Child's Primary Care Provider Research Articles

Factors Affecting Primary Care Provider and Caregiver Concordance for Pediatric Asthma Medications

Background. Lack of discussion regarding actual asthma medication use by physicians with caregivers of children with asthma may result in low caregiver and physician concordance about prescribed asthma medications. Objective. The primary objective was to examine the concordance between primary care providers (PCP) and caregivers regarding child asthma medication use. Methods. Current asthma medications in the home with verification from each child's PCP were obtained for 231 underserved children with persistent asthma. Kappas and chi-square statistics were calculated to measure the strength of the concordance. Caregiver and PCP dyads were categorized as concordant or discordant based on asthma medication use. Results. For all asthma prescriptions N = 479, two thirds of caregiver-PCP dyads (67.8) were categorized as concordant with at least one asthma medication. Concordance for asthma medications varied by type of medication ranging from 84% agreement for albuterol and 77% agreement for Flovent. In the final regression model predicting caregiver and PCP concordance, the number of PCP visits within the past 6 months and caregiver report of no limitation of child's activity due to asthma were significantly higher in caregivers who were considered concordant with their child's PCP while controlling for child age and frequency of symptom nights and number of ED visits in prior 6 months. In a model predicting the number of PCP visits, the number of ED visits was the only significant variable associated with the number of PCP visits while controlling for caregiver and PCP concordance. Conclusion. Caregiver and PCP concordance was significantly associated with increased number of PCP visits suggesting that increased exposure to a health care provider may increase agreement between a child's PCP and caregiver regarding prescribed asthma medications. However, there may be other important factors including increased emergency department visits that may also be associated with subsequent pediatric primary care visits for asthma.

Discussion of Maternal Stress During Pediatric Primary Care Visits

To determine whether the discussion of maternal stress in pediatric primary care is associated with the mother's satisfaction with her child's provider. Children ages 5-16 and their mothers (N=747) were recruited from the waiting rooms of 13 geographically diverse pediatric primary care sites from 2002 to 2005. Directly after the visit, the mother reported her satisfaction with the attention that the provider gave to her and her child's problems and also reported whether the provider understood the problems that she wanted to discuss during the visit. The mother also reported whether the visit included discussion of her "stresses and strains" and the discussion of child mood or behavior. Thirty-five percent of mothers discussed their stresses and strains with their child's provider. The mother was more likely to be "completely" satisfied with the attention that she and her child received from the provider (odds ratio [OR] 2.43, 95% confidence interval [95% CI], 1.43-4.11) and to agree "strongly" that the provider understood the problems she wanted to discuss (OR 1.95, 95% CI, 1.32-2.93) when the visit included the discussion of maternal stress after controlling for the reason for the visit, number of previous visits, provider specialty (family practice or pediatrics), youth mental health status, whether the visit included the discussion of child mood or behavior, and maternal distress measured with a standard screening tool. The mother was more satisfied with her child's primary care provider when maternal stress was discussed during the visit. This finding should somewhat alleviate fears that mothers will react negatively to discussion of their stress during pediatric visits.

Why Do Parents Bring Children to the Emergency Department for Nonurgent Conditions? A Qualitative Study

Nonurgent conditions account for 58% to 82% of pediatric emergency department (ED) visits, but only 1 preliminary qualitative study has examined reasons why parents bring children to the ED for nonurgent care. The aim of this study was to identify parents' reasons for choosing the ED over their primary care provider (PCP) for nonurgent pediatric care. Audiotaped ethnographic interviews in English and Spanish were conducted of parents of children presenting for nonurgent care on weekdays from 8 AM to 4 PM at a children's hospital ED over a 4-week period. For the 31 families interviewed, the mean parental age was 28 years, and mean child age, 3 years. Reasons cited by caregivers for choosing the ED over their child's PCP were long appointment waits, dissatisfaction with the PCP, communication problems (accents and unhelpful staff at PCP), health care provider referral, efficiency, ED resources, convenience, quality of care, and ED expertise with children. Some parents said they would like education on the urgency of pediatric problems. Parents bring their children to the ED for nonurgent care because of problems with their PCP, PCP referral, and perceived advantages to ED care. Although parents report that education on the urgency of pediatric conditions would be helpful, substantial reduction of pediatric nonurgent ED use may require improvements in families' PCP office access, efficiency, experiences, and appointment scheduling.

Implementation of Effective Treatments of Preschool Behavior Problems in a Clinic Setting

Epidemiological data indicate that nearly 20% of preschool aged children have significant behavioral problems. Parents typically consult their child's primary care provider, who frequently refers to child psychologists for treatment regarding these difficulties. Psychologists skilled in providing effective services for young children are in short supply, limiting accessibility, and parents often are reluctant to follow up with a mental health specialist, suggesting low acceptability. The Behavior Consultation Clinic is a structured clinic for preschool children designed to address these issues of effectiveness, accessibility and acceptability. A retrospective review of 550 patients seen over a 5-year period found that half were seen for one therapy session. Review of the remaining patients found that slightly more than half showed improvement (32% successful discharge with improvement, 24% premature discharge with improvement) with a typical range of two to seven half-hour sessions, about a quarter did not improve, and the remaining patients were referred to a higher level of service. These data indicate that a structured, brief clinic that focuses on the needs of preschool children utilizing evidence-based approaches can be effective, acceptable, and accessible. The Behavior Consultation Clinic also serves as a training clinic for psychology interns and pediatric medical residents.

