much lower than those for insured children, but among the children who have coverage (private, Medicaid, or other), specialist-utilization rates were similar (no statistically significant difference). Results of multivariate analyses predicting the use of specialists confirm the above-mentioned findings. Additionally, they show that use of specialist care was lower among children in the middle age group, minorities, children in families between 100% and 200% of the federal poverty level, and lower parental educational levels. We found no difference in specialist-visit rates between rural- and urban-dwelling children, by family status, or by gender. Differences in specialist use by gatekeeping status are found only among subgroups. CONCLUSIONS The results showed that, overall, 13% of children used a specialist in a year. Among the insured, a slightly greater percentage of children used such care (15%). These numbers were slightly lower than the 18% to 28% of pediatric patients referred per year in 5 US health plans, although the sources of data and definitions of specialist use differ. Our results showed that 26% of children with a chronic condition or disability who were insured by Medicaid use a specialist. Although the data are not directly comparable, this is within the range of previous findings showing annual rates by condition of use between 24% and 59%. These findings are consistent also with greater use of many different types of health care by children with special health care needs. Medicaid-utilization rates presented here were similar also to the rates found among privately insured children and children with "other" insurance. In our earlier work examining use of specialists by children insured by Medicaid, we speculated that Medicaid-insured children might face particular difficulty with access (eg, due to transportation or language barriers). The findings presented here suggest that children insured by Medicaid had no different use of specialists than other insured children. We do not know, however, whether similar rates are appropriate. As predicted, sociodemographic differences were pronounced and followed patterns typically found for use of health services. Lower rates of specialist use by non-Hispanic blacks and Hispanics remains even, controlling for chronic condition/disability, status, insurance, and socioeconomic status. This is an important issue that not only needs to be addressed in using specialist care but also in many areas in health care. It is the near poor who seem to have difficulty accessing care (as is evidenced by lower use of specialists). In a study of access to care, similar results were found, with those between 125% and 200% of the federal poverty level being less likely to have a usual source of care. This is roughly the population targeted by the State Children's Health Insurance Programs. These findings cannot determine whether rates of use are too high or too low. Additional work on outcomes for children who do and do not use specialist care would further inform the work presented here. Extending that work to examine patterns of care including but not limited to specialists and generalists would be even better.
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Affiliation(s)
- Karen Kuhlthau
- Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02114, USA.
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Stille CJ, Primack WA, Savageau JA. Generalist-subspecialist communication for children with chronic conditions: a regional physician survey. Pediatrics 2003; 112:1314-20. [PMID: 14654603 DOI: 10.1542/peds.112.6.1314] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To identify target areas for interventions to improve communication between pediatric generalists (PCPs) and pediatric subspecialists (SPs) in the outpatient care of children with chronic conditions. METHODS We constructed a 4-page mailed questionnaire probing communication practices, opinions about the role of communication in care, and perceived barriers and facilitators to PCP-SP communication in the care of children with chronic conditions. In the spring of 2001, we surveyed all 495 New England SPs who were members of the American Academy of Pediatrics (AAP) and/or SP societies and a random sample of 495 generalist AAP members in New England. Eligible were those actively providing outpatient care. Most items were rated on a 5-point scale. RESULTS Of those eligible, 48% (412/860) completed the questionnaire. Although 98% of respondents agreed that communication was important for good care, reported practices reflected large gaps in this area. Frequent receipt (>60% of the time) of communication about an initial referral was reported by only 28% of SPs. Barriers reported as most important involved inefficiencies in telephone contact, transcription delay, and failure to keep all providers informed when >1 specialist is involved. Important facilitators included letters or phone calls at or before the time of consultation, and clear and specific referral questions from PCPs. PCPs saw communication as more of a problem than did SPs (40% vs 28%), and reported several barriers as more important. Although 86% of respondents had access to e-mail in their practices, <20% used it often. CONCLUSIONS PCPs and SPs sharing care for children with chronic conditions are troubled by their frequent failure or inability to contact their colleagues by phone and letter. PCPs communicate less frequently than SPs yet perceive more problems with communication. Interventions to promote efficient contact between providers at or before the time of subspecialty visits can lead to improved coordination of care, which in turn may better meet the needs of families.
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Affiliation(s)
- Christopher J Stille
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts 01655, USA.
