Participation of Colorado pediatricians and family physicians in the Medicaid program.

The Pediatric Health Policy Group of the University of Colorado Health Sciences Center (Denver) surveyed 650 family physicians and 296 pediatricians in 1988, with 50% of family physicians and 48% of pediatricians responding. Half of the pediatricians in private practice and 35% of family physicians in private practice accepted all children who were Medicaid beneficiaries into their practice; 42% of pediatricians and 50% of family physicians accepted all non-Medicaid patients but only some new Medicaid patients; and 8% of pediatricians and 15% of family physicians accepted new non-Medicaid patients but no Medicaid patients. Practice location was associated with the level of Medicaid participation for these primary care physicians: Significantly more rural pediatricians and family physicians than those with urban practices accepted Medicaid patients. The average reimbursement level for these physicians was shown to be an important determinant of whether physicians would accept Medicaid patients. Nonparticipatory physicians were more concerned about excessive paperwork compared with physicians with limited participation. Among physicians with limited participation, family physicians and pediatricians both cited problems of excessive paperwork, reimbursement delays, and retroactive denials of payment as important deterrents to accepting Medicaid patients.     

Women in pediatrics: the experience in Quebec.

OBJECTIVES: To compare the practice patterns of female pediatricians in Quebec with those of their male counterparts and to identify specific factors influencing these practice patterns. DESIGN: Matched cohort questionnaire survey. SETTING: Primary, secondary and tertiary care pediatric practices in Quebec. PARTICIPANTS: All 146 female pediatricians and 133 of the 298 male pediatricians, matched for age as well as type and site of practice; 119 (82%) of the female and 115 (86%) of the male pediatricians responded. MAIN OUTCOME MEASURES: Demographic and family data as well as detailed information about the practice profile. RESULTS: The two groups were comparable regarding demographic data, professional work and patient care. Compared with the male respondents, the female pediatricians were younger and saw more outpatients. The mean number of hours worked per week, excluding on-call duty, was 40.5 (standard deviation [SD] 12.4) for the women and 48.9 (SD 12.0) for the men (p < 0.001). The female pediatricians were more likely than their male counterparts to have spouses who were also physicians (40%) or in another profession (45%). The female pediatricians without children worked significantly fewer hours than the male pediatricians with or without children (p < 0.001). Children (p = 0.006), but not the number of children (p = 0.452), had a significant effect on the number of hours worked by the female pediatricians. CONCLUSION: The duality of the role of female physicians as mothers and professional caregivers must be considered during workload evaluations. If the same style of practice and the increase in the proportion of female pediatricians continue, about 20% more pediatricians will be needed in 10 years to accomplish the same workload.     

Children seen frequently out of hours in one general practice.

OBJECTIVE--To identify reasons why some children receive more out of hours visits than most. DESIGN--A one year prospective study to identify the study group. This was followed by a case-control study involving a record search and personal interviews. SETTING--One three doctor urban general practice in West Lothian with 4812 patients. SUBJECTS--40 children aged under 10 years identified as high users of the out of hours service (more than two visits a year) and 40 age and sex matched controls. MAIN OUTCOME MEASURES--Numbers of visits; social factors such as lone motherhood, low educational attainment; score for management response to clinical vignette. RESULTS--147/756 (19%) out of hours visits in the study year were to children aged under 10 years; 109 (74%) to 41 children (6%). Problems seen were mainly minor, and little active management was required. Family and social factors which were significantly more common for the cases than for the controls included a lone mother (15 v 4), low educational attainment by the mother (25 v 14), receipt of income support (22 v 7), and non-ownership of the home (45 v 22) or a car (19 v 9). Mothers of the cases were more likely to choose to contact a doctor when presented with vignettes describing common childhood illnesses (median score for 16 vignettes 16.5 for cases v 14.5 for controls, Wilcoxon signed rank test, p = 0.01). CONCLUSIONS--Children seen more frequently than expected out of hours came from more socially disadvantaged families and their mothers were more likely to seek medical advice about minor childhood illness. Maternal education, to promote confidence in managing minor illness, may reduce their use of the out of hours service.     

