Child Care Visits Research Articles

Which physicians are providing health care to America's children? Trends and changes during the past 20 years.

Although pediatricians and family physicians are trained in the care of children, previous studies have revealed significant differences in the medical care and specialty referral patterns each provides. During the 1990s, several developments in the population and the health care system (eg, aging of the population and increases in Medicaid managed care) may have resulted in changes to the proportion of children seeking care from one or the other specialty. To determine any changes in the proportion of office visits for children from birth through the age of 17 years provided by pediatricians or family physicians from 1980 to 2000. Analysis of the National Ambulatory Medical Care Survey data sets from 1980 to 2000. During our years of interest, the total number of visits sampled ranged from 2524 to 9151. Visits were analyzed for physician type and patient age. There have been marked changes in the proportion of office visits to general pediatricians vs family physicians during the 1990s. Overall, the percentage of all nonsurgical physician office visits for children from birth through the age of 17 years made to general pediatricians increased significantly, from 56.2% in 1990 to 64.2% in 2000 (P<.001). During the same period, the percentage of all nonsurgical physician office visits for children from birth through the age of 17 years made to family physicians declined significantly, from 33.7% in 1990 to 23.9% in 2000 (P<.001). Visits to pediatric specialists, as a proportion of all visits, increased significantly, from 1.6% in 1980 to 4.5% in 2000 (P<.001). Pediatricians are providing more primary care visits for children in the United States, and this trend has accelerated during the past 5 years. These findings have implications for the cost of care, the physician workforce, and the training of future physicians. It is unknown if these changes have had a positive or negative impact on the health of our nation's children.

Effectiveness of anticipatory guidance: recent developments.

Anticipatory guidance is a key component of child health supervision. This review discusses the latest evidence on the effectiveness of anticipatory guidance and its impact on child and family functioning. Anticipatory guidance on parent-infant interaction, sleep patterns, and injury prevention improve functional outcomes of children and their families. Recent findings also demonstrate that encouraging parents to share books with their children and free book distribution during well child care visits are associated with improved child language development and increased home literacy activities. Guidance promoting injury prevention and reading at home is supported by the best evidence. Future models of child health supervision should address missed opportunities for anticipatory guidance and parents' desire for more information about what they can do to enhance their children's growth, development, and functioning.

Budesonide and nedocromil do not improve lung function, but reduce urgent care visits for children with asthma

Budesonide and nedocromil do not improve lung function, but reduce urgent care visits for children with asthma

Technical efficiency of public clinics in Kwazulu-Natal Province of South Africa.

In sub-Saharan Africa (SSA) much of the attention of policy makers, health care managers, health systems researchers and donors is focussed almost solely on mobilising additional resources and not on efficiency in their use. To investigate the technical inefficiencies among 155 primary health care clinics in Kwazulu-Natal Province of South Africa; and to draw policy implications. Cross-sectional provincial health clinic survey. SELLING: Kwazulu-Natal Provincial Department of Health Clinics survey, 1996. The analysis is based on 155 public clinics. Non-intervention Data Envelopment Analysis (DEA) study. Technical and scale efficiency scores. Forty seven (30%) were found to be technically efficient. Among the 108 (70%) technically inefficient facilities, 16% had an efficiency score of 50% or less. The presence of inefficiencies indicates that a clinic has excess inputs or insufficient outputs compared to those clinics on the efficiency frontier. To achieve technical efficiency, Kwazulu-Natal clinics would, in total have to decrease inputs by 417 nurses and 457 general staff. Alternatively, outputs would have to be increased by 115,534 antenatal visits, 1,010 births (deliveries), 179,075 child care visits, 5,702 dental visits, 121,658 family planning visits, 36,032 psychiatric visits, 56,068 sexually transmitted disease visits and 34,270 tuberculosis visits. There is need for more detailed studies in a number of the relativdy efficient clinics to determine why they are efficient with a view of documenting attributes of 'best practise' that other clinics can emulate. The potential benefit of replicating this kind of study in other provinces, and indeed, other SSA countries cannot be overemphasised.