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Abstract
BACKGROUND Patients' barriers to mental health services are well documented and include social stigma, lack of adequate insurance coverage, and underdiagnosis by primary care physicians. Little is known, however, about challenges primary care physicians face arranging mental health referrals and hospitalizations. OBJECTIVE To examine how practice setting and environment influence primary care physicians' ability to refer patients for medically necessary mental health services. DESIGN Cross-sectional analysis using nationally representative survey data from the 1998 to 1999 Community Tracking Study physician survey. The overall survey response rate was 61%. PARTICIPANTS A 1998 to 1999 telephone survey of 6586 primary care physicians. MEASUREMENTS Primary care physicians' report of whether they could obtain medically necessary referrals to high-quality mental health specialists or psychiatric admissions. RESULTS Overall, 54% of primary care physicians reported problems obtaining psychiatric hospital admissions, and 54% reported problems arranging outpatient mental health referrals. Primary care physicians practicing in staff and group model HMOs were much less apt to report difficulties than physicians in solo and small-group practices (P <.001). Reports of inadequate time with patients (P <.001) and smaller numbers of psychiatrists in a market area (P <.01) also were associated with problems obtaining mental health referrals. Pediatricians were more apt to report problems than general internists (P <.001). CONCLUSIONS Primary care physicians face greater hurdles obtaining mental health services than other medical services. Primary care is an important entry point for mental health services, yet inadequate referral systems between medical and mental health services may be hampering access.
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Affiliation(s)
- Sally Trude
- Center for Studying Health System Change, Washington, DC, 20024-2512, USA.
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Stille CJ, Korobov N, Primack WA. Generalist-subspecialist communication about children with chronic conditions: an analysis of physician focus groups. AMBULATORY PEDIATRICS : THE OFFICIAL JOURNAL OF THE AMBULATORY PEDIATRIC ASSOCIATION 2003; 3:147-53. [PMID: 12708892 DOI: 10.1367/1539-4409(2003)003<0147:gcacwc>2.0.co;2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To describe barriers and facilitators to effective generalist-subspecialist communication in the care of children with chronic conditions. METHODS We conducted 5 focus groups with 14 general pediatricians and 10 pediatric specialty providers to discuss factors that facilitate or obstruct effective communication. The specialty groups included 2 nurse practitioners; the rest were pediatricians from an academic medical center and the surrounding community. We performed a content analysis to generate groups of themes and classify them as barriers or facilitators, and we returned to the participants to solicit their feedback. RESULTS We identified 201 themes in 6 domains: the method, content, and timing of communication; system factors; provider education; and interpersonal issues. Barriers to communication mostly involved the method of communication and system factors. Most facilitating themes promoted timely communication, understanding of the reasons for referral and the nature of the child's condition, or appropriate definition of generalist and specialist roles. Participants described numerous examples where communication had direct effects on patient outcomes. Generalists and specialists agreed on many issues, although specialists discussed the pros and cons of curbside consults at length whereas generalists emphasized the importance of their own education in the referral-consultation process. CONCLUSIONS Efforts to improve communication between pediatric generalists and specialists in the care of children with chronic conditions should emphasize the importance of timely information transfer. The content of messages is important, but lack of receipt when needed is more of a problem. Improving generalist-subspecialist communication has great potential to improve the quality of care.
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Affiliation(s)
- Christopher J Stille
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA 01655, USA.
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Starfield B, Lemke KW, Bernhardt T, Foldes SS, Forrest CB, Weiner JP. Comorbidity: implications for the importance of primary care in 'case' management. Ann Fam Med 2003; 1:8-14. [PMID: 15043174 PMCID: PMC1466556 DOI: 10.1370/afm.1] [Citation(s) in RCA: 228] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Although comorbidity is very common in the population, little is known about the types of health service that are used by people with comorbid conditions. METHODS Data from claims on the nonelderly were classified by diagnosis and extent of comorbidity, using a case-mix measure known as the Johns Hopkins Adjusted Clinical Groups, to study variation in extent of comorbidity and resource utilization. Visits of patients (adults and children) with 11 conditions were classified as to whether they were to primary care physicians or to other specialists, and whether they involved the chosen condition or other conditions. RESULTS Comorbidity varied within each diagnosis; resource use depended on the degree of comorbidity rather than the diagnosis. When stratified by degree of comorbidity, the number of visits for comorbid conditions exceeded the number of visits for the index condition in almost all comorbidity groups and for visits to both primary care physicians and to specialists. The number of visits to primary care physicians for both the index condition and for comorbid conditions almost invariably exceeded the number of visits to specialists. These patterns differed only for uncommon conditions in which specialists played a greater role in the care of the condition, but not for comorbid conditions. CONCLUSIONS In view of the high degree of comorbidity, even in a nonelderly population, single-disease management does not appear promising as a strategy to care for patients. In contrast, the burden is on primary care physicians to provide the majority of care, not only for the target condition but for other conditions. Thus, management in the context of ongoing primary care and oriented more toward patients' overall health care needs appears to be a more promising strategy than care oriented to individual diseases. New paradigms of care that acknowledge actual patterns of comorbidities as well as the need for close coordination between generalists and specialists require support.