Walk-in clinics: implications for family practice.

To understand better the reasons for the growth in popularity of walk-in clinics in Canada we surveyed 321 patients with a regular physician in Toronto who attended a walk-in clinic in the same city over a 16-day period in February 1988. They were asked their reason for attending the clinic, their perception of the urgency of their problem, their choices as alternatives to walk-in clinics and their satisfaction and concerns with the type of care received at the clinic. The three most common reasons for attending the clinic were convenient location (in 33% of the cases), inability to see their regular physician soon enough (in 16%) and no appointment needed (in 13%). Most (80%) of the patients felt that they needed medical attention within 24 hours after the onset of their problem. Most (83%) of the respondents would have sought medical attention at another walk-in clinic, from their regular physician or at an emergency department had the clinic been closed. Only 36% and 18% of the patients respectively responded that their regular physician worked evenings or weekends. Most of the visits to the clinic were outside regular weekday business hours. The level of satisfaction with the service received at the clinic was high. The extended hours and no-appointment philosophy of walk-in clinics, coupled with family physicians'' reluctance to work evenings and weekends, have made such clinics an attractive option for patients with primary care problems that they believe require prompt attention.     

The Manchester regional screening programme: a 10-year exercise in patient and family care.

Up to the end of 1978 the Willink Biochemical Genetics Unit had screened 506821 babies for metabolic abnormalities over 10 years--98-99% of the children born in the region. Sixty-nine cases of phenylketonuria (PKU), 42 cases of histidinaemia, and six cases of homocystinuria were detected. As well as treating affected children, the staff of the unit have concentrated on providing full support for their families and maintaining good communications with parents, general practitioners, health visitors, and midwives. A clinic liaison sister has provided valuable support for health visitors and an important link between the unit and community services. A study of the costs of screening and treating cases of PKU for the year 1978 showed that this was cheaper, by pound 569000, than the costs of looking after patients with untreated PKU.     

The challenge of the well child

Upon general practitioners and pediatricians falls the responsibility of recognizing and treating most emotional problems in young children. This may be best carried out by the anticipation of expected problems, and the advance guidance or counseling of parents. That such problems are of high incidence was indicated in experience at a pediatric clinic where approximately 40 per cent of 7,000 children observed had psychosomatic symptoms. In order to utilize effectively the limited time available in office practice for Well Child care, a physician must have at hand certain basic information on personality development. Many of the normal behavior patterns in children which frequently are misinterpreted as "behavior problems" by parents are presented herein in chart form, divided into critical age periods, to help physicians quickly recognize what is normal and what abnormal in various periods of maximal crisis. Most of the problems of conflict within a child and of conflict between parents and child, it is felt, could be and should be handled at the pediatric level. Some seriously disturbed children need to be referred for psychiatric care. When this is necessary, skillful preparation of the parent and the child by the family physician for referral is most important to successful psychotherapy.     

THE CHALLENGE OF THE “WELL CHILD”

Upon general practitioners and pediatricians falls the responsibility of recognizing and treating most emotional problems in young children. This may be best carried out by the anticipation of expected problems, and the advance guidance or counseling of parents. That such problems are of high incidence was indicated in experience at a pediatric clinic where approximately 40 per cent of 7,000 children observed had psychosomatic symptoms.In order to utilize effectively the limited time available in office practice for Well Child care, a physician must have at hand certain basic information on personality development. Many of the normal behavior patterns in children which frequently are misinterpreted as “behavior problems” by parents are presented herein in chart form, divided into critical age periods, to help physicians quickly recognize what is normal and what abnormal in various periods of maximal crisis. Most of the problems of conflict within a child and of conflict between parents and child, it is felt, could be and should be handled at the pediatric level. Some seriously disturbed children need to be referred for psychiatric care. When this is necessary, skillful preparation of the parent and the child by the family physician for referral is most important to successful psychotherapy.     

