Pediatric Research In Office Settings Research Articles

The APA and the Rise of Pediatric Generalist Network Research

The Academic Pediatric Association (APA, formerly the Ambulatory Pediatric Association) first encouraged multi-institutional collaborative research among its members over 30 years ago. Individual APA members subsequently went on to figure prominently in establishing formal research networks. These enduring collaborations have been established to conduct investigations in a variety of generalist contexts. At present, 4 generalist networks—Pediatric Research in Office Settings (PROS), the Pediatric Emergency Care Applied Research Network (PECARN), the COntinuity Research NETwork (CORNET), and Pediatric Research in Inpatient Settings (PRIS)—have a track record of extensive achievement in generating new knowledge aimed at improving the health and health care of children. This review details the history, accomplishments, and future directions of these networks and summarizes the common themes, strengths, challenges, and opportunities inherent in pediatric generalist network research.

Effects of Local Institutional Review Board Review on Participation in National Practice-Based Research Network Studies

To describe the process and outcomes of local institutional review board (IRB) review for 2 Pediatric Research in Office Settings (PROS) studies. Pediatric Research in Office Settings conducted 2 national studies concerning sensitive topics: (1) Child Abuse Recognition Experience Study (CARES), an observational study of physician decision making, and (2) Safety Check, a violence prevention intervention trial. Institutional review board approval was secured by investigators' sites, the American Academy of Pediatrics, and practices with local IRBs. Practices were queried about IRB rules at PROS enrollment and study recruitment. Pediatric Research in Office Settings practices in 29 states. Eighty-eight PROS practices (75 IRBs). Main Exposure Local IRB presence. Local IRB presence, level of PROS assistance, IRB process, study participation, data collection completion, and minority enrollment. Practices requiring additional local IRB approval agreed to participate less than those that did not (CARES: 33% vs 52%; Safety Check: 41% vs 56%). Of the 88 practices requiring local IRB approval, 55 received approval, with nearly 50% needing active PROS help, many requiring consent changes (eg, contact name additions, local IRB approval stamps), and 87% beginning data collection. Median days to obtain approval were 81 (CARES) and 109 (Safety Check). Practices requiring local IRB approval were less likely to complete data collection but more likely to enroll minority patients. Local IRB review was associated with lower participation rates, substantial effort navigating the process (with approval universally granted without substantive changes), and data collection delays. When considering future reforms, the national human subject protections system should consider the potential redundancy and effect on generalizability, particularly regarding enrollment of poor urban children, related to local IRB review.

Child Abuse and Neglect: A System That Still Needs Pediatric Leadership

Four decades ago, a group of pediatricians published landmark research that substantiated abuse and neglect as an issue worthy of society's attention, providing the catalyst for cultural change and milestone legislation.1 Although a generation of child advocates has made remarkable progress, children remain at risk, and pediatricians must remain leaders in protecting vulnerable children. Every year in the United States, an estimated 900000 children are determined to be victims of child maltreatment, and more than 1500 die secondary to abuse and neglect. To ensure their safety, every year 800000 American children spend time in foster care. In addition, although the $100 billion annual cost of child abuse and neglect to US society is insignificant when compared with the measure of human suffering, it is not a trivial sum. Included in the August and September issues of Pediatrics are 2 articles about the child abuse identification and reporting behaviors of pediatricians.2,3 The Child Abuse Reporting Experience Study (CARES), conducted by the American Academy of Pediatrics (AAP) Pediatric Research in Office Settings (PROS) Network, has provided evidence-based confirmation of the perceptions of professionals who have spent entire careers evaluating cases of suspected abuse and neglect. CARES investigators found that health care providers do not report all cases of suspected abuse, in large part because of concerns over best outcomes, given a system perceived as dysfunctional. Previous research has suggested that the results of the CARES, although certainly unsettling for pediatricians, seem to be part of a larger and consistent picture of child abuse reporting (or the lack thereof) by professionals who are mandated to report it. For example, in 1994, Tilden et al4 surveyed a wider variety of … Address correspondence to Edward Bailey, MD, NSMC/North Shore Children's, 57 Highland Ave, Salem, MA 01970. E-mail: enbailey{at}partners.org

