Private Pediatricians Research Articles

Coordination of Care Between the Cancer Center and the Private Pediatrician's Office

Coordination of Care Between the Cancer Center and the Private Pediatrician's Office

The Influence of Provider Behavior, Parental Characteristics, and a Public Policy Initiative on the Immunization Status of Children Followed by Private Pediatricians: A Study From Pediatric Research in Office Settings

To determine the relative impact of parental characteristics, provider behavior, and the provision of free vaccines through state-sponsored vaccine volume programs (VVPs) on the immunization status of children followed by private pediatricians. Retrospective and cross-sectional surveys of immunization data. The offices of 15 private pediatricians, from 11 states, who were members of the Pediatric Research in Office Settings network. Seven of these physicians used vaccines provided through VVPs. Children 2 to 3 years old followed by the participating physicians. The immunization status of children was assessed from two separate samples. For sample 1, immunization data were abstracted from the medical records of 60 consecutive eligible children seen in each office. Parents of the selected children indicated the method of payment for immunizations and the education levels of the mothers. Because this cross-sectional survey might have oversampled frequent health care users, a retrospective chart review of up to 75 randomly selected children in each pediatrician's practice was also conducted (sample 2). Additional data were collected from the parents of children in sample 2 by telephone interviews. For both samples, patients were considered to be fully immunized if they had received four diphtheria-tetanus-pertussis/diphtheria-tetanus vaccines, three oral poliovirus/inactivated poliovirus vaccines, and one measles-mumps-rubella vaccine before their second birthdays. Before collecting vaccination data, pediatricians completed a survey detailing their immunization beliefs and practices. Logistic regression was used to identify factors that were independently associated with a child being fully immunized. For sample 1, 81.7% of the 857 children surveyed were fully immunized. Practitioner-specific immunization rates varied widely, ranging from 51% to 97%. The immunization rate of children who received vaccines provided by VVPs was similar to that of children whose immunizations were not provided by VVPs (81.2% vs 82.2%; odds ratio [OR] for a VVP as a predictor for being fully immunized, 0.94, 95% confidence interval [CI], 0.66 to 1.32). In addition, parents who paid for immunizations out of pocket were as likely to have fully immunized children as those who had little or no out-of-pocket expenditures for vaccines (OR, 1.13; 95% CI, 0.75 to 1.13). In the logistic model, only individual pediatrician and size of the metropolitan area in which the pediatrician's practice was located were significant predictors of a child's immunization status. The results from sample 2 were similar; 82.1% of the 772 surveyed patients were fully immunized. With sample 2, individual pediatrician and age of the child at the time of the survey were the only predictors of immunization status. The OR of a VVP as a predictor of a child being fully immunized was 1.37 (95% CI, 0.65 to 2.90). Individual provider behavior may be the most important determinant of the immunization status of children followed by private pediatricians. In our samples, the effect of parental characteristics was limited. State-sponsored VVPs were not associated with higher immunization rates, perhaps because cost of vaccines did not seem to be a significant barrier to immunization in this population.

A School‐Based Clinic for Elementary Schools in Phoenix, Arizona

A community hospital, a school district, and a private pediatrician's office collaborated to ensure all children enrolled in five elementary schools had access to health care services. The school nurse at each school identified children needing health care services and obtained parental consent. The school nurse referred children to a nurse practitioner who visited one school each day. School nurses and space in the nurse's office were provided by the school district. The hospital provided a nurse practitioner as well as pharmacy, radiology, laboratory, and emergency department services. The pediatrician as medical director for the program provided vision, training, and community connections, and served as collaborating physician for the nurse practitioner.