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Affiliation(s)
- Barbara Starfield
- Department of Health Policy and Management, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD 21205, USA.
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Forrest CB. Primary care in the United States: primary care gatekeeping and referrals: effective filter or failed experiment? BMJ 2003; 326:692-5. [PMID: 12663407 PMCID: PMC152368 DOI: 10.1136/bmj.326.7391.692] [Citation(s) in RCA: 112] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2003] [Indexed: 11/04/2022]
Affiliation(s)
- Christopher B Forrest
- Health Services Research and Development Center, Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
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Pati S, Shea S, Rabinowitz D, Carrasquillo O. Does gatekeeping control costs for privately insured children? Findings from the 1996 medical expenditure panel survey. Pediatrics 2003; 111:456-60. [PMID: 12612221 DOI: 10.1542/peds.111.3.456] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Gatekeeping requirements were widely adopted by health insurers in an attempt to control costs in the mid-1990s, but empirical evidence demonstrating decreased health expenditures for children enrolled in such plans is lacking. METHODS We analyzed data from 3254 children with private health insurance sampled in the 1996 Medical Expenditure Panel Survey (MEPS) to compare total per capita health expenditures among gatekeeping versus indemnity plan enrollees. This sample represents 40.4 million privately insured American children. Total expenditures were defined as payments from all sources, including third-party and out-of-pocket payments, but excluding administrative costs. MEPS data are based on information provided by patients, health care providers, and hospitals. Gatekeeping plans included all children enrolled in health maintenance organizations or other plans requiring a primary care gatekeeper. All others were considered indemnity plan enrollees. RESULTS Mean total per capita annual expenditures for children in gatekeeping versus indemnity plans differed by <1% (887 dollars vs 881 dollars, respectively). Third-party payments by gatekeeping plans on behalf of their beneficiaries were 636 dollars versus 595 dollars by indemnity plans. Out-of-pocket payments were on average 62 dollars less for gatekeeping enrollees than for indemnity enrollees. After multivariate adjustment, mean per capita expenditures were approximately 4% lower for gatekeeping enrollees than for indemnity enrollees. CONCLUSION In 1996, total per capita annual health expenditures for children in gatekeeping plans were approximately 8 dollars less than for those in indemnity plans. These data indicate that gatekeeping is not an effective cost-containment method for children.
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Affiliation(s)
- Susmita Pati
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
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Christakis DA, Wright JA, Zimmerman FJ, Bassett AL, Connell FA. Continuity of care is associated with well-coordinated care. AMBULATORY PEDIATRICS : THE OFFICIAL JOURNAL OF THE AMBULATORY PEDIATRIC ASSOCIATION 2003; 3:82-6. [PMID: 12643780 DOI: 10.1367/1539-4409(2003)003<0082:cociaw>2.0.co;2] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
CONTEXT The importance of continuity of care as a means to promote care coordination remains controversial. OBJECTIVE To determine if there is an association between having an objective measure of continuity of care and parental perception that care is well coordinated. DESIGN Cross-sectional study. SETTING AND POPULATION Seven hundred fifty-nine patients presenting to a primary care clinic completed surveys that included 5 items from the Components of Primary Care Index (CPCI) that relate to care coordination. MAIN PREDICTOR VARIABLE: A continuity of care index (COC) that quantifies the degree of dispersion of care among providers. MAIN OUTCOME MEASURES Likelihood of parents reporting high scores on the care coordination domain as well as each of the 5 individual CPCI items related to care coordination. RESULTS Greater continuity of care was associated with higher scores on the CPCI care-coordination domain (P <.001). Continuity of care was also specifically associated with increased odds of agreeing with all 5 individual CPCI items, including reporting that their child's provider "always knows about care my child received in other places" (OR 3.97 [2.11-7.49]), "communicates with the other health care providers my child sees" (OR 2.98 [1.63-5.44]), "knows the results of my child's visits to other doctors" (OR 2.02 [1.08-3.80]), and "always follows up on a problem my child has had, either at the next visit or by phone" (OR 6.20 [2.88-13.35]) and wanting one provider to coordinate all of the health care that the child receives (OR 3.28 [1.48-7.27]). CONCLUSIONS Greater continuity of primary care is associated with better care coordination as perceived by parents. Efforts to improve and maintain continuity may be justified.
