Pediatric Medical Subspecialist Use in Outpatient Settings

Importance

A first step toward understanding whether pediatric medical subspecialists are meeting the needs of the nation's children is describing rates of use and trends over time.

Objectives

To quantify rates of outpatient pediatric medical subspecialty use.

Design, Setting, and Participants

This repeated cross-sectional study of annual subspecialist use examined 3 complementary data sources: electronic health records from PEDSnet (8 large academic medical centers [January 1, 2010, to December 31, 2021]); administrative data from the Healthcare Integrated Research Database (HIRD) (14 commercial health plans [January 1, 2011, to December 31, 2021]); and administrative data from the Transformed Medicaid Statistical Information System (T-MSIS) (44 state Medicaid programs [January 1, 2016, to December 31, 2019]). Annual denominators included 493 628 to 858 551 patients younger than 21 years with a general pediatric visit in PEDSnet; 5 million beneficiaries younger than 21 years enrolled for at least 6 months in HIRD; and 35 million Medicaid or Children's Health Insurance Program beneficiaries younger than 19 years enrolled for any amount of time in T-MSIS.

Exposure

Calendar year and type of medical subspecialty.

Main Outcomes and Measures

Annual number of children with at least 1 completed visit to any pediatric medical subspecialist in an outpatient setting per population. Use rates excluded visits in emergency department or inpatient settings.

Results

Among the study population, the proportion of girls was 51.0% for PEDSnet, 51.1% for HIRD, and 49.3% for T-MSIS; the proportion of boys was 49.0% for PEDSnet, 48.9% for HIRD, and 50.7% for T-MSIS. The proportion of visits among children younger than 5 years was 37.4% for PEDSnet, 20.9% for HIRD, and 26.2% for T-MSIS; most patients were non-Hispanic Black (29.7% for PEDSnet and 26.1% for T-MSIS) or non-Hispanic White (44.9% for PEDSnet and 43.2% for T-MSIS). Annual rates for PEDSnet ranged from 18.0% to 21.3%, which were higher than rates for HIRD (range, 7.9%-10.4%) and T-MSIS (range, 7.6%-8.6%). Subspecialist use increased in the HIRD commercial health plans (annual relative increase of 2.4% [95% CI, 1.6%-3.1%]), but rates were essentially flat in the other data sources (PEDSnet, -0.2% [95% CI, -1.1% to 0.7%]; T-MSIS, -0.7% [95% CI, -6.5% to 5.5%]). The flat PEDSnet growth reflects a balance between annual use increases among those with commercial insurance (1.2% [95% CI, 0.3%-2.1%]) and decreases in use among those with Medicaid (-0.9% [95% CI, -1.6% to -0.2%]).

Conclusions and Relevance

The findings of this cross-sectional study suggest that among children, 8.6% of Medicaid beneficiaries, 10.4% of those with commercial insurance, and 21.3% of those whose primary care is received in academic health systems use pediatric medical subspecialty care each year. There was a small increase in rates of subspecialty use among children with commercial but not Medicaid insurance. These data may help launch innovations in the primary-specialty care interface.

National Research Agenda on Health Systems for Children and Youth With Special Health Care Needs

Children and youth with special health care needs (CYSHCN) "have or are at increased risk for chronic physical, developmental, behavioral or emotional conditions and also require health and related services of a type or amount beyond that required by children generally." CYSHCN rely on health systems, which extend beyond traditional health care entities, to optimize their health and well-being. The current US health system is not fully equipped and functioning to meet the needs of CYSHCN. Recognizing this, the Maternal and Child Health Bureau and the US Health Resources and Services Administration established the Research Network on Health Systems for CYSHCN (CYSHCNet, http://www.cyshcnet.org). With input from >800 US stakeholders, CYSHCNet developed a national research agenda on health systems for CYSHCN designed to: 1) highlight important health system challenges faced by key stakeholders (ie, patients and families, health care providers, insurers, administrators, etc.); 2) organize research topics and goals to identify opportunities for improvement, to address challenges and to promote progress toward the ideal health system; and 3) provide a blueprint for health systems research ideas and studies that will guide CYSHCN investigators and other stakeholders going forward. We introduce the 6 research topics currently included in the research agenda-transition to adulthood, caregiving, family health, child health care, principles of care, and financing-to inform and guide investigators as they embark on a trajectory of health systems research on CYSHCN.

Moving From Spending to Investment: A Research Agenda for Improving Health Care Financing for Children and Youth With Special Health Care Needs

Children and youth with special health care needs (CYSHCN) use disproportionately more health care resources than non-CYSHCN, and their unique needs merit additional consideration. Spending on health care in the United States is heavily concentrated on acute illnesses through fee-for-service (FFS). Payment reform frameworks have focused on shifting away from FFS, addressing health outcomes and the experience of care while lowering costs, particularly for high resource utilizers. The focus of payment reform efforts to date has been on adults with chronic illnesses, with less priority given to investment in children's health and life course. Spending for children's health is also considered an investment in their growth and development with long-term outcomes at stake, so research questions should focus on where and how such spending should be targeted. This paper discusses high-priority research topics in the area of health care financing for CYSHCN in the context of what is currently known and important knowledge gaps related to investment for CYSHCN. It proceeds to describe 3 potential research projects that can address these topics, following a framework informed by the priority questions identified in a previous multistakeholder research agenda development process. We focus on 3 areas: benefits, payment models, and quality measures. Specific aims and hypotheses are offered, as well as suggestions for approaches and thoughts on potential implications.

Health System Research Priorities for Children and Youth With Special Health Care Needs

OBJECTIVES

In this study, we sought to establish priorities for a national research agenda for children and youth with special health care needs (CYSHCN) through a structured, multistakeholder, mixed-methods approach.