Antibiotic Prophylaxis for the Prevention of Recurrent Urinary Tract Infection in Children With Low Grade Vesicoureteral Reflux: Results From a Prospective Randomized Study

Antibiotic prophylaxis is given to children at risk for urinary tract infection. However, evidence concerning its effectiveness in grade I to III vesicoureteral reflux is lacking. The objective of this study was to determine whether antibiotic prophylaxis reduces the incidence of urinary tract infection in young children with low grade vesicoureteral reflux. Children 1 month to 3 years old with grade I to III vesicoureteral reflux were assigned randomly to receive daily cotrimoxazole or no treatment, and followed for 18 months. A urinary tract infection constituted an exit criterion. Infection-free survival rates were calculated using the Kaplan-Meier method and compared using the log rank test. A total of 225 children were enrolled in the study. Distribution of gender, age at inclusion and reflux grade were similar between the 2 groups. There was no significant difference in the occurrence of urinary tract infection between the 2 groups (17% vs 26%, p = 0.2). However, a significant association was found between treatment and patient gender (p = 0.017). Prophylaxis significantly reduced urinary tract infection in boys (p = 0.013), most notably in boys with grade III vesicoureteral reflux (p = 0.042). These data suggest that antibiotic prophylaxis does not reduce the overall incidence of urinary tract infection in children with low grade vesicoureteral reflux. However, such a strategy may prevent further urinary tract infection in boys with grade III reflux.

Improving Pediatric Practice Immunization Rates Through Distance-Based Quality Improvement: A Feasibility Trial from PROS

The feasibility and effectiveness of a distance-based quality improvement model were examined in a cohort of Pediatric Research in Office Settings (PROS) practices, with the goal of improving immunization rates and practitioner behaviors and attitudes. Of an initially assessed 82 practices, 29 with baseline rates of < or =88% for children 8 to 15 months of age were randomized into year-long paper-based education or distance-based quality improvement intervention groups. Outcomes were utility/helpfulness of quality improvement modalities, immunization rate change, and behavior/attitude change. Quality improvement participants attended approximately 75% of monthly conference calls but used the quality improvement Listserv and Web site infrequently (mean 1.09 and 0.92 uses, respectively). Helpfulness ratings of quality improvement modalities mirrored usage. Analyses revealed a 4.9% increase in quality improvement group immunization rates (P = .061), a 0.8% education group increase (P = .752), and a 4.1% difference between groups (P = .261). More quality improvement practices adopted systems identifying children behind in immunizations. A distance-based quality improvement model is feasible and may improve immunization rates.

Office-Based Motivational Interviewing to Prevent Childhood Obesity

To determine whether pediatricians and dietitians can implement an office-based obesity prevention program using motivational interviewing as the primary intervention. Nonrandomized clinical trial. Fifteen pediatricians belonging to Pediatric Research in Office Settings, a national practice-based research network, and 5 registered dietitians were assigned to 1 of 3 groups: (1) control; (2) minimal intervention (pediatrician only); or (3) intensive intervention (pediatrician and registered dietitian). Primary care pediatric offices. Ninety-one children presenting for well-child care visits met eligibility criteria of being aged 3 to 7 years and having a body mass index (calculated as the weight in kilograms divided by the height in meters squared) at the 85th percentile or greater but lower than the 95th percentile for the age or having a normal weight and a parent with a body mass index of 30 or greater. Pediatricians and registered dietitians in the intervention groups received motivational interviewing training. Parents of children in the minimal intervention group received 1 motivational interviewing session from the physician, and parents of children in the intensive intervention group received 2 motivational interviewing sessions each from the pediatrician and the registered dietitian. Change in the body mass index-for-age percentile. At 6 months' follow-up, there was a decrease of 0.6, 1.9, and 2.6 body mass index percentiles in the control, minimal, and intensive groups, respectively. The differences in body mass index percentile change between the 3 groups were nonsignificant (P=.85). The patient dropout rates were 2 (10%), 13 (32%), and 15 (50%) for the control, minimal, and intensive groups, respectively. Fifteen (94%) of the parents reported that the intervention helped them think about changing their family's eating habits. Motivational interviewing by pediatricians and dietitians is a promising office-based strategy for preventing childhood obesity. However, additional studies are needed to demonstrate the efficacy of this intervention in practice settings.