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Forrest CB, Nutting P, Werner JJ, Starfield B, von Schrader S, Rohde C. Managed health plan effects on the specialty referral process: results from the Ambulatory Sentinel Practice Network referral study. Med Care 2003; 41:242-53. [PMID: 12555052 DOI: 10.1097/01.mlr.0000044903.91168.b6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The specialty referral process is one of the chief targets of managed care constraints on ambulatory medical decision-making. This study examines the influence of gatekeeping arrangements and capitated primary care physician (PCP) payment on the specialty referral process in primary care settings. RESEARCH DESIGN Primary care practice-based study of referred and nonreferred office visits. SUBJECTS The study comprised 14,709 visits made by privately insured, nonelderly patients who were seen by 139 primary care physicians in 80 practices located in 31 states. MEASURES Visits were grouped by health plan type: gatekeeping with capitated PCP payment; gatekeeping with fee-for-service PCP payment; no gatekeeping. Dependent measures included the proportion of visits referred, characteristics of referrals, and physician coordination activities. RESULTS The percentages of office visits resulting in a referral were similar between the two gatekeeping groups and higher than the no gatekeeping group. Patients in plans with capitated PCP payment were more likely to be referred for discretionary indications than those in nongatekeeping plans (15.5% v 9.9%, P < 0.05). The frequency of referring physician coordination activities did not vary by health plan type. The proportion of patients in gatekeeping health plans within a practice was directly related to employing staff as referral coordinators, allowing nurses to refer without physician consultation, and permitting patients to request referrals by leaving recorded telephone messages. CONCLUSION The specialty referral process for privately insured nonelderly patients enrolled in managed health plans is generally similar, regardless of the presence of gatekeeping arrangements and capitated PCP payment. An increase in the number of discretionary referrals among patients in plans with capitated PCP payment provides support for exploring strategies that encourage PCPs to manage in their entirety conditions that straddle the boundaries between primary and specialty care. In response to increasing numbers of patients enrolled in managed health plans with gatekeeping arrangements, physicians appear to modify the structure of their practices to facilitate access to and coordination of referrals.
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Affiliation(s)
- Christopher B Forrest
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Grembowski DE, Martin D, Diehr P, Patrick DL, Williams B, Novak L, Deyo R, Katon W, Dickstein D, Engelberg R, Goldberg H. Managed care, access to specialists, and outcomes among primary care patients with pain. Health Serv Res 2003; 38:1-19. [PMID: 12650378 PMCID: PMC1360871 DOI: 10.1111/1475-6773.00102] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To determine whether managed care controls were associated with reduced access to specialists and worse outcomes among primary care patients with pain. DATA SOURCES/STUDY SETTING Patient, physician, and office manager questionnaires collected in the Seattle area in 1996-1997, plus data abstracted from patient records and health plans. STUDY DESIGN A prospective cohort study of 2,275 adult patients with common pain problems recruited in the offices of 261 primary care physicians in Seattle. DATA COLLECTION Patients completed a waiting room questionnaire and follow-up surveys at the end of the first and sixth months to measure access to specialists and outcomes. Intensity of managed care controls measured by plan managed care index and benefit/cost-sharing indexes, office managed care index, physician compensation, financial incentives, and use of clinical guidelines. PRINCIPAL FINDINGS A financial withhold for referral was associated with a lower likelihood of referral to a physician specialist, a greater likelihood of seeing a specialist without referral, and a lower patient rating of care from the primary physician. Otherwise, patients in more managed offices and with greater out-of-network plan benefits had greater access to specialists. Patients with more versus less managed care had similar health outcomes, but patients in more managed offices had lower ratings of care provided by their primary physicians. CONCLUSIONS Increased managed care controls were generally not associated with reduced access to specialists and worse health outcomes for primary care patients with pain, but patients in more managed offices had lower ratings of care provided by their primary physicians.