METHODS

Using surveys, we solicited responses from >800 members of expert-nominated stakeholder organizations, including CYSHCN families, health care providers, researchers, and policymakers, to identify what research with or about CYSHCN they would like to see in a national research agenda. From 2835 individual free-text responses, 96 research topics were synthesized and combined. Using an adapted RAND/UCLA Appropriateness Method (a modified Delphi approach), an expert panel rated research topics across 3 domains: need and urgency, research impact, and family centeredness. Domains were rated on 9-point Likert scales. Panelist ratings were used to sort research topics into 4 relative-priority ranks. Rank 1 (highest priority) research topics had a median of ≥7 in all domains.

RESULTS

The RAND/UCLA Appropriateness Method was used to prioritize CYSHCN research topics and depict their varying levels of stakeholder-perceived need and urgency, research impact, and family centeredness. In the 15 topics that achieved rank 1, social determinants of health (disparities and rurality), caregiving (family resilience and care at home), clinical-model refinement (effective model elements, labor divisions, telemedicine, and system integration), value (stakeholder-centered value outcomes, return on investment, and alternative payment models), and youth-adult transitions (planning, insurance, and community supports) were emphasized.

CONCLUSIONS

High-priority research topics identified by CYSHCN experts and family leaders underscore CYSHCN research trends and guide important directions. This study is the first step toward an efficient and cohesive research blueprint to achieve highly-effective CYSHCN health systems.

Prescribing Physical, Occupational, and Speech Therapy Services for Children With Disabilities

Pediatric health care providers are frequently responsible for prescribing physical, occupational, and speech therapies and monitoring therapeutic progress for children with temporary or permanent disabilities in their practices. This clinical report will provide pediatricians and other pediatric health care providers with information about how best to manage the therapeutic needs of their patients in the medical home by reviewing the International Classification of Functioning, Disability and Health; describing the general goals of habilitative and rehabilitative therapies; delineating the types, locations, and benefits of therapy services; and detailing how to write a therapy prescription and include therapists in the medical home neighborhood.

Psychosocial Factors in Children and Youth With Special Health Care Needs and Their Families

Children and youth with special health care needs (CYSHCN) and their families may experience a variety of internal (ie, emotional and behavioral) and external (ie, interpersonal, financial, housing, and educational) psychosocial factors that can influence their health and wellness. Many CYSHCN and their families are resilient and thrive. Medical home teams can partner with CYSHCN and their families to screen for, evaluate, and promote psychosocial health to increase protective factors and ameliorate risk factors. Medical home teams can promote protective psychosocial factors as part of coordinated, comprehensive chronic care for CYSHCN and their families. A team-based care approach may entail collaboration across the care spectrum, including youth, families, behavioral health providers, specialists, child care providers, schools, social services, and other community agencies. The purpose of this clinical report is to raise awareness of the impact of psychosocial factors on the health and wellness of CYSHCN and their families. This clinical report provides guidance for pediatric providers to facilitate and coordinate care that can have a positive influence on the overall health, wellness, and quality of life of CYSHCN and their families.

The Role of Integrated Care in a Medical Home for Patients With a Fetal Alcohol Spectrum Disorder

Fetal alcohol spectrum disorder (FASD) is an umbrella term used to describe preventable birth defects and intellectual and/or developmental disabilities resulting from prenatal alcohol exposure. The American Academy of Pediatrics has a previous clinical report in which diagnostic criteria for a child with an FASD are discussed and tools to assist pediatricians with its management can be found. This clinical report is intended to foster pediatrician awareness of approaches for screening for prenatal alcohol exposure in clinical practice, to guide management of a child with an FASD after the diagnosis is made, and to summarize available resources for FASD management.

Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway?

Children with medical complexity (CMC) have multiple chronic conditions and require an array of medical- and community-based providers. Dedicated care coordination is increasingly seen as key to addressing the fragmented care that CMC often encounter. Often conceptually misunderstood, care coordination is a team-driven activity that organizes and drives service integration. In this article, we examine models of care coordination and clarify related terms such as care integration and case management. The location of care coordination resources for CMC may range from direct practice provision to external organizations such as hospitals and accountable care organizations. We discuss the need for infrastructure building, design and implementation leadership, use of care coordination tools and training modules, and appropriate resource allocation under new payment models.

Care System Redesign for Preterm Children After Discharge From the NICU

Approximately 1 in 8 children in the United States are born preterm. Existing guidelines and research examine the cost of prematurity from the NICU stay and developmental surveillance and outcomes after discharge from the NICU. Preterm children are at greater risk for excess hospitalizations, outpatient visits, and societal costs after NICU discharge. Improved delivery of care and health promotion from the community setting, particularly from the patient-centered medical home, may result in improved growth, health, and development, with accompanying reduction of post-NICU discharge costs and encounters. There has been comparatively little focus on how to promote health and wellness for children born preterm, particularly for community-based providers and payers. Accordingly, health care delivery for NICU graduates is often fragmented, with little guidance on medical management beyond tertiary care follow-up. In this article, we use what is known about chronic care and practice transformation models to present a framework for health care system redesign for children born preterm. We discuss the rationale for NICU graduates as a priority population for health system redesign. Promotion of health and wellness for children born preterm who are discharged to the community setting entails population health management from the patient-centered medical home; comanagement, clinical care protocols, and clinical support from the tertiary care-based tertiary care-based center; and a favorable payer strategy that emphasizes support for chronic care management. Practical suggestions are provided for the practicing physician for the child born preterm as health care systems are redesigned.

Barriers to Care Coordination and Medical Home Implementation

BACKGROUND

Pediatricians are central in leading the family-centered medical home (FCMH), yet little is known about how provider-perceived barriers to and attitudes toward the FCMH affect implementation. This study aims to assess the relationship between pediatrician-perceived barriers to and attitudes toward FCMH and reported care coordination.