A School‐Based Clinic for Elementary Schools in Phoenix, Arizona

ABSTRACT: A community hospital, a school district, and a private pediatrician's office collaborated to ensure all children enrolled in five elementary schools had access to health care services. The school nurse at each school identified children needing health care services and obtained parental consent. The school nurse referred children to a nurse practitioner who visited one school each day. School nurses and space in the nurse's office were provided by the school district. The hospital provided a nurse practitioner as well as pharmacy, radiology, laboratory, and emergency department services. The pediatrician as medical director for the program provided vision, training, and community connections, and served as collaborating physician for the nurse practitioner.

Maternal Discipline of Young Children: Context, Belief, and Practice

This report describes maternal discipline of infants and toddlers, focusing on how the context of the misbehavior affects maternal beliefs and practices. Mothers of 1- to 4-year-old children were interviewed using a 20-minute, structured questionnaire at two practice sites: (1) an inner-city teaching hospital pediatric clinic (n = 104) and (2) a private pediatrician's office in a nearby suburban neighborhood (n = 100). Measures were constructed to assess beliefs and practices about three kinds of discipline (teaching, spanking, and removing) and about two approaches to discipline (positive or negative). We found that mothers believe significantly (p < .001) more strongly in all three kinds of discipline for dangerous misbehavior compared with annoying ones. Belief in teaching, spanking, and negative approach increase with age; belief in removing decreases (p < .001); and belief in positive approach remains stable. Belief in spanking starts earlier than belief in teaching, and belief in negative tone increases with age. Mothers seem to have better formulated beliefs about spanking and negative and positive approach to discipline than about teaching or removing. Eighty-five percent believe time-out is at times appropriate for 2 year old, but only 67% had practiced it in the past week. Belief and practice of time-out varied by the age of the child and practice site. Explaining, distracting, and praising were practiced frequently, whereas bribing was less common. Less than half (44%) reported that they had ever discussed discipline with their child's physician, although 85% thought that their physician could give good advice. There is evidence that mothers change their minds about the appropriateness of time-out as their child gets older, but beliefs about other kinds of discipline remain relatively constant. We conclude that the type of misbehavior and the age of the child affect a mother's beliefs about discipline. These findings suggest a role for pediatricians in exploring and broadening parents' concepts of discipline.

The association between parental health beliefs and immunization status among children followed by private pediatricians.

To determine the association between parental health beliefs and the immunization status of their children, parents of children seen in two private pediatric practices completed a questionnaire on attitudes about immunizations. Five components of health beliefs were surveyed: perceived benefits of immunizations, susceptibility to diseases prevented by immunizations, severity of those diseases, parental feelings of self-efficacy in promoting their child's health, and barriers to immunization. Responses to the health-beliefs statements were transformed to an ordinal scale between 1 and 6, with "6" corresponding to strongly positive feelings about immunizations. Immunization data were abstracted from practice medical records. Overall, 162/194 (83.3%) study children were fully immunized. There were no significant differences between parents of fully immunized children and those of under-immunized children in total health-beliefs score or for the benefits, susceptibility, severity, or barriers components. Self-efficacy scores were significantly higher among parents of fully immunized children (P = 0.019); however, this was largely due to differences in the subgroup of children of mothers with lower education levels. The results of this study suggest that among parents of children followed by private pediatricians, health beliefs do not significantly influence immunization status.

Are You Interested in Telephone Triage Research?

In the fall of 1993, we described our 5-year experience in providing after-hours telephone triage and advice for patients of private pediatricians in metropolitan Denver (The After-Hours Program).1 In the year since our report, we have come to recognize a rapidly growing interest in large scale programs that offer centralized after-hours pediatric telephone triage and advice provided by well-trained nurses using standardized guidelines. In the past year our program has expanded to serve approximately 165 pediatricians throughout Colorado (95% of Denver private pediatricians and 75% of Colorado private pediatricians).