Involving Families with Osteogenesis Imperfecta in Health Service Research: Joint Development of the OI/ECE Questionnaire

Background

Despite the growing interest in understanding the psycho-social impact of rare genetic diseases, few studies examine this concept and even fewer seek to obtain feedback from families who have lived the experience. The aim of this project was to involve families of children living with osteogenesis imperfecta (OI) in the development of a tool to assess the impact of OI on the lives of patients and their families.

Methods

This project used an integrated knowledge translation approach in which knowledge users (clinicians and people living with OI and their families) were consulted throughout the four steps of development, that is: content mapping, item generation, tool appraisal and pre-testing of the questionnaires. The International Classification of Functioning and Health was used as a framework for content mapping. Based on a scoping review we selected two validated tools to use as a basis for developing the questionnaire. The final parent self-report version measured six domains: experience of diagnosis; use of health services; use of social and psychological support services; expectations about tertiary specialized centers; and socio-demographic information.

Results

A total of 27 out of 40 families receiving care at the Shriners Hospital for Children-Canada and invited to participate in the pre-test returned the completed questionnaires. In more than two-thirds of families (69%; n = 18) OI was suspected either at or within the first 3 months after birth. Up to 46% of families consulted between 3 and 5 doctors (46%; n = 12) prior to final diagnosis. The use of services by families varied from 0 to 16 consultations, 0 to 9 exploratory examinations and 1 to 10 types of allied health services. In the 12 months prior to the study, fewer than a quarter of children had been admitted, for treatment, for hospital stays of longer than 8 hours or to an emergency department (24% and 9% respectively). Only 29% of parents received psychological support.

Conclusion

This joint development process generated a tool, with good psychometric properties, that provides unique insight into the experiences of patients and families with OI, the psycho-social impact of the illness, and their service needs and expectations.     

Head injuries related to the use of baby walkers.

To determine what proportion of head injuries in children under 24 months of age who presented to an emergency department were related to the use of baby walkers, we reviewed the charts of 52 such children. Walkers were involved in 42% of the head injuries in the children under 12 months of age and in none of those in the children aged 12 to 24 months. All walker-related injuries, including skull fractures in three children, involved stairs (p less than 0.001). Questionnaires were also sent to all families with children aged 3 to 18 months attending a private pediatric practice to determine the prevalence of falls involving baby walkers among these children and the factors associated with such falls. Of the 152 responding families 82% reported using or having used a walker. Thirty-six percent of the families reported that their child had a fall while in a walker, with 8.8% of the falls resulting in contact with a doctor. Walker-related falls were directly associated with time spent in the walker (p less than 0.001) and with a previous fall from the walker by an older sibling (p less than 0.03). Since there is no demonstrated benefit of walkers, their use should not be encouraged, and parents should be advised of their potential danger.     

Early detection of visual defects in infancy

To determine the part played by screening in detecting visual defects questionnaires were sent to 240 families with blind or partially sighted children identified from the Family Fund''s database. Questions were asked on social and family background, the visual disorder and its severity, any other disability, and how and when the disabilities were discovered and subsequently managed. Data from 189 families were analysed, constituting all those with children with major visual defects from the 219 families who replied. The visual defect was first discovered in 111 children by parents, friends, and neighbours, and in 36 by a doctor at the neonatal examination. In only three children who did not have a family history of visual impairment was the defect discovered during a formal screening examination at a child health clinic. Dissatisfaction about medical services was expressed by about a third of the parents, particularly a lack of provision of information and consideration of their worries and a failure to refer the child promptly to educational and treatment services.Visual defects in children under 5 are generally detected by family and friends, not by screening, but detection by the medical profession could be improved by increased awareness and observation and quick referral.     

Child sexual abuse--children and families referred to a treatment project and the effects of intervention.