METHODS

Pediatricians working in ambulatory care responded to the American Academy of Pediatrics Periodic Survey of Fellows #79 (N = 572, response rate, 59%). Our primary care coordination outcomes were whether pediatricians were: (1) leading a multidisciplinary team; (2) developing care plans; and (3) connecting with support services. Independent variables included barriers to FCMH implementation (lack of communication skills, support services, and time). Associations between outcomes and barriers were assessed by multivariate logistic regression, controlling for pediatrician and practice characteristics.

RESULTS

Lack of sufficient personnel was significantly associated with fewer care coordination activities: leading a multidisciplinary team (odds ratio [OR], 0.53), developing care plans (OR, 0.51), and connecting with support services (OR, 0.42). Lacking communication skills was significantly associated with lower odds of development of care plans (OR, 0.56) and assistance with support services (OR, 0.64). Lack of time was significantly associated with lower odds of leading a multidisciplinary team (OR, 0.53). A pediatrician's belief that the FCMH encourages the use of preventive services was significantly associated with increased support services (OR, 2.06).

CONCLUSIONS

Pediatricians report a need for sufficient personnel and communication skills to provide care coordination, a core component of the FCMH. Interventions to boost FCMH implementation should focus on providing resources to develop these characteristics.

The medical home and integrated behavioral health: advancing the policy agenda

There has been a considerable expansion of the patient-centered medical home model of primary care delivery, in an effort to reduce health care costs and to improve patient experience and population health. To attain these goals, it is essential to integrate behavioral health services into the patient-centered medical home, because behavioral health problems often first present in the primary care setting, and they significantly affect physical health. At the 2013 Patient-Centered Medical Home Research Conference, an expert workgroup convened to determine policy recommendations to promote the integration of primary care and behavioral health. In this article we present these recommendations: Build demonstration projects to test existing approaches of integration, develop interdisciplinary training programs to support members of the integrated care team, implement population-based strategies to improve behavioral health, eliminate behavioral health carve-outs and test innovative payment models, and develop population-based measures to evaluate integration.

Adapting practice-based intervention research to electronic environments: opportunities and complexities at two institutions

BACKGROUND AND PURPOSE

Primary care practice-based research has become more complex with increased use of electronic health records (EHRs). Little has been reported about changes in study planning and execution that are required as practices change from paper-based to electronic-based environments. We describe the evolution of a pediatric practice-based intervention study as it was adapted for use in the electronic environment, to enable other practice-based researchers to plan efficient, effective studies.

METHODS

We adapted a paper-based pediatric office-level intervention to enhance parent-provider communication about subspecialty referrals for use in two practice-based research networks (PBRNs) with partially and fully electronic environments. We documented the process of adaptation and its effect on study feasibility and efficiency, resource use, and administrative and regulatory complexities, as the study was implemented in the two networks.

RESULTS

Considerable time and money was required to adapt the paper-based study to the electronic environment, requiring extra meetings with institutional EHR-, regulatory-, and administrative teams, and increased practice training. Institutional unfamiliarity with using EHRs in practice-based research, and the consequent need to develop new policies, were major contributors to delays. Adapting intervention tools to the EHR and minimizing practice disruptions was challenging, but resulted in several efficiencies as compared with a paper-based project. In particular, recruitment and tracking of subjects and data collection were easier and more efficient.

CONCLUSIONS

Practice-based intervention research in an electronic environment adds considerable cost and time at the outset of a study, especially for centers unfamiliar with such research. Efficiencies generated have the potential of easing the work of study enrollment, subject tracking, and data collection.

Summary of STARNet: Seamless Transitions and (Re)admissions Network

The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012 to synthesize ongoing hospital-to-home transition work, discuss goals, and develop a plan to centralize transition information in the future. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from hospital groups, private payers, as well as representatives from current transition collaboratives. In this report, we (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and list potential measures for transition quality. STARNet met with the support of the American Academy of Pediatrics' Quality Improvement Innovation Networks and the Section on Hospital Medicine.

Parent partnerships in communication and decision making about subspecialty referrals for children with special needs

OBJECTIVE

To describe factors that influence parent-clinician partnerships in information exchange and shared decision making (SDM) when children with special health care needs are referred to subspecialists.

METHODS

We conducted focus groups with parents of children with special health care needs and pediatric primary care and subspecialty clinicians about how to include parents as partners in information exchange and SDM. Five parent and 5 clinician groups were held to identify themes to inform the development of interventions to promote parent partnerships; evaluate a prototype referral care plan and related parent supports as one example of a partnership tool; and compare the views of parents and clinicians. We used investigator triangulation and member checking to improve validity.

RESULTS

Nineteen parents and 23 clinicians participated. Parents discussed partnerships more easily than clinicians did, though clinicians offered more ideas as sessions progressed. Parents and clinicians agreed on the importance of 3-way communication and valued primary care involvement in all stages of referral and consultation. SDM was seen by all as important; clinicians cited difficulties inherent in discussing unclear options, while parents cited insufficient information as a barrier to understanding. Use of a brief referral care plan, with parent coaching, was embraced by all parents and most clinicians. Clinicians cited time pressures and interference with work flow as potential barriers to its use.

CONCLUSIONS

Parents and clinicians endorse partnership in referrals, though relatively greater enthusiasm from parents may signal the need for work in implementing this partnership. Use of a care plan to support parent engagement appears promising as a partnership tool.

Medication errors in the homes of children with chronic conditions

BACKGROUND

Children with chronic conditions often have complex medication regimens, usually administered at home by their parents.

OBJECTIVE

To describe the types of medication errors in the homes of children with chronic conditions. METHODS Our home visit methods include direct observation of administration, medication review and prescription dose checking. Parents of children with sickle cell disease and seizure disorders taking daily medications were recruited from paediatric subspecialty clinics from November 2007 to April 2009. Potential errors were reviewed by two physicians who made judgments about whether an error had occurred or not, and its severity.