Spanking Infants and Toddlers: Maternal Belief and Practice

To describe maternal beliefs and practices of spanking infants and toddlers and the relations between factors affecting these beliefs and practices. Cross-sectional survey. Site 1 was an inner-city teaching hospital pediatric clinic. Site 2 was a private pediatrician's office in a nearby suburban neighborhood. Mothers of children less than 4 years old in the waiting area. Site 1: n = 104; site 2: n = 100. Systematic sample of convenience. Mothers were interviewed using a 20-minute structured questionnaire. Measures were constructed to assess beliefs (Cronbach's alpha = .90) and practices about spanking and approach to discipline (alpha > .71). Belief in spanking correlated significantly (P < .001) with belief in negative approach (r = .52) and with the practice (r = .46) and severity (r = .34) of spanking. Nineteen percent of the mothers believed that there are times when it is appropriate to spank a child less than 1 year old, and 74% believed this about children 1 to 3 years old. Forty-two percent reported that they had spanked their own child in the past week. Mothers believed more strongly in spanking for dangerous misbehaviors than for annoying ones (P < .001). Belief in spanking and negative approach were stronger for older toddlers (P < .001). Belief in and frequency of spanking were more common at the inner-city site (P < .001). The belief in and practice of spanking are prevalent in disciplining very young children. The context of the spanking affects beliefs and practices. The finding that belief and practice of spanking are highly correlated suggests that belief rather than impulse largely explains spanking of children less than 4 years old. The high correlation between spanking and negative approach toward discipline raises questions about whether negative consequences of spanking are the result of spanking per se, the negative approach toward the child, or both.

Anticipatory Guidance for the Adolescent

Parents' opinions regarding anticipatory guidance for adolescents have not been adequately investigated. In this study, 932 parents of adolescents completed a computerized questionnaire listing 30 common psychosocial-medical concerns of adolescence. Respondents were asked how important it is for private pediatricians to discuss these topics with their teenagers during regular checkups. Ten items were rated important by > or = 90% of parents, 22 items by > or = 80%, and 29 items by > or = 66%. Heeding parents' expectations and concerns, pediatricians should incorporate discussions of psychosocial-medical issues as a meaningful component of routine adolescent health care.

Relevance of infectious diseases in a pediatric practice

According to official statistics, infectious diseases only play a minor role in German children. To test this assumption, 1685/3405 charts of a private pediatrician were randomly chosen for further evaluation. 1112/1685 children had been seen in the office during the study period, 934 of them because of an infectious disease (83%). 700/934 charts were further reviewed in a standardized fashion. Pharyngo-tonsillitis was the most frequent diagnosis (18.6%), followed by (non-obstructive) bronchitis (18.5%), infectious diseases of the skin (10.2%) and Otitis media (9.9%). Typical "childhood diseases" (measles, mumps, rubella, varicella) only played a minor role. For some diseases age-specific as well as seasonal changes in incidence could be observed. These data suggest that infectious diseases largely contribute to the morbidity in German children. Prospective epidemiological trials are needed to obtain reliable data for appropriate public health decisions.

A study of infant feeding practices in an urban Indian community

Thirty mothers, attending either a paediatric clinic at a Government hospital or a private paediatrician's surgery, both in Tirupati, Andhra Pradesh, South East India, were questioned about their infant feeding practices. A sample of milk from their child's bottle was requested and subsequently analysed for the presence of dilution. Over-dilution, defined as less than 75% of the standard concentration, was found to be common (P<.05). No significant correlations were found between the incidence of over-dilution and either family income or educational status of the mothers due to the small sample size. The study suggests the need for practical education on the reconstitution of milk feeds.

Partnership improves access, helps practice thrive

Private pediatricians and public health officials in Haywood County, N.C., may have stumbled on a cure for what has long ailed health care in the rural United States. Private and public health providers in this far western North Carolina community have developed a barrier-free, comprehensive, health care system that ensures care for its low-income population, while providing its few pediatricians with financial incentives.