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Affiliation(s)
- David E Grembowski
- Department of Health Services, School of Public Health and Community Medicine, University of Washington, Seattle 98195-7660, USA
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Cabana M, Bruckman D, Rushton JL, Bratton SL, Green L. Receipt of asthma subspecialty care by children in a managed care organization. AMBULATORY PEDIATRICS : THE OFFICIAL JOURNAL OF THE AMBULATORY PEDIATRIC ASSOCIATION 2002; 2:456-61. [PMID: 12437392 DOI: 10.1367/1539-4409(2002)002<0456:roascb>2.0.co;2] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Although proper outpatient asthma management sometimes requires care from subspecialists, there is little information on factors affecting receipt of subspecialty care in a managed care setting. OBJECTIVE To determine factors associated with receipt of subspecialty care for children with asthma in a managed care organization. METHODS We conducted an analysis of the claims from 3163 children with asthma enrolled in a university-based managed care organization from January 1998 to October 2000. We used logistic regression analysis to determine factors associated with an outpatient asthma visit with an allergist or pulmonologist. RESULTS Of the 3163 patients, 443 (14%) had at least 1 subspecialist visit for asthma; 354 (80%) were seen by an allergist, 63 (14%) were seen by a pulmonologist, and 26 (6%) were seen by both. In multivariate analysis, patients with more severe asthma (odds ratio [OR], 3.81; 95% confidence interval [CI], 2.99-4.86) and older patients (OR, 1.04; 95% CI, 1.02-1.07) were more likely to receive care from a subspecialist. Compared with Medicaid patients, both non-Medicaid patients with copayment (OR, 2.52; 95% CI, 1.85-4.43) and non-Medicaid patients without any copayment (OR, 3.40; 95% CI, 2.35-4.93) were more likely to receive care from an asthma subspecialist. CONCLUSIONS Children insured by Medicaid are less likely to receive care from subspecialists for asthma. Reasons may be due to health care system-related factors, such as accessibility of subspecialists, to physician referral decisions, and/or to patient factors, such as adherence to recommendations to see a subspecialist. Our findings suggest a need to further investigate health care system barriers, physician referral, and patient acceptance and completion of subspecialty referral.
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Affiliation(s)
- Michael Cabana
- Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, University of Michigan Health Care System, Ann Arbor 48109-0456, USA.
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Perrin JM, Kuhlthau KA, Gortmaker SL, Beal AC, Ferris TG. Generalist and subspecialist care for children with chronic conditions. AMBULATORY PEDIATRICS : THE OFFICIAL JOURNAL OF THE AMBULATORY PEDIATRIC ASSOCIATION 2002; 2:462-9. [PMID: 12437393 DOI: 10.1367/1539-4409(2002)002<0462:gascfc>2.0.co;2] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine, among Medicaid-enrolled children with chronic conditions, associations of indicators of morbidity and expenditures with different patterns of generalist, subspecialist, and pediatric subspecialist use. DESIGN AND SETTING Cross-sectional analysis of Medicaid claims, enrollment, and provider data from 4 states (California, Georgia, Michigan, and Tennessee). SAMPLE All children enrolled in Supplemental Security Income (aged 0-21 years) and a sample of other Medicaid-enrolled children matched for age and gender. We included 11 chronic conditions, including both uncommon conditions (eg, spina bifida, hemophilia) and common ones (eg, asthma, attention deficit hyperactivity disorder). MAIN OUTCOME MEASURES We determined the number of visits per year to generalists and subspecialists (pediatric and other), using only subspecialists relevant to that condition. We categorized patterns of care as generalist only, predominantly generalist, or predominantly subspecialist, and examined patterns by condition and an indicator of morbidity. Among children seeing subspecialists, we also compared morbidity by pediatric and other subspecialists. We used linear regression to determine per-year total expenditures, controlling for demographic characteristics and morbidity. RESULTS Most children (60.7%) saw generalists only. Twenty-eight percent were in predominantly generalist arrangements, and 11% were in predominantly subspecialist arrangements. Children in predominantly generalist arrangements had higher morbidity than children in generalist-only or predominantly subspecialist arrangements. Among children seeing subspecialists, those seeing pediatric subspecialists had generally higher morbidity than those seeing other subspecialists. Mean yearly expenditures varied from 1306 dollars (attention deficit hyperactivity disorder) to 11,633 dollars (acquired immunodeficiency syndrome). Children who saw only generalists had significantly lower expenditures for 6 of the 11 conditions, after adjusting for morbidity. CONCLUSIONS Medicaid-enrolled children in predominantly generalist arrangements appear to have more complicated conditions than children in generalist-only or predominantly subspecialist arrangements, engendering also higher expenditures. Although children who saw generalists only had lower expenditures than those seeing subspecialists, this finding may reflect unmeasured variations in morbidity.
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Affiliation(s)
- James M Perrin
- Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, Boston 02114, USA.