RESULTS

On 52 home visits, the authors reviewed 280 medications and found 61 medication errors (95% CI 46 to 123), including 31 with a potential to injure the child and 9 which did injure the child. Injuries often occurred when parents failed to fill prescriptions or to change doses due to communication problems, leading to further testing or continued pain, inflammation, seizures, vitamin deficiencies or other injuries. Errors not previously reported in the literature included communication failures between two parents at home leading to administration errors and difficulty preparing the medication for administration. 95% of parents not using support tools (eg, alarms, reminders) for medication use at home had an error compared to 44% of those using supports (χ(2)=13.9, p=0.0002).

CONCLUSIONS

Home visits detected previously undescribed types of outpatient errors which were common among children with sickle cell disease and seizure disorders. These should be targeted in future intervention development.

Development and validation of a tool to improve paediatric referral/consultation communication

OBJECTIVE

To develop a template to promote brief but high-quality communication between paediatric primary care clinicians and consulting specialists.

METHODS

Through an iterative process with academic and community-based paediatric primary care providers and specialists, the authors identified what content elements would be of value when communicating around referrals. The authors then developed a one-page template to encourage both primary care and specialty clinicians to include these elements when communicating about referrals. Trained clinician reviewers examined a sample of 206 referrals from community primary care providers (PCPs) to specialists in five paediatric specialties at an academic medical centre, coding communication content and rating the overall value of the referral communication. The relationship between the value ratings and each content element was examined to determine which content elements contributed to perceived value.

RESULTS

Almost all content elements were associated with increased value as rated by clinician reviewers. The most valuable communications from PCP to specialist contained specific questions for the specialist and/or physical exam features, and the most valuable from specialist to PCP contained brief education for the PCP about the condition; all three elements were found in a minority of communications reviewed.

CONCLUSIONS

A limited set of communication elements is suitable for a brief communication template in communication from paediatric PCPs to specialists. The use of such a template may add value to interphysician communication.

Building communication between professionals at children's specialty hospitals and the medical home

OBJECTIVE

Build a quality improvement (QI) intervention to improve communication between a children's specialty hospital and referring primary care providers (PCPs).

METHODS

A network of charitable children's hospitals identified improving communication as a systemwide goal. At one model hospital, we used qualitative telephone interviewing of hospital specialists and staff, and referring PCPs, to characterize the communication system and identify potential improvements. We identified potential high-impact areas through content analysis and developed a QI change package with hospital leadership.

RESULTS

Participants described inconsistent communication, with no systematic identification of PCPs. Families were the typical means of inter-physician communication. Multiple non-PCP referral sources were a major contributor to communication breakdowns. Respondents identified a system for identification and communication with PCPs as an essential first step.

CONCLUSIONS

Systems for communication with PCPs are underdeveloped at a children's charitable specialty hospital. Straightforward changes could build an effective system that is generalizable to other hospitals.

Care coordination for children and youth with special health care needs: a descriptive, multisite study of activities, personnel costs, and outcomes

OBJECTIVES

Objectives included testing use of the care-coordination measurement tool in pediatric primary care practices; describing care-coordination activities for children and youth that occur in primary care practices; assessing the relationship of care-coordination activities in the medical home with outcomes related to resource use; and measuring the direct personnel costs of care-coordination activities.

METHODS

Six general pediatric practices were selected, representing a diverse range of sizes, locations, patient demographics, and care-coordination activity model types. The care-coordination measurement tool was used over a period of 8 months in 2003 to record all of the nonreimbursable care-coordination activity encounters performed by any office-based personnel. The tool enabled recording of activities, resources-use outcomes, and time. Cost of personnel performing care-coordination activities was derived by extrapolation from the time spent.

RESULTS

Care-coordination activity services were used by patients of all complexity levels. Children and youth with special health care needs with acute-onset, family-based psychosocial problems experienced 14% of the care-coordination activity encounters and used 21% of the care-coordination activities minutes. Children and youth without special health care needs, without complicating family psychosocial problems, received 50% of the encounters and used 36% of the care-coordination activity minutes. The average cost per care-coordination activity encounter varied from $4.39 to $12.86, with an overall mean of $7.78. A principal cost driver seemed to be the percentage of care-coordination activities performed by physicians. Office-based nurses prevented a large majority of emergency department visits and episodic office visits.

CONCLUSIONS

Care-coordination activity was assessed at the practice level, and the care-coordination measurement tool was used successfully during the operations of typical, pediatric, primary care settings. The presence of acute, family-based social stressors was a significant driver of need for care-coordination activities. A high proportion of dependence on care-coordination performed by physicians led to increased costs. Office-based nurses providing care coordination were responsible for a significant number of episodes of avoidance of higher cost use outcomes.

Physician responses to a community-level trial promoting judicious antibiotic use

PURPOSE

In an environment of multiple campaigns promoting judicious antibiotic use in children, identification of effective strategies is important. We assessed physician responses to a community-level intervention with respect to antibiotic prescribing, related practices, and perceived effectiveness.

METHODS

This study was a mixed qualitative and quantitative evaluation of a randomized controlled community-wide educational intervention in 16 Massachusetts communities. Physicians in intervention communities received locally endorsed guidelines, group educational sessions, and biweekly newsletters. Parents simultaneously received materials in physicians' offices and by mail. After the intervention, we conducted a mailed physician survey and individual interviews to assess the impact of the intervention. We compared survey responses for intervention and control physicians, and we analyzed interview transcripts to provide in-depth information about selected topics.