The characteristics of a series of 274 families who were referred to a sexual abuse treatment programme were analysed. Information was obtained on 411 abused children and 362 non-abused children. Different forms of sexual abuse were noted, with 77% of girls and 23% of boys affected. Boys tended to be abused at a younger age, more severely, and for longer periods than girls. There was a predominance of lower social class groups among the parents, and a wide variety of family structures, with reasonable stability over time. Ninety six per cent of perpetrators were men, and biological and step-parents predominated. Contributing factors in both the family history and the current perpetrators and their wives included sexual abuse, violence, chaotic families, marital problems, sexual difficulties, alcoholism, and subnormality. Follow up of 120 families, 180 victims, and 226 siblings showed that prosecution occurred in 60% of cases, with a high percentage of perpetrators being imprisoned. Treatment was offered to 87% of families, but because the treatment programme was in the early stages of development a variable number of children and parents were offered family treatment or treatment in groups for parents and children separately. There was an improvement in the victim''s circumstances in 61% of cases, and a noticeable reduction in "sexualised" and general emotional difficulties among victims, but there was reabuse rate of 16%. Protection of children was achieved through changes of family attitude and changes in family structure including divorce and separation: 14% of victims were rehabilitated to both parents, 33% to mothers only, and 26% to new families or other residences. Consensus in the family that abuse had occurred was seen as an important factor in determining which children could be rehabilitated with both their parents, with their mothers only, or with new families; which families could be offered or accepted treatment; and whether positive changes in the family occurred.     

Male attitudes towards family planning in Khartoum, Sudan

Knowledge of, attitudes toward, and use of contraception were investigated in a 1982 survey of 250 men living in Khartoum, Sudan. Interviews were conducted at mosques, marketplaces, a government office building, and a textile factory. 75% of respondents were ages 21-40. 92% of respondents expressed the belief that Khartoum is overcrowded, although this was attributed by 57% to rural-urban migration. Despite the fact that 85-95% linked overpopulation with social problems such as inflation, food shortages, and unemployment, 72% expressed a desire for 5 or more children. Only 30% of the men interviewed supported the concept of family size limitation, largely for economic reasons. The majority of those opposing family size limitation cited religious reasons. Attitudes toward child spacing were more favorable, with 80% indicating approval 59% of the men with wives at risk of pregnancy reported that they were using some form of contraception, but only 21% were using an effective method. Two-thirds of respondents reported that they do not discuss contraception with their spouse. 60% identified either the mass media or friends and relatives as their source of family planning information. Although 64% indicated an awarencess of where to obtain family planning services, only 2.8% had ever received services from a family planning clinic. 79% voiced an interest in more information on family planning, and 59% with wives of reproductive age wanted to use family planning services. Most respondents desired more information on sexual sterilization and, although surgical contraception is not available in Sudan, 10% said they would consider this method when they attained their desired family size. The belief that family size should be limited increased dramatically with education, from 9% among those with no formal schooling to 45% among men with 13 or more years of school. Men under 40 years of age had more favorable attitudes toward family planning than older men. Surprisingly, men interviewed at mosques had the most favorable attitudes whereas government employees were the most conservative. Overall, these fndings suggest that the present family planning clinic system in Sudan may be falling short of meeting the demand for information services.     

Childhood Obesity: Do Parents Recognize This Health Risk?

Objective: This study examined parents’ understanding of excess weight as a health risk, knowledge of healthy eating habits, and recognition of obesity in their children. Research Methods and Procedures: An anonymous questionnaire was distributed during well‐care visits involving children 4 to 8 years of age at a pediatric faculty practice. Parents indicated their level of concern about excess weight and other familiar health risks using a four‐point Likert scale, answered multiple‐choice questions concerning healthy eating patterns, and communicated their perceptions about their child's weight using a visual analog scale. A parent's perception was considered “accurate” if it deviated from the child's growth chart percentile by <30 points. Results: Of the 83 parents surveyed, 23% (19/83) had overweight children (≥95th percentile of age‐ and gender‐specific BMI growth charts). These parents did not differ from other parents in their level of concern about excess weight as a health risk or in their knowledge of healthy eating patterns, but the two groups of parents did differ in the accuracy of their perceptions about their children's weight. Only 10.5% of parents of overweight children (2/19) perceived their child's weight accurately compared with 59.4% of other parents (38/64; p < 0.001). Parents of overweight children invariably underestimated their children's weight. The median difference between their perception and the growth chart percentile was ?45 points. Discussion: Given that most parents of overweight children fail to recognize that their child has a weight problem, pediatricians should develop strategies to help these parents correct their misperceptions.     