What Do Pediatric Primary Care Providers Think Are Important Research Questions? A Perspective From PROS Providers

To describe what pediatric primary care providers involved in the Pediatric Research in Office Settings (PROS) research network think are important yet inadequately addressed questions in pediatric primary care research. A total of 1785 pediatric primary care providers in the PROS network were asked what they thought were important yet inadequately addressed areas of primary care research. We used a single, open-ended question in a mail survey. Written answers to this question were analyzed by qualitative methods to determine the main themes of interest to pediatric primary care providers. Overall survey response rate was 48.7%; the open-ended question yielded 1109 individual answers. Six lines of inquiry were identified as being important to these providers: (1) effective counseling techniques to use in anticipatory guidance; (2) strategies to prevent and treat obesity; (3) the effectiveness of well-child care; (4) ongoing management of patients with attention-deficit/hyperactivity disorder; (5) the role of the primary care provider in caring for children with mental health needs; and (6) optimal organization of office practices. The translation of research into practice may be improved by a better understanding of the needs and interests of those who see pediatric patients in the primary care setting.

Two decades of PROS lead to improved practice policies

Twenty years ago when Robert J. Haggerty, M.D., FAAP, pushed for the initiation of Pediatric Research in Office Settings (PROS) for the Academy, he never could have imagined how large and successful it would turn out to be. Since its inception in 1986, groundbreaking practice-based research

Patient Visits to a National Practice-Based Research Network: Comparing Pediatric Research in Office Settings With the National Ambulatory Medical Care Survey

Our objective with this study was to assess the extent to which patients who are seen by practitioners in Pediatric Research in Office Settings, a national primary care practice-based research network, are representative of those who are seen in ambulatory office-based pediatric primary care in the United States. Pediatric Research in Office Settings patient data were collected from the offices of 57 randomly selected network practitioners as part of an Agency for Healthcare Research and Quality-funded effort to describe primary care visits and replicate the National Ambulatory Medical Care Survey in primary care practice-based research networks. These data were from 1706 randomly selected pediatric patient visits that occurred between March and June 2002. National comparison data were 948 randomly selected pediatric patient visits that occurred between March and June 2000 in the offices of the 33 primary care pediatric practitioners who had participated in the National Ambulatory Medical Care Survey. The groups were compared on patient demographics (age, gender, race, ethnicity, and socioeconomic status, as represented by Medicaid status), visit characteristics (percentages of patients referred, practitioner designation of visit as acute versus nonacute, and continuity of care), the top patient/parent-articulated reasons for visit, and the top practitioner diagnoses. Comparisons revealed substantial similarities between Pediatric Research in Office Settings and national data, including gender, ethnicity, socioeconomic status, and visit characteristics. Differences were noted for age and race, with Pediatric Research in Office Settings children approximately 1 year older and comprising a significantly lower proportion of black patients than their National Ambulatory Medical Care Survey counterparts. Although the top 6 reasons that were articulated by parents for outpatient visits in the 2 groups were remarkably similar in rank order and proportions, there were overall differences, mostly attributable to a larger number of the "other" category in the Pediatric Research in Office Settings cases. There were no significant differences among the top 5 practitioner visit diagnoses between the Pediatric Research in Office Settings and National Ambulatory Medical Care Survey data. The Pediatric Research in Office Settings patient population is reasonably representative of patients who are seen in US ambulatory office-based pediatric primary care practices; therefore, the Pediatric Research in Office Settings is an appropriate laboratory for studies of care in such settings.

An Update on Female Puberty

Puberty is best defined at the period of life during which one acquires reproductive capabilities. As a female transitions from childhood to adulthood, one witnesses a significant reactivation of the hypothalamicpituitary- ovarian (HPO) axis; this axis is functional in utero.The hallmarks of pubertal development include:All this may take three to five years for completion.The American Academy of Pediatrics Pediatric Research in Office Settings (PROS) Study has provided the latest information regarding age of onset of specific pubertal milestones. PROS focused on breast development— thelarche (an early sign of the onset of puberty) occurs in African-American girls at 8.87 years and in white American girls at 9.96 years of age; the onset of pubic and axillary hair development, i.e. pubarche, occurs in African-American girls at 8.78 years and in white girls at 10.51 years of age.1,2Additional information is detailed inTable 1.