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Affiliation(s)
- Thomas F Boat
- University of Cincinnati College of Medicine, Department of Pediatrics, Ohio, USA
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McMillan JA. Distribution of specialized care to children: role of the pediatric generalist and subspecialist. J Pediatr 2002; 140:491-2. [PMID: 12032508 DOI: 10.1067/mpd.2002.123886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Julia A McMillan
- Pediatrics, Johns Hopkins University School of Medicine in Baltimore, Maryland, USA
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Grembowski DE, Martin D, Patrick DL, Diehr P, Katon W, Williams B, Engelberg R, Novak L, Dickstein D, Deyo R, Goldberg HI. Managed care, access to mental health specialists, and outcomes among primary care patients with depressive symptoms. J Gen Intern Med 2002; 17:258-69. [PMID: 11972722 PMCID: PMC1495032 DOI: 10.1046/j.1525-1497.2002.10321.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether managed care is associated with reduced access to mental health specialists and worse outcomes among primary care patients with depressive symptoms. DESIGN Prospective cohort study. SETTING Offices of 261 primary physicians in private practice in Seattle. PATIENTS Patients (N = 17,187) were screened in waiting rooms, enrolling 1,336 adults with depressive symptoms. Patients (n = 942) completed follow-up surveys at 1, 3, and 6 months. MEASUREMENTS AND RESULTS For each patient, the intensity of managed care was measured by the managedness of the patient's health plan, plan benefit indexes, presence or absence of a mental health carve-out, intensity of managed care in the patient's primary care office, physician financial incentives, and whether the physician read or used depression guidelines. Access measures were referral and actually seeing a mental health specialist. Outcomes were the Symptom Checklist for Depression, restricted activity days, and patient rating of care from primary physician. Approximately 23% of patients were referred to mental health specialists, and 38% saw a mental health specialist with or without referral. Managed care generally was not associated with a reduced likelihood of referral or seeing a mental health specialist. Patients in more-managed plans were less likely to be referred to a psychiatrist. Among low-income patients, a physician financial withhold for referral was associated with fewer mental health referrals. A physician productivity bonus was associated with greater access to mental health specialists. Depressive symptom and restricted activity day outcomes in more-managed health plans and offices were similar to or better than less-managed settings. Patients in more-managed offices had lower ratings of care from their primary physicians. CONCLUSIONS The intensity of managed care was generally not associated with access to mental health specialists. The small number of managed care strategies associated with reduced access were offset by other strategies associated with increased access. Consequently, no adverse health outcomes were detected, but lower patient ratings of care provided by their primary physicians were found.
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Affiliation(s)
- David E Grembowski
- Center for Cost and Outcomes Research, Department of Health Services, University of Washington, Seattle, Wash 98195-7660, USA.
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Glade GB, Forrest CB, Starfield B, Baker AE, Bocian AB, Wasserman RC. Specialty referrals made during telephone conversations with parents: a study from the pediatric research in office settings network. AMBULATORY PEDIATRICS : THE OFFICIAL JOURNAL OF THE AMBULATORY PEDIATRIC ASSOCIATION 2002; 2:93-8. [PMID: 11926839 DOI: 10.1367/1539-4409(2002)002<0093:srmdtc>2.0.co;2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To characterize variation in pediatricians' telephone referral practices, to identify differences in the types of referrals made during telephone versus office visit encounters, and to examine the impact of referring by telephone on coordination and outcomes of the referral as assessed by physicians. METHODS We conducted a prospective study of a consecutive sample of referrals (N = 1856) made from the offices of 142 pediatricians in a national practice-based research network. During 20 consecutive practice-days, physicians completed questionnaires about patients referred during regular business hours. They used office records 3 months later to complete questionnaires about referral outcomes. RESULTS Pediatricians made 1 telephone referral every 5 practice-days, which constituted 27.5% of all referrals they made during office hours. Pediatricians who saw more patients per day, saw more patients in gatekeeping health plans, and referred more during office visits made more telephone referrals than their counterparts. Compared with specialty referrals made during office visits, those occurring during telephone encounters were more frequently at the request of parents or because of insurance administrative guidelines. Office visit referrals were more often made for diagnostic evaluation or a surgical procedure. Referrals made during telephone conversations were less well coordinated: office staff or referring physicians scheduled fewer specialty appointments and were less likely to send information to specialists. Three months after referrals were made, specialist feedback and referring physician satisfaction with specialty care were comparable between the two groups. CONCLUSIONS Specialty referrals made during telephone conversations with patients are a regular occurrence in pediatric practice. Changes in the health system that lead to greater demands on primary care physician productivity or more patients in gatekeeping health plans will likely increase the number of referrals made during telephone conversations with parents. Pediatricians are less likely to coordinate telephone referrals than office visit referrals. Pediatricians are frequently unaware whether or not referrals are completed.
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Affiliation(s)
- Gordon B Glade
- Pediatric Research in Office Settings (PROS), Center for Child Health Research, American Academy of Pediatrics, Elk Grove Village, IL, USA.