Caregiving Arrangement and Nutrition: Good News with Some Reservations

The objective of this study was to assess the impact of caregiving arrangement on the iron and folate status of infants and toddlers reared at home or enrolled in centre-based, independent home, or licensed home care. One hundred and eighty-nine children aged 2 to 29 months were assessed 1 month prior to child care entry and at 6 months after entry into child care. Dietary (24-hour records), anthropometric (height, weight, head circumference) and biochemical (red blood cell folate, hematocrit, transferrin, and serum ferritin concentrations) methods were used to assess nutritional status. Frequency of illness was determined by a series of telephone interviews. Median intake of nutrients exceeded Canadian recommendations, regardless of care arrangement. Fifteen of 65 children had hematocrit values below age-specific cutoffs at the 6-month post-entry to child care visit. Children were frequently taken to obtain medical advice (average of 4 to 6 times during the study period) and 75% of subjects were prescribed at least one course of antibiotics. In conclusion, infants and toddlers in this study were generally well nourished, regardless of child care arrangement; however, iron status may remain an issue in this sample of infants and toddlers.

CROSS-SECTIONAL SURVEY TO CHARACTERIZE THE CLINICAL COURSE AND MANAGEMENT OF CONSTIPATION IN A PRIMARY CARE PEDIATRIC SETTING WITHIN A HEALTH MAINTENANCE ORGANIZATION

81 Background: Children with constipation are managed by primary care providers (PCP) and/or specialists. Timing for referral to a specialist remains unclear. The purpose of this study is to characterize the clinical course and management of constipation in a primary care pediatric setting within a managed care organization. Methods: In a cross-sectional survey, we characterized the period prevalence of constipation, duration of clinical symptoms and therapeutic management of children, identified by questioning to have clinical constipation, during a well child care (WCC) visit. WCC visits transpired at 6 pediatric offices, staffed by 25 pediatricians, owned by the Fallon Clinic, an HMO in Central MA. To identify children with a clinical history of constipation, all parents of children (ages 1-14yo) were asked to complete a screening questionnaire, prior to seeing the pediatrician. An extensive follow-up (F/U) questionnaire was conducted by telephone within 3 months of WCC visit. Results: Over a 7 month period, screening questionnaires were distributed to the parents of 8093 children, undergoing consecutive WCC visits, with 6193 completed (76.5% response rate). 320 (5.2%) children were found to have clinical constipation, defined as: a recent history of bowel movements (BM)< every other day and at least 1 of the following: abdominal pain, soiling, painful defecation, withholding behavior and/or excessive large BMs. To date, F/U was completed on 261/320 eligible children (81.6%). 87(33%) children continued to exhibit a clinical history of constipation on F/U questionnaire: 87(100%) Bms <every other day for 36/36 (mean/median) months, 46(52%) abdominal pain for 23/12 months, 42(48%) soiling for 31/24 months, 38(43%) painful defecation for 26/24 months, 43(49%) withholding behavior for 23/12 months, Approximately, one third of these 87 children were receiving medication/high fiber supplements. Conclusion: Although the majority of constipation in children is self limiting, approximately one third of patients exhibit long term refractory constipation requiring further intervention.

Rehospitalization of infants born to adolescent mothers

This study defines the variables that predict rehospitalization of infants born to teen mothers. Rehospitalization was defined as hospital admission during the first year of life subsequent to hospitalization at birth. Normal birth weight (NBW), but not low birth weight (LBW), infants of adolescent mothers had higher rehospitalization rates than infants of older mothers. NBW infants of young vs. older mothers had significantly higher rehospitalization rates for gastroenteritis. Among infants of adolescent mothers, the variables associated with increased risk of rehospitalization were unemployed household head, presence of a congenital anomaly or developmental delay, and an unusually high or low number of well child care visits. Although individual variables were significant at the bivariate level, in combination, these variables were poor predictors of which infants would be rehospitalized. Our study suggests that all teen mothers of NBW infants may require additional education to prevent excess rehospitalization of their infants.