Choice of Urine Collection Methods for the Diagnosis of Urinary Tract Infection in Young, Febrile Infants

The optimal method of urine collection in febrile infants is debatable; catheterization, considered more accurate, is technically difficult and invasive. To determine predictors of urethral catheterization in febrile infants and to compare bag and catheterized urine test performance characteristics. Prospective analysis of infants enrolled in the Pediatric Research in Office Settings' Febrile Infant Study. A total of 219 practices from within the Pediatric Research in Office Settings' network, including 44 states, the District of Columbia, and Puerto Rico. A total of 3066 infants aged 0 to 3 months with temperatures of 38 degrees C or higher. We calculated adjusted odds ratios for predictors of catheterization. Diagnostic test characteristics were compared between bag and catheterization. Urinary tract infection was defined as pure growth of 100 000 CFU/mL or more (bag) and 20 000 CFU/mL or more (catheterization). Seventy percent of urine samples were obtained by catheterization. Predictors of catheterization included female sex, practitioner older than 40 years, Medicaid, Hispanic ethnicity, nighttime evaluation, and severe dehydration. For leukocyte esterase levels, bag specimens demonstrated no difference in sensitivity but somewhat lower specificity (84% [bag] vs 94% [catheterization], P<.001) and a lower area under the receiver operating characteristic curve for white blood cells (0.71 [bag] vs 0.86 [catheterization], P = .01). Infection rates were similar in bag and catheterized specimens (8.5% vs 10.8%). Ambiguous cultures were more common in bag specimens (7.4% vs 2.7%, P<.001), but 21 catheterized specimens are needed to avoid each ambiguous bag result. Most practitioners obtain urine from febrile infants via catheterization, but choice of method is not related to the risk of urinary tract infection. Although both urine cultures and urinalyses are more accurate in catheterized specimens, the magnitude of difference is small but should be factored into clinical decision making.

Navigating the recent articles on girls' puberty in Pediatrics: what do we know and where do we go from here?

After the publication of the Pediatric Research in Office Settings (PROS) study on the age of onset of pubertal characteristics and menses in US girls in 1997,1 a spate of related articles have appeared on emerging questions and controversies over recent pubertal data and the implications of these findings for clinical practice. The purpose of this commentary is to 1) summarize the consistencies and contradictions among some of these newer communications, 2) address misconceptions and misinterpretations of the PROS data, and 3) identify legitimate points of disagreement and areas for additional investigation. A survey of just some of the recent articles demonstrates the scope of additional research both in our country and abroad.2–17 The 1997 PROS study, a convenience sample of 17 077 white and black girls seen in pediatric practices across the United States and Puerto Rico used the Tanner method18 to describe the ages of onset of breast development, pubic hair growth, and menarche. It found that the mean ages for these characteristics varied significantly between white and black girls (with black girls being at younger ages), the median age of menarche for black girls had dropped over the past several decades, and the ages for the onset of development seemed to be earlier than previous US studies as well as Marshall and Tanner’s classic 1969 study.18 The PROS study pointed out that the prevalence of secondary sexual characteristics in girls <8 years old was substantially higher than what had been believed previously and “that more appropriate standards for defining delayed and precocious puberty may need to be developed, that the timing of sex education in the schools may need revision, and that the etiology and effects require further study.” The authors stated, “The findings of this study need to be confirmed … Reprint requests to (M.E.H.-G.) North Carolina Child Advocacy Institute, 311 E Edenton St, Raleigh, NC 27601. E-mail: mherman-giddens{at}unc.edu Dr Kaplowitz’s present address: Department of Endocrinology, Children’s National Medical Center, Washington, DC

Management and outcomes of care of fever in early infancy.