RESULTS

Among survey respondents (n = 168), 91% of intervention and 4% of control physicians reported receiving intervention materials. Physicians received information from multiple other sources. More intervention than control physicians reported decreased antibiotic prescribing from 2000-2003 (75% vs 58%, P = .03), but there were no differences between groups in knowledge, attitudes, or behaviors favoring judicious antibiotic use. Both groups were concerned about antibiotic resistance and reported room to reduce their own prescribing. Interviewed physicians suggested frequent repetition of messages, brief written materials on specific topics for themselves and patients, and promotion in the mass media as the most effective strategies to reduce prescribing.

CONCLUSIONS

In multiple communities an intervention in physician offices to promote judicious antibiotic prescribing reached its intended audience, but physicians' self-reported attitudes and practices were similar in intervention and control communities. Campaigns that repeat brief, consistent reminders to multiple stakeholder groups may be most effective at assuring judicious antibiotic use.

Impact of a 16-community trial to promote judicious antibiotic use in Massachusetts

OBJECTIVES

Reducing unnecessary antibiotic use, particularly among children, continues to be a public health priority. Previous intervention studies have been limited by size or design and have shown mixed results. The objective of this study was to determine the impact of a multifaceted, community-wide intervention on overall antibiotic use for young children and on use of broad-spectrum agents. In addition, we sought to compare the intervention's impact on commercially and Medicaid-insured children.

METHODS

We conducted a controlled, community-level, cluster-randomized trial in 16 nonoverlapping Massachusetts communities, studied from 1998 to 2003. During 3 years, we implemented a physician behavior-change strategy that included guideline dissemination, small-group education, frequent updates and educational materials, and prescribing feedback. Parents received educational materials by mail and in primary care practices, pharmacies, and child care settings. Using health-plan data, we measured changes in antibiotics dispensed per person-year of observation among children who were aged 3 to <72 months, resided in study communities, and were insured by a participating commercial health plan or Medicaid.

RESULTS

The data include 223,135 person-years of observation. Antibiotic-use rates at baseline were 2.8, 1.7, and 1.4 antibiotics per person-year among those aged 3 to <24, 24 to <48, and 48 to <72 months, respectively. We observed a substantial downward trend in antibiotic prescribing, even in the absence of intervention. The intervention had no additional effect among children aged 3 to <24 months but was responsible for a 4.2% decrease among those aged 24 to <48 months and a 6.7% decrease among those aged 48 to <72 months. The intervention effect was greater among Medicaid-insured children and for broad-spectrum agents.

CONCLUSIONS

A sustained, multifaceted, community-level intervention was only modestly successful at decreasing overall antibiotic use beyond substantial secular trends. The more robust impact among Medicaid-insured children and for specific medication classes provides an argument for specific targeting of resources for patient and physician behavior change.

Parents as information intermediaries between primary care and specialty physicians

OBJECTIVE

In this study we assessed the views of parents of children referred to specialty care and the views of the children's primary care and specialty physicians about parents' roles as information intermediaries.

METHODS

We enrolled 179 patients who were newly referred from primary care pediatricians in 22 practices to 15 pediatric subspecialists in 5 specialties in a study of primary care pediatrician-specialist communication. Parents, primary care pediatricians, and specialists completed questionnaires by mail or telephone at the first visit and 6 months later. Questions included perceived responsibilities of parents as information conduits between primary care pediatricians and specialists. Opinions of parents, primary care pediatricians, and specialists about parents' roles were compared for the sample as a whole, as well as for individual cases. Agreement between parents and providers was assessed. Demographic and clinical determinants of parents reporting themselves as "comfortable with" or "acting" as primary intermediaries were assessed using logistic regression.

RESULTS

More parents (44%) than primary care physicians (30%) felt comfortable with parents acting as primary communicators between their children's physicians; 31% of parents who reported that they were the primary communicators felt uncomfortable in that role, and there was no agreement between parents and physicians about the role of parents in individual cases. Although no demographic characteristics of children or parents were associated with parent comfort as the primary communicator, parents of children who saw the same specialist more than once during the 6-month period felt more comfortable in this role. The presence of a chronic condition was not associated with parent comfort.

CONCLUSIONS

Although parents report more comfort with their own ability as information intermediaries than do their children's physicians, the role in which they feel comfortable is highly variable. Physicians should discuss with parents the roles they feel comfortable in assuming when specialty referrals are initiated.

Parental knowledge about antibiotic use: results of a cluster-randomized, multicommunity intervention

OBJECTIVE

The goal was to determine the impact of a community-wide educational intervention on parental misconceptions likely contributing to pediatric antibiotic overprescribing.

METHODS

We conducted a cluster-randomized trial of a 3-year, community-wide, educational intervention directed at parents of children < 6 years of age in 16 Massachusetts communities to improve parental antibiotic knowledge and attitudes and to decrease unnecessary prescribing. Parents in 8 intervention communities were mailed educational newsletters and exposed to educational materials during visits to local pediatric providers, pharmacies, and child care centers. We compared responses from mailed surveys in 2000 (before the intervention) and 2003 (after the intervention) for parents in intervention and control communities. Analyses were performed on the individual level, clustered according to community.

RESULTS

There were 1106 (46%) and 2071 (40%) respondents to the 2000 and 2003 surveys, respectively. Between 2000 and 2003, the proportion of parents who answered > or = 7 of 10 knowledge questions correctly increased significantly in both intervention (from 52% to 64%) and control (from 54% to 61%) communities. We did not detect a significant intervention impact on knowledge regarding appropriate antibiotic use in the population overall. In a subanalysis, we did observe a significant intervention effect among parents of Medicaid-insured children, who began with lower baseline knowledge scores.

CONCLUSIONS

Although knowledge regarding appropriate use of antibiotics is improving without additional targeted intervention among more socially advantaged populations, parents of Medicaid-insured children may benefit from educational interventions to promote judicious antibiotic use. These findings may have implications for other health education campaigns.