Asthma Coaching in the Pediatric Emergency Department

Coaching and monetary incentives have been used to modify medical behavior of individuals with several chronic diseases, including asthma. The authors performed a randomized, controlled trial of an intervention combining asthma coaching during an emergency department (ED) visit for asthma, and monetary incentive to improve follow-up with primary care providers (PCP). Subjects were parents of children 2-12 years of age, with Medicaid or no medical insurance, receiving treatment for asthma in the ED. The primary outcome was a verified PCP visit for asthma within two weeks of the index ED visit. All parents received 15 dollars for their time in the ED. Parents in the intervention group were told that they would receive an additional 15 dollars monetary incentive if a PCP visit was completed. The coach engaged in a dialogue with the parent during the ED visit, and discussed the importance and advantages of seeking follow-up care with the child's PCP. All parents received the usual discharge instructions, including advice to see the PCP within three days. The authors enrolled 92 parents; outcome data were available for 86 (42 controls, 50 intervention). Demographic characteristics were similar in both groups. There was no significant difference in the proportion of patients who had follow-up PCP visits between the intervention (22.0%; 95% confidence interval [95% CI] = 11.5% to 36.0%) and control (23.8%; 95% CI = 12.0% to 39.4%) groups (p = 0.99). An intervention combining asthma coaching during acute ED visits and a monetary incentive to return for a PCP visit does not appear to increase follow-up with the PCP.

A randomized trial of primary care provider prompting to enhance preventive asthma therapy

Context Urban children often receive inadequate therapy for asthma. One reason may be that primary care providers are unaware of the severity of their patients' symptoms. Objective To determine whether systematic school-based asthma screening, coupled with primary care provider notification of asthma severity, will prompt providers to prescribe a new preventive medication or modify a current dose. Design Randomized controlled trial. Setting Rochester, New York. Participants Children age 3 to 7 years with mild persistent to severe persistent asthma. Interventions Children were assigned randomly to a provider notification group (child's primary care provider notified of asthma severity) or a control group (provider not notified of asthma severity). Primary care providers of children in the intervention group were sent a facsimile indicating the child's symptoms and recommending medication action based on national criteria. Interviewers blinded to the child's group assignment called parents 3 to 6 months later to determine whether preventive actions had been taken. Main Outcome Measures Number of children who received a preventive medication action. Results Of 164 eligible children, 151 (92.1%) were enrolled. Children in the provider notification group were not more likely to receive a preventive medication action than were children in the control group (21.9% vs 26.0%; P=.57). Additional preventive measures, including encouraging compliance with medications (33.3% vs 31.3%; P =.85), recommending environmental modifications (39.3% vs 42.4%; P =.86), and making referrals for specialty care (6.6% vs 6.0%; P =.99), also did not differ between the provider notification and control groups. At the end of the study, 52.4% of children in both groups with no medication changes were still experiencing persistent symptoms. Conclusions School-based asthma screening identified many symptomatic children in need of medication modification. Provider notification did not improve preventive care, however. The findings suggest that more powerful interventions are needed to make systematic asthma screening effective.

A Randomized Trial of Primary Care Provider Prompting to Enhance Preventive Asthma Therapy

Guidelines recommend preventive medications for all children with persistent asthma, yet young urban children often receive inadequate therapy. This may occur in part because primary care providers are unaware of the severity of their patients' symptoms. To determine whether systematic school-based asthma screening, coupled with primary care provider notification of asthma severity, will prompt providers to take preventive medication action (prescribe a new preventive medication or change a current dose). Children aged 3 to 7 years with mild persistent to severe persistent asthma were identified at the start of the 2002-2003 school year in Rochester. Children were assigned randomly to a provider notification group (child's primary care provider notified of asthma severity) or a control group (provider not notified of severity). Primary care providers of children in the provider notification group were sent a facsimile indicating the child's symptoms and recommending medication action based on national criteria. Interviewers blinded to the child's group assignment called parents 3 to 6 months later to determine if preventive actions were taken. Of 164 eligible children with mild persistent or more severe asthma, 151 (92.1%) were enrolled. Children in the provider notification group were not more likely to receive a preventive medication action than were children in the control group (21.9% vs 26.0%; P = .57). Additional preventive measures, including encouraging compliance with medications (33.3% vs 31.3%; P = .85), recommending environmental modifications (39.3% vs 42.4%; P = .86), and referrals for specialty care (6.6% vs 6.0%; P > .99), also did not differ between the provider notification and control groups. At the end of the study, 52.4% of children in both groups with no medication changes were still experiencing persistent symptoms. School-based asthma screening identified many symptomatic children in need of medication modification. Provider notification, however, did not improve preventive care. Findings suggest that more powerful interventions are needed to make systematic asthma screening effective.