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Ferris TG, Perrin JM, Manganello JA, Chang Y, Causino N, Blumenthal D. Switching to gatekeeping: changes in expenditures and utilization for children. Pediatrics 2001; 108:283-90. [PMID: 11483789 DOI: 10.1542/peds.108.2.283] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Gatekeeping has been a central strategy in the cost-containment initiatives of managed care organizations. Little empirical research describes the impact of switching into a gatekeeping plan on health care expenditures and utilization for children. OBJECTIVE To determine the likelihood of a parent with a chronically ill child enrolling in a health plan with gatekeeping, as well as the effects of gatekeeping on health care expenditures and utilization for children, especially those with chronic conditions. DESIGN We followed a cohort of 1839 children who either voluntarily switched to a gatekeeping plan or remained in an indemnity plan from 1991 through 1994. Study participants were children of employees of a large hospital. The gatekeeping plan was virtually identical to the previous indemnity plan except for lower monthly employee contribution and the requirement for a primary care physician to preapprove subspecialty referrals. We determined the likelihood of a household containing a child with a chronic condition enrolling in the gatekeeping plan, as well as mean annual total, subspecialty, and primary care expenditures and utilization for all children and children with chronic conditions. RESULTS Households switching to gatekeeping were less likely to have children with chronic illness (8% vs 15%). Total and subspecialty expenditures for all children decreased more in the gatekeeping group (53% and 59%, respectively) than in the indemnity group (11% and 6%, respectively). For children with chronic conditions, mean visits to subspecialists decreased 57% in the gatekeeping group but increased 31% in the indemnity group. Mean visits to primary care physicians decreased 23% in the gatekeeping group compared with 13% in indemnity group. CONCLUSION Parents of children with a chronic condition were much less likely than other parents to switch to a gatekeeping plan. Switching to gatekeeping was associated with reduced visits to specialists but did not increase the involvement of primary care physicians in the management of children with chronic conditions. The implications of these findings for the health of children are unknown.
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Affiliation(s)
- T G Ferris
- Institute for Health Policy, Division of General Medicine, Massachusetts General Hospital for Children and Harvard Medical School, Boston, Massachusetts 02114, USA.
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Brach C, Sanches L, Young D, Rodgers J, Harvey H, McLemore T, Fraser I. Wrestling with typology: penetrating the "black box" of managed care by focusing on health care system characteristics. Med Care Res Rev 2001; 57 Suppl 2:93-115. [PMID: 11105508 DOI: 10.1177/1077558700057002s06] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The health care system has undergone a fundamental transformation undermining the usefulness of the typology of the health maintenance organization, the independent practice association, the preferred provider organization, and so forth. The authors present a new approach to studying the health care system. In matrix form, they have identified a set of organizational and delivery characteristics with the potential to influence outcomes of interest, such as access to services, quality, health status and functioning, and cost. The matrix groups the characteristics by domain--financial features, structure, care delivery and management policies, and products--and by key roles in the health care system--sponsor, plan, provider intermediary organization, and direct services provider. The matrix is a tool for researchers, administrators, clinicians, data collectors, regulators, and other policy makers. It suggests a new set of players to be studied, emphasizes the relationships among the players, and provides a checklist of independent, control, and interactive variables to be included in analyses.
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Stoddard JJ, Cull WL, Jewett EA, Brotherton SE, Mulvey HJ, Alden ER. Providing pediatric subspecialty care: A workforce analysis. AAP Committee on Pediatric Workforce Subcommittee on Subspecialty Workforce. Pediatrics 2000; 106:1325-33. [PMID: 11099584 DOI: 10.1542/peds.106.6.1325] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To provide a snapshot of pediatric subspecialty practice, examine issues pertaining to the subspecialty workforce, and analyze subspecialists' perspective on the health care market. BACKGROUND Before the effort of the Future of Pediatric Education II (FOPE II) Project, very little information existed regarding the characteristics of the pediatric subspecialty workforce. This need was addressed through a comprehensive initiative involving cooperation between subspecialty sections of the American Academy of Pediatrics and other specialty societies. METHODS Questionnaires were sent to all individuals, identified through exhaustive searches, who practiced in 17 pediatric medical and surgical subspecialty areas in 1997 and 1998. The survey elicited information about education and practice issues, including main practice setting, major professional activity, referrals, perceived competition, and local workforce requirements. The number of respondents used in the analyses ranged from 120 (plastic surgery) to 2034 (neonatology). In total, responses from 10 010 pediatric subspecialists were analyzed. RESULTS For 13 of the subspecialties, a medical school setting was specified by the largest number of respondents within each subspecialty as their main employment site. Direct patient care was the major professional activity of the majority of respondents in all the subspecialties, with the exception of infectious diseases. Large numbers of subspecialists reported increases in the complexity of referral cases, ranging between 20% (cardiology) and 44% (critical care), with an average of 33% across the entire sample. In all subspecialties, a majority of respondents indicated that they faced competition for services in their area (range: 55%-90%; 71% across the entire sample); yet in none of the subspecialties did a majority report that they had modified their practice as a result of competition. In 15 of the 17 subspecialties, a majority stated that there would be no need in their community over the next 3 to 5 years for additional pediatric subspecialists in their discipline. Across the entire sample, 42% of respondents indicated that they or their employer would not be hiring additional, nonreplacement pediatric subspecialists in their field in the next 3 to 5 years (range: 20%-63%). CONCLUSION This survey provides the first comprehensive analysis to date on how market forces are perceived to be affecting physicians in the pediatric subspecialty workforce. The data indicate that pediatric subspecialists in most areas are facing strong competitive pressures in the market, and that the market's ability to support additional subspecialists in many areas may be diminishing.