Determinants and impact of generalist-specialist communication about pediatric outpatient referrals

OBJECTIVE

Effective communication between primary care and specialty physicians is essential for comanagement when children are referred to specialty care. We sought to determine rates of physician-reported communication between primary care physicians and specialists, the clinical impact of communication or its absence, and patient- and practice system-level determinants of communication for a cohort of children referred to specialty care.

METHODS

We enrolled 179 patients newly referred from general pediatricians in 30 community practices to 15 pediatric medical specialists in 5 specialties. Primary care physicians and specialists completed questionnaires at the first specialty visit and 6 months later. Questions covered communication received by primary care physicians and specialists, its impact on care provision, system characteristics of practices, and roles of physicians in treatment. We used multivariate logistic regression to determine associations between practice system and patient characteristics and the dependent variable of reported primary care physician-specialist communication.

RESULTS

Specialists reported communication from referring primary care physicians for only 50% of initial referrals, whereas primary care physicians reported communication from specialists after 84% of initial consultations. Communication was strongly associated with physicians' reported ability to provide optimal care. System characteristics associated with reported primary care physician-specialist communication were computer access to chart notes and lack of delays in receipt of information. Associated patient characteristics included non-Medicaid insurance, no additional specialists seen, and specialty to which referred. Physicians favored comanagement of referred patients in more than two thirds of the cases.

CONCLUSIONS

Although a prerequisite for optimal care, communication from primary care physicians to specialists is frequently absent. Interventions should promote widely accessible clinical information systems and target children with complex needs and public insurance.

Targeted child psychiatric services: a new model of pediatric primary clinician--child psychiatry collaborative care

Between 15% and 25% of children and adolescents seen in pediatric primary care have a behavioral health disorder with significant psychopathology, high functional impairment, and frequent psychiatric diagnostic comorbidity. Because child psychiatry services are frequently unavailable, primary care clinicians are frequently left managing these children without access to child psychiatry consultation. We describe Targeted Child Psychiatric Services (TCPS), a new model of pediatric primary clinician-child psychiatry collaborative care, and describe program utilization and characteristics of children referred over the first 18 months of the program using a retrospective chart review. The TCPS model can serve a large number of pediatric primary care practices and provide collaborative help with the evaluation and treatment of complex attention deficit hyperactivity disorder, depression, anxiety disorders, and pediatric psychopharmacology.

Potential medication dosing errors in outpatient pediatrics

OBJECTIVE

To determine the prevalence of potential dosing errors of medication dispensed to children for 22 common medications.

STUDY DESIGN

Using automated pharmacy data from 3 health maintenance organizations (HMOs), we randomly selected up to 120 children with a new dispensing prescription for each drug of interest, giving 1933 study subjects. Errors were defined as potential overdoses or potential underdoses. Error rate in 2 HMOs that use paper prescriptions was compared with 1 HMO that uses an electronic prescription writer.

RESULTS

Approximately 15% of children were dispensed a medication with a potential dosing error: 8% were potential overdoses and 7% were potential underdoses. Among children weighing <35 kg, only 67% of doses were dispensed within recommended dosing ranges, and more than 1% were dispensed at more than twice the recommended maximum dose. Analgesics were most likely to be potentially overdosed (15%), whereas antiepileptics were most likely potentially underdosed (20%). Potential error rates were not lower at the site with an electronic prescription writer.

CONCLUSIONS

Potential medication dosing errors occur frequently in outpatient pediatrics. Studies on the clinical impact of these potential errors and effective error prevention strategies are needed.

Watchful waiting for acute otitis media: are parents and physicians ready?

OBJECTIVE

To assess the current use of initial observation ("watchful waiting") of acute otitis media among community physicians and the acceptability of this option to parents of young children.

SETTING

Sixteen nonoverlapping Massachusetts communities enrolled in a community intervention study on appropriate antibiotic use.

DESIGN

Pediatricians, family physicians, and a random sample of parents of children <6 years old were surveyed. Parents predicted what their satisfaction would be with initial observation of an ear infection without antibiotics if suggested by their physician and concerns they would have regarding this watchful-waiting approach. Physicians reported the frequency with which they use this approach in children > or =2 years and those <2 years old. Separate multivariable models identified factors independently associated with parental satisfaction and with frequency of self-reported use by physicians. All models accounted for clustering of responses within communities.

RESULTS

Two thousand fifty-four (40%) parents and 160 (58%) physicians responded. Of the parents, 34% would be somewhat or extremely satisfied if initial observation was recommended, another 26% would be neutral, and the remaining 40% would be somewhat or extremely dissatisfied. The multivariable model showed lower parental education (odds ratio [OR]: 0.50; 95% confidence interval [CI]: 0.35, 0.71, for high school education or less compared with college graduation) and Medicaid enrollment (OR: 0.77; CI: 0.57, 1.0) was associated with lower predicted satisfaction. Higher antibiotic-related knowledge (OR: 1.2; CI: 1.1, 1.3, per question correct), belief that antibiotic resistance is a serious problem (OR: 2.3; CI: 1.8, 2.8), and reporting feeling included in medical decisions (OR: 1.4; CI: 1.1, 1.7) all were independently associated with higher predicted satisfaction. Thirty-eight percent of physicians treating children > or =2 years old never or almost never reported using initial observation, 39% reported use occasionally, 17% sometimes, and 6% most of the time. In a multivariable model, only more years in practice (OR: 0.96; CI: 0.93, 0.99) was associated with a decreased likelihood of occasional or more-frequent use of watchful waiting (compared with those who never use initial observation). However, a secondary model that combined occasional users with nonusers (compared with those reporting use sometimes or more often) identified several correlates of use of observation: years in practice (OR: 0.95; CI: 0.91, 0.99), family medicine specialization (OR: 4.5; CI: 1.9, 11), belief that antibiotic resistance is a significant problem (OR: 4.3; CI: 1.3, 14.5), and practice in a community receiving a judicious antibiotic-use intervention (OR: 3.5; CI: 1.3, 9.1).