Agreement on smoking behavior and asthma medications among rural school age children with asthma, their parents and primary care providers (PCPs)

Rationale Parental self-report of smoking behavior is often underestimated. We examined agreement between mothers' reports of smoking indoors and children's reports of mothers' smoking, and also agreement between parents' reports of child's asthma medications and primary care providers' (PCPs) reports. Methods Parental smoking behavior was collected by personal interviews of children with asthma in 3 rural MD counties. Parent reports of smoking behavior and the child's asthma medications were obtained from telephone surveys of 114 parents. Smoking behavior data was analyzed for 94 mother-child pairs. Information about children's asthma medications was obtained from 97 PCPs (85%). Medication agreement indicates agreement on drug name, frequency, dose and route. Results Children reported 15 mothers (16%) smoked indoors. Nine of these mothers reported not smoking indoors, while 7 children (78%) reported they did. Of the 6 smoking mothers who admitted to smoking indoors, 5 children (83%) stated that these mothers did (McNemar's chi-square <0.03). PCP reports indicated 141 prescriptions for rescue medications and 89 for controllers. For rescue medications, there was total agreement between parent and PCP on 111 (79%) prescriptions, and total agreement on 70 (79%) of the controller medications. Conclusions In this rural population, when smoking mothers reported that they did not smoke in the home, there was little agreement with their child's report. This finding indicates that it may be important to ask children with asthma about smoking in the home. Agreement between parents and PCPs on controller medication prescriptions was higher in this population than previously reported. This finding warrants further exploration.

Use of Evidence-Based Practice As a Method for Evaluating the Effects of Secretin on a Child with Autism

Standardized assessment instruments and direct observation data were collected pre-and postadministration (2 weeks after administration) on the effects of secretin on a 4-year-old boy diagnosed with autism. Information was collected on the three major diagnostic categories associated with autism: communication deficiencies, repetitive behavior and interests, and impaired social interactions. No changes in communication functioning, occurrences of stereotypic behavior, or social interaction were observed 2 weeks after administration of secretin. A 3-month follow-up interview with the child's primary care provider supported empirical data suggesting no substantial behavioral changes after the secretin administration. Results are discussed in terms of controversial treatments for children with autism and related developmental disorders.

Recruitment of Participants in the Childhood Asthma Management Program (CAMP). I. Description of Methods

The Childhood Asthma Management Program (CAMP), a multicenter clinical trial sponsored by the Division of Lung Diseases of the National Heart, Lung, and Blood Institute (NHLBI), is the largest outcome study of mild to moderate asthma in children to be undertaken, with eight clinical centers in the United States and Canada participating. The initial recruitment goal was 960 children within an 18-month recruitment period. Recruitment was extended to 23 months, with 1041 children randomized from late December, 1993, to early September, 1995. In this time interval each of the eight centers met the recruitment goal of 120 using a variety of self-selected recruitment strategies. The goal for minority recruiting was 33%, or 320 of the planned 960 children to be recruited. CAMP achieved the overall goal for the number of minorities, with 330 patients. Three centers recruited at or above the expected rate from the beginning. The other five centers had significant delays in recruitment. Examination of the recruitment experiences of the centers with and without delays did not indicate any single recruitment strategy that was certain to be successful. The most commonly cited factors for success were a cohesive staff, endorsement of participation by the child's primary care provider, and ability of the staff to be flexible and honest in assessing progress and the value of recruiting methods being used.

Lower Parental Satisfaction with Child's Primary Care Provider (PCP) in Early Childhood Asthma † 626

Lower Parental Satisfaction with Child's Primary Care Provider (PCP) in Early Childhood Asthma † 626

Factors Associated With Delay in Diagnosis of Childhood Amblyopia

The prevention of permanent visual impairment from amblyopia is an important goal of pediatric vision screening. Unfortunately, many cases of amblyopia are not diagnosed until the child is too old to benefit maximally from treatment. A review of patient records from the practice of a private pediatric ophthalmologist confirmed that late detection is a frequent occurrence among children with amblyopia who have had good access to health care. A case-control study was then used to identify factors associated with delayed diagnosis, in which children with an adverse outcome (diagnosed at or after 5 years of age) were compared with those with an optimal outcome (diagnosed before 5 years of age). The chart review identified 161 children with amblyopia who participated in this study; 75 had late diagnoses (case patients) and 86 served as control patients. Children with early diagnoses more often had the following characteristics: a positive family history of strabismus, greater degrees of strabismus (when strabismus was present), higher maternal educational level, greater parental suspicion that an eye problem existed, and an increased chance that the parents requested the eye examination that led to the diagnosis. The parents of children with late diagnoses expressed less concern over the seriousness of amblyopia but were more likely to report that their children had suffered adverse consequences of amblyopia. When diagnosed early, amblyopia was more often detected by the child's primary health care provider. Physicians of the children with early diagnoses more often reported compliance with both the American Academy of Pediatrics guidelines for vision screening in infancy and referral for vision problems.(ABSTRACT TRUNCATED AT 250 WORDS)