Fever in infants challenges clinicians in distinguishing between serious conditions, such as bacteremia or bacterial meningitis, and minor illnesses. To date, the practice patterns of office-based pediatricians in treating febrile infants and the clinical outcomes resulting from their care have not been systematically studied. To characterize the management and clinical outcomes of fever in infants, develop a clinical prediction model for the identification of bacteremia/bacterial meningitis, and compare the accuracy of various strategies. Prospective cohort study. Offices of 573 practitioners from the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics in 44 states, the District of Columbia, and Puerto Rico. Consecutive sample of 3066 infants aged 3 months or younger with temperatures of at least 38 degrees C seen by PROS practitioners from February 28, 1995, through April 25, 1998. Management strategies, illness frequency, and rates and accuracy of treating bacteremia/bacterial meningitis. The PROS clinicians hospitalized 36% of the infants, performed laboratory testing in 75%, and initially treated 57% with antibiotics. The majority (64%) were treated exclusively outside of the hospital. Bacteremia was detected in 1.8% of infants (2.4% of those tested) and bacterial meningitis in 0.5%. Well-appearing infants aged 25 days or older with fever of less than 38.6 degrees C had a rate of 0.4% for bacteremia/bacterial meningitis. Frequency of other illnesses included urinary tract infection, 5.4%; otitis media, 12.2%; upper respiratory tract infection, 25.6%; bronchiolitis, 7.8%; and gastroenteritis, 7.2%. Practitioners followed current guidelines in 42% of episodes. However, in the initial visit, they treated 61 of the 63 cases of bacteremia/bacterial meningitis with antibiotics. Neither current guidelines nor the model developed in this study performed with greater accuracy than observed practitioner management. Pediatric clinicians in the United States use individualized clinical judgment in treating febrile infants. In this study, relying on current clinical guidelines would not have improved care but would have resulted in more hospitalizations and laboratory testing.

Office-based research: A new era and new opportunities

Office-based research: A new era and new opportunities

Practitioner policies and beliefs and practice immunization rates: a study from Pediatric Research in Office Settings and the National Medical Association.

To identify vaccination policies and beliefs associated with practice immunization rates (PIR) among office-based pediatricians. Primary care pediatricians recruited from the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics or the Pediatric Section of the National Medical Association abstracted immunization data from a consecutive sample of children who were 8 to 35 months old and seen in the office for any reason; 1 provider per practice collected this information. PIR were determined at 8 and 19 months of age by calculating the percentage of children in the sample who were fully immunized at that age. Before collecting the immunization data, all practitioners in each participating practice completed a questionnaire detailing his or her policies and beliefs regarding the administration of vaccines. Part of the questionnaire was a scenario involving a 4-month-old child who was due for a diphtheria-tetanus-acellular pertussis immunization at a health supervision visit. A list of 13 possible clinical conditions in this hypothetical patient were presented; practitioners were asked which of these were a contraindication to vaccination. One set of policies and beliefs was computed for each practice using a weighted average of the responses of each provider in a particular practice. Regression analyses were used to assess the association between each policy and belief and PIR at 8 and 19 months, after controlling for potentially confounding sociodemographic characteristics. Data were analyzed from 112 practices; median PIR at 8 and 19 months were 85% and 71%, respectively. The following policies and beliefs were not statistically associated with PIR at either 8 or 19 months: use of acute visits for vaccinations, conducting an immunization audit within the previous 12 months, perceived difficulties in implementing new vaccine recommendations or staying informed about new recommendations, conducting practice meetings to discuss immunization policies, perception of profitability of providing vaccinations, appointment reminders for scheduled visits, and specific tracking mechanisms for patients who are due for or behind in immunizations. After controlling for sociodemographic characteristics, recommending inactivated poliovirus vaccine and having fewer contraindications to vaccination were associated with statistically higher PIR at 8 months and 19 months. Increasing the maximum number of injections administered at 1 visit was associated with a higher PIR at 8 months but not 19 months of age. Policies and beliefs linked to many official recommendations for increasing immunization rates were not associated with higher PIR. However, accepting fewer contraindications to vaccination, administering all vaccines for which an infant is eligible at each health supervision visit, and adopting recommended changes in immunization schedules may help providers fully vaccinate a higher percentage of their patients.