Survey of parents' attitudes to the recommended Haemophilus influenzae type b vaccine program.

A survey was conducted in a general pediatric practice to determine parents'' attitudes to and compliance with the recommended Haemophilus influenzae type b vaccine program. Of 133 families surveyed 127 (95%) responded to the questionnaire. About one third of the parents did not have their children vaccinated. The decision against vaccination was made despite parent education, follow-up telephone contact and the pediatrician''s expressed support of the vaccine program. Most of the respondents (86%) had no previous knowledge of the vaccine. The factor of greatest concern was the possibility of an adverse reaction. This concern was significantly more common among the parents who decided not to have their children vaccinated than among those who had their children vaccinated (chi 2 = 6.52, p less than 0.025). One third of the parents who indicated that they intended to have their children vaccinated required a telephone reminder. The findings suggest a need for public education about the vaccine, with particular emphasis directed at allaying fears about side effects.     

Death certification in general practice: review of records.

The records of death that had been certified by general practitioners in one practice over 18 years were assessed in the light of the recent joint publications of the Royal College of Physicians and the Royal College of Pathologists. Over this period roughly 30% of the deaths in the practice population occurred outside hospital and a total of 262 certificates were issued. A review of 262 counterfoils of records of death certification showed that 12 counterfoils (4.6%) had no age and sex mentioned, and three counterfoils did not describe the place of death. The average age at death outside hospital was 71.6 years--the age of women being 75.1 years compared with that of men of 68.2 years. Only 2% of patients had had a necropsy. The common causes of death stated in the certificates were: cardiovascular 41%, carcinoma 35%, respiratory 15%, and stroke 8%. All contributory causes are also mentioned. Ninety seven per cent of the patients were seen after death by the doctors in the practice and 68% had been seen in the two days preceding death. We emphasise the importance of keeping accurate records of deaths in general practice for audit and research as well as for planning services for terminally ill and recently bereaved patients.     

Why are children admitted to hospital?

The criteria for admitting children to hospital for medical care were examined in 399 consecutive, non-planned admissions to the Nottingham Children''s Hospital between October 1975 and January 1976. Sixty-one per cent of the children were referred direct to the casualty department by their parents. Over 20% were admitted primarily for social reasons, and many of the remainder came from homes judged to be at a disadvantage. The hospital medical services for children should be aware of the needs of parents as well as of the needs of sick children in their catchment area.     

Understanding Low-Acuity Visits to the Pediatric Emergency Department

Background

Canadian pediatric emergency department visits are increasing, with a disproportionate increase in low-acuity visits locally (33% of volume in 2008-09, 41% in 2011-12). We sought to understand: 1) presentation patterns and resource implications; 2) parents’ perceptions and motivations; and 3) alternate health care options considered prior to presenting with low-acuity problems.

Methods

We conducted a prospective cohort study at our tertiary pediatric emergency department serving two provinces to explore differences between patients with and without a primary care provider. During four, 2-week study periods over 1 year, parents of low-acuity visits received an anonymous survey. Presentation times, interventions, diagnoses and dispositions were captured on a data collection form linked to the survey by study number.

Results

Parents completed 2,443 surveys (74.1% response rate), with survey-data collection form pairs available for 2,146 visits. Overall, 89.7% of respondents had a primary care provider; 68% were family physicians. Surprisingly, 40% of visits occurred during weekday office hours and 27.3% occurred within 4 hours of symptom onset; 67.5% of those early presenters were for injuries. Few parents sought care from their primary care provider (25%), health information line (20.7%), or urgent care clinic (18.5%); 36% reported that they believed their child’s problem required the emergency department. Forty-five percent required only a history, physical exam and reassurance; only 11% required an intervention not available in an office setting. Patients without a primary care provider were significantly more likely to present during weekday office hours (p = 0.003), have longer symptom duration (p<0.001), and not know of other options (p = 0.001).