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Affiliation(s)
- J J Stoddard
- American Academy of Pediatrics, Elk Grove Village, Illinois, USA.
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Altemeier WA. Office education: "lunch says this is an atrial septal defect". Pediatr Ann 2000; 29:460, 462. [PMID: 10960947 DOI: 10.3928/0090-4481-20000801-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Miller MR, Forrest CB, Kan JS. Parental preferences for primary and specialty care collaboration in the management of teenagers with congenital heart disease. Pediatrics 2000; 106:264-9. [PMID: 10920149 DOI: 10.1542/peds.106.2.264] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We examined parental preferences for locus of service delivery for their teenager's congenital heart disease (CHD) and the influence of disease severity, sociodemographic factors, and insurance on these preferences. METHODS A consecutive sample of parents of teenagers followed in a pediatric cardiology clinic completed a mailed questionnaire. Disease severity was classified as low (</=1 cardiovascular procedure), moderate (>1 cardiovascular procedure), and high (cyanosis or single ventricle physiology). RESULTS Eighty-six of 148 parents responded (58%): 40, low severity; 36, moderate severity; and 10, high severity of illness. Parents preferred using primary care providers (PCPs) as a point of first contact for all 11 of 11 general health concerns and 5 of 7 potential cardiovascular-related concerns: chest pain (52%), syncope (73%), seeming seriously ill (79%), sports physical examination (79%), and endocarditis prophylactic antibiotics (94%). Increasing disease severity was significantly associated with preferring cardiologists for 6 of 7 cardiovascular-related concerns. Overall, 58% of parents viewed their care as a PCP-cardiologist comanagement model versus a cardiologist-dominated model. Lower family income (odds ratio [OR]: 1.5; confidence interval [CI]: 1.0-2.2) and severity of illness (OR: 2.1; CI: 1.0-4.4) were associated with a comanagement model of health care versus a cardiologist-dominated model. CONCLUSIONS This study suggests that the majority of parents of teenagers with CHD prefer to use their teenager's PCP for all routine health care needs and many cardiovascular health needs. Severity of illness and family income are positively associated with greater preference for cardiologist care.
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Affiliation(s)
- M R Miller
- Division of Pediatric Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Briggs-Gowan MJ, Horwitz SM, Schwab-Stone ME, Leventhal JM, Leaf PJ. Mental health in pediatric settings: distribution of disorders and factors related to service use. J Am Acad Child Adolesc Psychiatry 2000; 39:841-9. [PMID: 10892225 DOI: 10.1097/00004583-200007000-00012] [Citation(s) in RCA: 227] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To examine child psychiatric disorders in pediatric settings and identify factors associated with parents' use of pediatricians as resources concerning emotional/behavioral issues and use of mental health services. METHOD The sample consists of 5- to 9-year-olds (mean = 7.17 years, SD = 1.41) from a representative sample (N = 1,060) of pediatric practices. Parent interviews included assessments of psychiatric disorders with the Diagnostic Interview Schedule for Children (DISC-R), parental depression/anxiety, possible child abuse, stress, support, and the use of mental health services. RESULTS The prevalence of any DISC disorder was 16.8%. Parental depression/anxiety and possible child abuse were associated independently with 2- to 3-times higher rates of disorder. Many parents (55%) who reported any disorder did not report discussing behavioral/emotional concerns with their pediatrician. Factors associated with discussing behavioral/emotional issues were the presence of any disorder and financial stress. Factors related to seeing a mental health professional were discussing behavioral/emotional issues with the pediatrician, single parenthood, and stressful life events. CONCLUSIONS The prevalence rates of disorders in this setting suggest that pediatricians are well-placed to identify and refer children with psychiatric disorders. However, most parents do not discuss behavioral/emotional issues with their pediatrician. Methods for improving rates of identification and referral (e.g., routine screening) are considered.
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Affiliation(s)
- M J Briggs-Gowan
- Yale University Department of Psychology, New Haven, CT 06520, USA
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