Urine testing and urinary tract infections in febrile infants seen in office settings: the Pediatric Research in Office Settings' Febrile Infant Study.

To determine the predictors and results of urine testing of young febrile infants seen in office settings. Prospective cohort study. Offices of 573 pediatric practitioners from 219 practices in the American Academy of Pediatrics Pediatric Research in Office Settings' research network. A total of 3066 infants 3 months or younger with temperatures of 38 degrees C or higher were evaluated and treated according to the judgment of their practitioners. Urine testing results, early and late urinary tract infections (UTIs), and UTIs with bacteremia. Fifty-four percent of the infants initially had urine tested, of whom 10% had a UTI. The height of the fever was associated with urine testing and a UTI among those tested (adjusted odds ratio per degree Celsius, 2.2 for both). Younger age, ill appearance, and lack of a fever source were associated with urine testing but not with a UTI, whereas lack of circumcision (adjusted odds ratio, 11.6), female sex (adjusted odds ratio, 5.4), and longer duration of fever (adjusted odds ratio, 1.8 for fever lasting > or = 24 hours) were not associated with urine testing but were associated with a UTI. Bacteremia accompanied the UTI in 10% of the patients, including 17% of those younger than 1 month. Among 807 infants not initially tested or treated with antibiotics, only 2 had a subsequent documented UTI; both did well. Practitioners order urine tests selectively, focusing on younger and more ill-appearing infants and on those without an apparent fever source. Such selective urine testing, with close follow-up, was associated with few late UTIs in this large study. Urine testing should focus particularly on uncircumcised boys, girls, the youngest and sickest infants, and those with persistent fever.

Impact of the change to inactivated poliovirus vaccine on the immunization status of young children in the United States: a study from pediatric research in office settings and the National Medical Association.

To determine whether the change from an all oral poliovirus vaccine (OPV) schedule to an inactivated poliovirus vaccine (IPV)-containing schedule has adversely affected the immunization status of young children in the United States. Immunization data were abstracted from the medical records of children 8 to 35 months old seen consecutively for any reason in the offices of practicing pediatricians who are members of the Pediatric Research in Office Settings network of the American Academy of Pediatrics or the National Medical Association. Data on up to 120 eligible children were collected in each practice between March 1998 and January 2000. Patients were classified as fully immunized at 8 months old if they had received 3 diphtheria-tetanus-pertussis, 2 Haemophilus influenzae type b, 2 hepatitis B, and 2 poliovirus vaccines. Study children who were >/=12 months of age at the time that data were collected were categorized as being fully immunized at 12 months if they had received the same vaccines before their first birthday. To assess the effect of type of poliovirus vaccines on these outcomes, study patients were classified as being in an IPV or OPV group based on the initial type of vaccine received. Logistic regression was used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) for IPV as a predictor of being fully immunized at 8 and 12 months of age, after adjusting for race/ethnicity of the patient, maternal education level, year of birth, and method of payment for vaccines. In addition, the effect of clustering of children within practices was accounted for by the use of generalized estimation equation techniques. Data were analyzed on 13 520 children from 177 practices in 42 states; 79.4% of patients were fully immunized at 8 months of age, and 88.7% of those eligible were fully immunized at 12 months of age. A total of 6910 patients (51.1%) were classified as OPV recipients, wheras 5282 (39.1%) received IPV. In addition, 1328 children (9.8%) were documented as having received poliovirus vaccine, but the particular type could not be determined. Compared with OPV recipients and after controlling for the confounding variables and the effect of clustering within practices, children in the IPV group were as likely as were OPV recipients to be fully immunized at 8 months of age (OR: 1.04; 95% CI: 0.88,1.23). At 12 months of age, the OR for IPV as a predictor of being fully immunized was 1.08 (95% CI: 0.90,1.30). When compared with OPV recipients, adjusted ORs for children in the undetermined poliovirus vaccine type group being fully immunized at 8 and 12 months of age were 0.84 (95% CI: 0.68,1.04) and 0.84 (95% CI: 0.67,1.07), respectively. The results of this national study indicate that the implementation of an IPV-containing poliovirus vaccine schedule has not had an adverse effect on the immunization status of young children who were vaccinated in the offices of practicing pediatricians.