Conclusions

Many parents seek pediatric emergency department care for low-acuity problems despite their child having a primary care provider. Ensuring timely access to these providers may help reduce pediatric emergency department overuse. Educational initiatives should inform parents about low-acuity problems and where appropriate care can/should be accessed.     

Follow-up survey of parents of children with major birth defects in New York State

BACKGROUND: One of the objectives of the New York State birth defect surveillance system, the New York State Congenital Malformations Registry (CMR), is to identify children in need of special programs and assist prevention/intervention programs and services with evaluation. In 1999, the CMR started a statewide mass-mailing program to inform parents of children with major birth defects about programs and support groups that might be helpful to them. A follow-up survey by mail was conducted in 2002 to evaluate the usefulness of the mailing program. METHODS: The survey was mailed between September and December of 2001 to parents of children born in 2001 and reported to the CMR with selected major birth defects. Non-respondents were followed-up by telephone. RESULTS: Of the 226 eligible families, 54% (122) responded to the survey. Approximately 66% of responding parents stated that the information provided by the mailing program was helpful, and 48% had contacted and/or used the programs and services listed in the information sheets. Parents with children younger than 6 months of age at the time of mailing were more likely to find the information helpful, compared to parents with children 6 months of age or older. The majority of responding parents had contacted and/or used the Early Intervention Program. CONCLUSION: The findings from the current survey show that the statewide information-mailing program administered by CMR is helpful and useful to the families of children with major birth defects in New York State.     

Which physicians make home visits and why? A survey

BACKGROUND: Recent changes in the North American health care system and certain demographic factors have led to increases in home care services. Little information is available to identify the strategies that could facilitate this transformation in medical practice and ensure that such changes respond adequately to patients'' needs. As a first step, the authors attempted to identify the major factors influencing physicians'' home care practices in the Quebec City area. METHODS: A self-administered questionnaire was sent by mail to all 696 general practitioners working in the Quebec City area. The questionnaire was intended to gather information on physicians'' personal and professional characteristics, as well as their home care practice (practice volume, characteristics of both clients and home visits, and methods of patient assessment and follow-up). RESULTS: A total of 487 physicians (70.0%) responded to the questionnaire, 283 (58.1%) of whom reported making home visits. Of these, 119 (42.0%) made fewer than 5 home visits per week, and 88 (31.1%) dedicated 3 hours or less each week to this activity. Physicians in private practice made more home visits than their counterparts in family medicine units and CLSCs (centres locaux des services communautaires [community centres for social and health services]) (mean 11.5 v. 5.8 visits per week), although the 2 groups reported spending about the same amount of time on this type of work (mean 5.6 v. 5.0 hours per week). The proportion of visits to patients in residential facilities or other private residences was greater for private practitioners than for physicians from family medicine units and CLSCs (29.7% v. 18.9% of visits), as were the proportions of visits made at the patient''s request (28.0% v. 14.2% of visits) and resulting from an acute condition (21.4% v. 16.0% of visits). The proportion of physicians making home visits at the request of a CLSC was greater for those in family medicine units and CLSCs than for those in private practice (44.0% v. 11.3% of physicians), as was the proportion of physicians making home visits at the request of a colleague (18.0% v. 4.5%) or at the request of hospitals (30.0% v. 6.8%). Physicians in family medicine units and CLSCs did more follow-ups at a frequency of less than once per month than private practitioners (50.9% v. 37.1% of patients), and they treated a greater proportion of patients with cognitive disorders (17.2% v. 12.6% of patients) and palliative care needs (13.7% v. 8.6% of patients). Private practitioners made less use of CLSC resources to assess home patients or follow them. Male private practitioners made more home visits than their female counterparts (mean 12.8 v. 8.3 per week), although they spent an almost equal amount of time on this activity (mean 5.7 v. 5.2 hours per week). INTERPRETATION: These results suggest that practice patterns for home care vary according to the physician''s practice setting and sex. Because of foreseeable increases in the numbers of patients needing home care, further research is required to evaluate how physicians'' practices can be adapted to patients'' needs in this area.