The effect of independent practice association plans on use of pediatric ambulatory medical care in one group practice

We compared the use of pediatric ambulatory medical care of 640 children who switched from a traditional Blue Cross plan to more comprehensive independent practice association plans with that of matched patients who remained with Blue Cross in one large, suburban pediatric practice in Rochester, NY. A quasiexperimental, retrospective cohort design was used. Use of pediatric ambulatory medical care by patients in the independent practice association plan and control patients was determined by medical chart review for 1 year before and 1 year after each patient's switch. During the baseline year, patients who would join the independent practice association plan already had 19% more acute-illness visits than control patients. During the second year, patients in the independent practice association plan averaged 42% more acute-illness visits, 22% more well child—care visits, 93% more chronic-illness visits, 27% more after-hours visits, 53% more weekend visits, 185% more laboratory studies, and 70% more referrals. The shift toward independent practice association plans in this open-market setting increased use of ambulatory medical care for pediatric patients. (<i>JAMA</i>. 1990;263:2198-2203)

The Effect of Independent Practice Association Plans on Use of Pediatric Ambulatory Medical Care in One Group Practice

We compared the use of pediatric ambulatory medical care of 640 children who switched from a traditional Blue Cross plan to more comprehensive independent practice association plans with that of matched patients who remained with Blue Cross in one large, suburban pediatric practice in Rochester, NY. A quasi-experimental, retrospective cohort design was used. Use of pediatric ambulatory medical care by patients in the independent practice association plan and control patients was determined by medical chart review for 1 year before and 1 year after each patient's switch. During the baseline year, patients who would join the independent practice association plan already had 19% more acute-illness visits than control patients. During the second year, patients in the independent practice association plan averaged 42% more acute-illness visits, 22% more well child-care visits, 93% more chronic-illness visits, 27% more after-hours visits, 53% more weekend visits, 185% more laboratory studies, and 70% more referrals. The shift toward independent practice association plans in this open-market setting increased use of ambulatory medical care for pediatric patients.

Mothers' clinical judgment: A randomized trial of the Acute Illness Observation Scales

The purpose of this study was to investigate whether the reliability, sensitivity, and specificity of mothers' judgments about acute illnesses in their children could be improved by using the Acute Illness Observation Scales (AIOS). At the 2-week well child care visit in a primary care center and a private practice, 369 mothers were divided at random into an intervention group (n = 183) and a control group (n = 186). A teaching film and booklet were used to educate mothers in the intervention group about the AIOS; control group mothers were taught a 3-point global scoring system for evaluating the chance of serious illness. In the 32 months of follow-up, 704 acute illnesses were evaluated in tandem and independently by mothers and pediatricians before the history and physical examination; 20 of these illnesses were serious. The judgments of the intervention group were more reliable than those of the control group (weighted kappa = 0.50 vs 0.26, respectively), as was the specificity of their judgments (85% vs 52%, respectively; p less than 0.0001). No difference was noted in the sensitivity of intervention group and control group mothers' judgments (80% vs 90%, respectively). Teaching parents to assess specific clinical information, as represented in the AIOS, has its greatest effect on the reliability and specificity, not the sensitivity, of their judgments. Such teaching could lead to fewer unnecessary office visits during acute illnesses.

Vaginal Hygiene of Girls Seen in Well Child Care Visits

To the Editor.— Pediatricians and nurse practitioners often find that the vaginal hygiene of female infants seen in routine well-baby visits is inadequate. Fecally stained secretions are often found in the intracoitus, labial folds, or groin of these children. During a two-month period, we prospectively surveyed mothers seen in our offices for their knowledge of adequate hygiene practices for female infant genitalia. We specifically asked the mothers to demonstrate how they routinely wiped their baby girls' perineal and vaginal areas after "a messy diaper."