CONCLUSIONS

A majority of physicians reported at least occasionally using initial observation, but few use it frequently. Many parents have concerns regarding this option, but acceptability is increased among those with more education and those who feel included in medical decisions. Substantial change in both parental and provider views would be needed to make initial observation a widely used alternative for acute otitis media.

Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice

Coordinated care is a defining principle of primary care, but it is becoming increasingly difficult to provide as the health care delivery system in the United States becomes more complex. To guide recommendations for research and practice, the evidence about implementation of coordinated care and its benefits must be considered. On the basis of review of the published literature this article makes recommendations concerning needs for a better-developed evidence base to substantiate the value of care coordination, generalist practices to be the hub of care coordination for most patients, improved communication among clinicians, a team approach to achieve coordination, integration of patients and families as partners, and incorporation of medical informatics. Although coordination of care is central to generalist practice, it requires far more effort than physicians alone can deliver. To make policy recommendations, further work is needed to identify essential elements of care coordination and prove its effectiveness at improving health outcomes.

Coordination of care for children with special health care needs

PURPOSE OF REVIEW

Coordination of care is an essential function of pediatric primary care, needed most by children with special health care needs (CSHCN). Although complex, its necessity has become better recognized with the recent increase in attention in the United States to the comprehensive "medical home" model of care.

RECENT FINDINGS

Coordination is highly dependent on effective communication within the health care system and between the health care system and the larger community. While coordination may best be undertaken at the level of the physician practice, a team approach involving nonphysician staff and families as primary participants may be the best option in many cases. More attention is being paid at the health policy level to the implementation of coordination of care, although solutions to reimbursement barriers have yet to be implemented. Considerable progress on methods to improve care coordination in the primary care practice setting has been made recently. Many of these efforts have used quality improvement techniques adapted from the business world. Emerging measures of the process of care coordination are also being developed, although few studies have been published to date showing a positive impact of care coordination.

SUMMARY

The value of coordination of care as an essential part of medical care for children with special health care needs is becoming widely recognized. Methods to implement it within pediatric primary care practices are being developed, although more data demonstrating its value are needed to inform policy changes.

Increased use of second-generation macrolide antibiotics for children in nine health plans in the United States

BACKGROUND

Widespread use of broad-spectrum antibiotics contributes to increasing rates of bacterial resistance to antibiotics. Second-generation macrolides have become popular for use among children because of their broad spectrum and favorable dosing and side-effect profiles, although experts do not generally recommend them for use as initial treatment of infections among younger children.

OBJECTIVE

To assess trends in second-generation macrolide use from 1996 to 2000 among children treated as outpatients in 9 US health plans, including associated diagnoses and use as initial treatment.

METHODS

We sampled claims data for 25000 children, 3 months to <18 years of age, who were enrolled between September 1, 1995, and August 31, 2000, in each of 9 US health plans. Medications dispensed were linked with ambulatory visit claims to assign diagnoses. Dispensings without another antibiotic dispensing recorded in the previous 42 days were analyzed as initial treatment of a new illness episode. We analyzed trends in prescribing overall, for initial therapy, and, within specific diagnoses, for differences among health plans.

RESULTS

From 1995-1996 to 1999-2000, although overall antibiotic use decreased from 1.15 to 0.91 dispensings per person-year, second-generation macrolide use increased from 0.022 to 0.063 dispensings per person-year. Use as a proportion of all antibiotic dispensings increased from 1.9% to 6.9%, and use as initial therapy increased from 1.4% to 6%. For children <6 years of age, second-generation macrolide use as initial therapy increased from 0.9% to 5.0% for otitis media and from 5.2% to 24.0% for pneumonia. There was a wide range of prescribing rates among health plans during the last year of the study, from 0.006 to 0.135 dispensings per person-year.

CONCLUSIONS

Despite recent trends toward decreased antibiotic use among children, the use of second-generation macrolides among children has increased dramatically, even among younger children, for whom use for initial treatment of illness is not recommended. Large differences in prescribing rates exist among health plans. Continued efforts to promote the use of narrower-spectrum agents when appropriate are needed.

Generalist-subspecialist communication for children with chronic conditions: a regional physician survey

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.

Generalist-subspecialist communication about children with chronic conditions: an analysis of physician focus groups

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.

A simple provider-based educational intervention to boost infant immunization rates: a controlled trial

We sought to determine if a simple educational intervention initiated at the first well-child care visit, with reinforcement at subsequent visits, can improve inner-city infant immunization rates. We conducted a controlled trial involving 315 newborn infants and their primary caregivers in 3 inner-city primary care centers. Child health care providers gave caregivers in the intervention group an interactive graphic card with verbal reinforcement. At later visits, stickers were applied to the card when immunizations were given. Routine information was given to controls. After the trial, age-appropriate immunization rates at 7 months were 58% in each group. Intervention infants had 50% fewer missed opportunities to immunize (p=0.01) but cancelled 77% more appointments (p=0.04) than controls. We conclude that a brief educational intervention at the first well-child care visit did not boost 7-month immunization rates, although it was associated with fewer missed opportunities to immunize.

Determining immunization rates for inner-city infants: statewide registry data vs medical record review

OBJECTIVE

This study evaluated the benefit of consulting a statewide immunization registry for inner-city infants whose immunizations appeared, after single-site chart review, to have been delayed.

METHODS

We prospectively enrolled 315 newborns in 3 inner-city pediatric clinics. When the infants turned 7 months old, we obtained immunization data from clinic charts and the state registry.

RESULTS

On the basis of chart review, 147 infants (47%) were assessed to be delayed in their immunizations; of these, registry data revealed that 28 (19%) had received additional immunizations and 15 (10%) were actually up to date.

