Pediatric guidelines and managed care: who is using what and what difference does it make?

Increasing the screening and counseling of adolescents for risky health behaviors: a primary care intervention

OBJECTIVE

To determine whether a systems intervention for primary care providers resulted in increased preventive screening and counseling of adolescent patients, compared with the usual standard of care.

METHODS

The intervention was conducted in 2 outpatient pediatric clinics; 2 other pediatric clinics in the same health maintenance organization served as comparison sites. The intervention was implemented in 2 phases: first, pediatric primary care providers attended a training workshop (N = 37) to increase screening and counseling of adolescents in the areas of tobacco, alcohol, drugs, sexual behavior, and safety (seatbelt and helmet use). Second, screening and charting tools were integrated into the intervention clinics. Providers in the comparison sites (N = 39) continued to provide the usual standard of care to their adolescent patients. Adolescent reports were used to assess changes in provider behavior. After a well visit, 13- to 17-year olds (N = 2628) completed surveys reporting on whether their provider screened and counseled them for risky behavior.

RESULTS

Screening and counseling rates increased significantly in each of the 6 areas in the intervention sites, compared with rates of delivery using the usual standard of care. Across the 6 areas combined, the average screening rate increased from 58% to 83%; counseling rates increased from 52% to 78%. There were no significant increases in the comparison sites during the same period. The training component seems to account for most of this increase, with the tools sustaining the effects of the training.

CONCLUSIONS

The study offers strong support for an intervention to increase clinicians' delivery of preventive services to a wide age range of adolescent patients.

Screening and counseling for adolescent alcohol use among primary care physicians in the United States

OBJECTIVE

To examine the prevalence and quality of alcohol prevention services delivered to adolescents in the United States.

METHODS

A national, stratified random sample of pediatricians and family practitioners was drawn from the American Medical Association Masterfile. The response rate was 63%, and the final sample size was 1842 physicians. Quality of services delivered was assessed by 2 scales: quality of screening (percentage of patients screened and depth of screening questions used) and quality of education (level of effectiveness of educational methods used and frequency of use).

RESULTS

Although most physicians reported providing some degree of alcohol prevention services, their efforts were typically inconsistent, not in enough depth, and they failed to incorporate the most effective educational methods. Reported rates of universal screening and counseling were low, and younger adolescents were less likely to receive services. Physicians' beliefs about their alcohol management skills and perceptions of resource availability were the most consistent correlates of higher quality service.

CONCLUSIONS

Prospective studies that elucidate the conditions under which individual physicians do and do not screen, as well as future efforts to educate physicians about the most effective brief intervention approaches, seem warranted.

A national study of commercial health insurance and medicaid definitions of medical necessity: what do they mean for children?

OBJECTIVE

To analyze medical necessity standards used by state Medicaid agencies and the largest commercial insurers in the United States on the basis of criteria related to scope of health problems covered and requirements for effectiveness and cost.

METHODS

Information was obtained from managed care contract documents used by the 45 state Medicaid agencies enrolling children into managed care organizations and from certificates of coverage used by the largest health maintenance and preferred provider organization insurers in each state.

RESULTS

Commercial insurers are more likely than Medicaid agencies to articulate medical necessity standards that limit coverage to treatment for illnesses and injuries and to include stringent requirements for cost and evidence of effectiveness.

CONCLUSION

To reduce the discretion retained by insurers in determining medical necessity, particularly around the scope of health problems covered, much greater clarity and uniformity in medical necessity language will be required in the future.

Pediatric practice guidelines: implications for nurse practitioners

Practice guidelines are promoted as an important means of achieving high-quality, cost-effective health care. Nurse practitioners must understand what practice guidelines are and how they are developed and be willing to put them into practice. This discussion begins with a description of practice guidelines specific to pediatrics. The terminology used in reference to these "clinical tools" are differentiated and their historic and contemporary influences are summarized. The complexity of guideline development and attributes of a quality practice guideline are described. Finally, the pivotal roles nurse practitioners can play in putting guidelines into practice are suggested.