Uninsured Children With Psychosocial Problems: Primary Care Management

Nearly 14% of children in the United States are uninsured. We compared the prevalence of psychosocial problems and mental health services received by insured and uninsured children in primary care practices. The Child Behavior Study was a cohort study conducted by Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Network. Four hundred one primary care clinicians enrolled an average sample of 55 consecutive children (4-15 years old) per clinician. Of the 13 401 visits to clinicians with 3 or more uninsured patients, 12 518 were by insured children (93.4%) and 883 were by uninsured children (6. 6%). A higher percentage of adolescents, Hispanic children, those with unmarried parents, and those with less educated parents were uninsured. According to clinicians, uninsured children and insured children had similar rates of psychosocial problems (19%) and severe psychosocial problems (2%). For children with a clinician-identified psychosocial problem, we found no differences in clinician-reported counseling, medication use, or referral to mental health professionals. Among children served in primary care practices, uninsured children have similar prevalence of clinician-identified psychosocial and mental health problems compared with insured children. Within their practices, clinicians managed uninsured children much the same way as insured children. psychosocial problems, uninsured children, pediatrics, family medicine, primary care.

Primary care treatment of pediatric psychosocial problems: A study from pediatric research in office settings and ambulatory sentinel practice network.

Psychosocial problems cause much of the morbidity among children, and their frequency of presentation in primary care is growing. How is primary care treatment of children's psychosocial problems affected by child symptoms, physician training, practice structure, insurance, physician/patient relationship, and family demographics? Questionnaire study of treatment of psychosocial problems during office visits by children. At total of 401 primary care offices from 44 US states, Puerto Rico, and Canada. From 21 150 children seen in office visits, we selected children with an identified psychosocial problem but who were not already receiving specialty mental health services (n = 2618 children). Clinicians' decisions to counsel families, to refer children to mental health specialists, or to prescribe medication. The treatment choices of primary care clinicians (PCCs) were generally independent of patients' demographics or insurance status. Clinicians' training, beliefs about mental health, and practice structure had no effect on treatment choices. However, clinicians seeing their own patients were more likely to prescribe medications for attention problems. The clinician's perception about whether the parent agreed with the treatment choice was important for every treatment modality. Counseling and referral were more common and medication was less common when a problem was newly recognized at the visit. Structural factors such as practice type, insurance coverage, and physician training were less important for treatment than were process factors, such as whether the visit was a psychosocial problem visit, whether the problem was newly or previously recognized, and whether the family and clinician were familiar with each other and in accord about treatment.

Problems in diagnosing attention and activity.

In this month's Pediatrics electronic pages is an important report by Wasserman and associates entitled “Identification of Attentional and Hyperactivity Problems in Primary Care: A Report From PROS and ASPN.” This extensive, valuable study describes how a sample of 401 primary care pediatricians and family practice physicians with a patient cohort of over 22 000 children found that 18.7% of them had behavioral difficulties and about half of these, or 9.2% of the total sample, showed evidence of attentional or hyperactivity problems (AHPs). Another main conclusion of the project was that the diagnosis was not made more frequently with children from “disadvantaged backgrounds.” This commentary explores the third principal result of the work, that “primary care assessment of AHPs lacks standardization.” A great strength of the report is the large and diverse sample of children studied. If anyone needs proof of the value of the Pediatric Research in Office Settings (PROS) Network, here it is. It makes available an enormous cohort of the general population. Instead of the generally skewed samples typically used in studies based at tertiary academic centers, the Network provides a more realistic cross section of children in the community. Questions of incidence and prevalence are among the issues that can be investigated more accurately in primary care than at referral centers.1 Another important conclusion of the report is that pediatricians can and do pick up a substantial number of behavioral problems in their practices.2 Perhaps this detection is sometimes not as thorough as it should be, but it is probably not as negligent as some nonpediatric critics have claimed.3 One need not dwell at length on the methodologic issues in the study, because every such effort has them. The fact that the physician participants were volunteers may have meant that they were not a …