CONCLUSIONS

A statewide registry can capture immunizations from multiple sources, improving accurate determination of immunization rates in a mobile, inner-city population.

Methylxanthine treatment of smooth muscle cells differentially modulates adenylate cyclase responsiveness

The DDT1 MF-2 smooth muscle cell line was used to study regulation of the A1 and A2 adenosine receptor (AR)-adenylate cyclase system by two different methylxanthines. 3-isobutyl 1-methylxanthine (IBMX) is both an AR antagonist and a phosphodiesterase inhibitor, while xanthine amine congener is an AR antagonist without phosphodiesterase activity. Incubation of cells for 18 hr with 100 microM IBMX produced a significant (P less than .05) decrease in the basal, isoproterenol- and sodium fluoride-stimulated adenylate cyclase activity. This generalized decrease in adenylate cyclase activity was associated with a significant decrease in the quantity of alpha s (Gs) as determined by Western blotting. In contrast, no alteration in alpha i (Gi) was observed in these same membranes. A significant increase in both the quantity of A1AR and the receptors' affinity for agonist occurred; however, no alteration in the ability of an A1AR selective agonist to inhibit adenylate cyclase activity was observed. Treatment for 18 hr with 50 nM xanthine amine congener, conversely, resulted in an increase in basal and isoproterenol stimulated adenylate cyclase activity with no change in membrane alpha s (Gs). With IBMX, there was an increase in agonist affinity for the A1AR without an associated change in the effect of adenosine agonists on adenylate cyclase activity. These data indicate that methylxanthine analogs which lack the ability to inhibit phosphodiesterases regulate receptor-mediated transmembrane signaling systems quite differently from those possessing such characteristics. The more prototypic methylxanthines regulate both receptors and G proteins in these smooth muscle cells.

Hydrophobic strip-of-helix algorithm for selection of T cell-presented peptides

In extension of the hypothesis that an amphipathic alpha helix of Ii (Phe146-Val164) bound to the foreign antigen-presenting site (desetope) of class II MHC molecules through hydrophobic amino acid residues (Phe146, Leu150, Leu153, Met157, Ile160, Val164) which were present in an axial strip along one side of the Ii helix, we developed an algorithm to search for T cell-presented peptides showing a similar hydrophobic strip-of-helix. Such peptides might bind to the class II MHC molecule site which was complementary to the Ii hydrophobic strip-of-helix. The strip-of-helix hydrophobicity index was the mean hydrophobicity (from Kyte-Doolittle values) of sets of amino acids in axial strips down sides of helices for 3-6 turns, at positions, n, n + 4, N + 7, n + 11, n + 14, and n + 18. Peptides correlating well with T cell responsiveness had: (1) 12-19 amino acids (3-5 cycles or 4-6 turns of an alpha helix), (2) a strip with highly hydrophobic residues, (3) adjacent, moderately hydrophilic strips, and (4) no prolines. The degree of hydrophilicity of the remainder of a putative antigenic helix above a threshold value did not count in this index. That is, the magnitude of amphipathicity was not judged to be the principal selecting factor for T cell-presented peptides. This simple algorithm to quantitate strip-of-helix hydrophobicity in a putative amphipathic alpha helix, allowing otherwise generally hydrophilic residues, predicted 10 of 12 T cell-presented peptides in seven well-studied proteins. The derivation and application of this algorithm were analyzed.

An hypothesis on the binding of an amphipathic, alpha helical sequence in Ii to the desetope of class II antigens

When we investigated the hypothesis that amphipathic alpha helical peptides digested from foreign antigen bind to class II major histocompatability complex (MHC) molecules' binding site (desetope) for foreign antigen to be presented to T cell receptors, we found such an extended amphipathic helix in Ii. This amphipathic helix was hypothesized to bind Ii to class II MHC antigens until release in endosomes containing digested foreign antigen. Then these amphipathic Ii polypeptides might polymerize so as not to compete with foreign antigen for binding to class II MHC molecules. Various structural models were consistent with these views and led to the suggestion of specific forms of polymeric interaction.

An hypothesis on the binding of an amphipathic, alpha helical sequence in Ii to the desetope of class II antigens

When we investigated the hypothesis that amphipathic alpha helical peptides digested from foreign antigen bind to class II major histocompatability complex (MHC) molecules' binding site (desetope) for foreign antigen to be presented to T cell receptors, we found such an extended amphipathic helix in Ii. This amphipathic helix was hypothesized to bind Ii to class II MHC antigens until release in endosomes containing digested foreign antigen. Then these amphipathic Ii polypeptides might polymerize so as not to compete with foreign antigen for binding to class II MHC molecules. Various structural models were consistent with these views and led to the suggestion of specific forms of polymeric interaction.

Hyperexpressed hairy leukemic cell Ii might bind to the antigen-presenting site of class II MHC molecules

The p35 protein which is hyperexpressed on hairy leukemic cells was determined to be Ii, the electrophoretically invariant glycoprotein that is associated with class II major histocompatibility complex (Ia) antigens from the time of their synthesis. The principal function of class II MHC antigens is to present to T cell receptors those digested foreign antigenic peptides that probably fold as amphipathic alpha-helices and adsorb to a hydrophobic surface (desetope) on Ia. By a novel strip-of-helix hydrophobicity algorithm we found that the sequence Leu-142 to His-170 in Ii formed a five-cycle, amphipathic, alpha-helix, the highest scoring one among a series of proteins commonly used as experimental antigens. This finding led to the hypothesis that this sequence in Ii bound to the antigen-binding site (desetope) of Ia until release and self-aggregation in the endosome in order that digested foreign peptides could then bind to Ia. Abundant expression of Ii in leukemic cells might be associated with an altered capacity of those cells to present foreign or leukemic antigens to the host's immune system.