Primary health care and immunisation in Iran

The Primary Health Care (PHC) network of Iran consists of a rural and an urban branch. While the rural branch presently covers a sizeable portion of the rural population, the urban PHC project is in its early stages of implementation. The Expanded Programme on Immunisation (EPI) in Iran, which started as an independent and vertical project in early 1983, is being gradually integrated into the PHC network as the latter expands. Results of the second PHC programme review of Iran shows that immunisation coverage of children has improved appreciably since the first PHC review, especially for BCG which stands at 56.3%. Complete immunisation at first birthday in the rural areas with the PHC services is 44.1%, whereas for urban areas other than Teheran it is 28.1%. While the high coverage in the rural areas is attributed to the 'active' approach and vigilance of the providers of immunisation (i.e. the community health workers and the vaccinators of the mobile teams), the higher coverage in the capital city of Teheran is attributed to the involvement of private paediatricians and the generally higher social, economic, and educational status as well as higher interest of mothers. It is noticed that the results of cluster sampling for determination of immunisation coverage in large metropolitan areas of the developing world must be interpreted with much care. The reason is that in these areas extreme fluctuations in the crude birth rate are common and therefore results tend to over-represent the attributes of the segment of population with lower birth rate. It is also argued that complete immunisation might not be the best indicator for assessing the progress of the immunisation efforts. These and other findings are discussed in detail. are discussed in detail.

Impact of rapid antigen tests for Group A streptococcal pharyngitis on physician use of antibiotics and throat cultures

Using case scenarios and an interview guided by a decision tree diagram, the clinical strategies of 150 physicians (50 private pediatricians, 50 health maintenance organization pediatricians and 50 pediatric residents) were assessed for the management of pharyngitis under three conditions: (1) no rapid antigen detection test available for diagnosing Group A streptococcal disease; (2) antigen test result available in 20 minutes; and (3) antigen test result available in 4 hours. The sensitivity of the antigen test was designated as 0.95 if the growth of rare or few Group A streptococci on throat culture was discounted and 0.82 if any growth was considered significant, and the specificity was set at 0.98. In a standardized pediatric case with a prior probability of Group A streptococcal disease of 0.58, 84% of clinicians would order a 20-minute test and 39% would order a 4-hour test. The 20-minute test would reduce throat culture use by 54%, reduce the proportion of patients exposed to antibiotics from 86% to 65% and reduce total antibiotic treatment days by 13.8%. Effects would be less pronounced for a low probability case or if results of antigen testing were not available for 4 hours. Provided a test with a documented high sensitivity and specificity were used, a rapid antigen test with results promptly available would substantially reduce throat culture use and unnecessary antibiotic exposures in children with a moderate prior probability of streptococcal disease.

Neonatologist Versus General Pediatrician

In Reply.— Dr. Scanlon's remarks are timely and appropriate. There are no easy answers to the dilemmas Dr Scanlon raises. Indeed, neonatologists commonly are available on an around-the-clock basis in the neonatal intensive care unit (NICU). This availability may well be one significant factor responsible for the decrease in neonatal mortality rates seen in recent years. The Committee on Hospital Care (COHC) of the American Academy of Pediatrics has observed in its statement that "the neonatologist is much more available to the newborn than is the private pediatrician."

Warning labels. A source of toxicity information for parents.

The Hazardous Substances Act specifies that warning labels for household products contain specific signal words. This study was designed to determine whether this warning label format provides enough information for parents to accurately assess product toxicity. One hundred forty-two parents from two different sites (community health clinic, private pediatrician's office) were asked to rate the toxicity of four common household products (Crystal Drano, Lysol Basin/Tub and Tile Cleaner, Clorox Bleach, Tempera Poster Paint) and four imaginary products based on the warning labels found on them. Parents had a fairly accurate perception of the toxicity of products and the toxicity to be anticipated based on the warning label. There was considerable variability in response for products which were less toxic or nontoxic. Confusion was noted regarding the meaning of the term nontoxic.

Home Care for the Infant with Congenital Heart Disease

Infants who have been diagnosed as having a cardiac anomaly often go home before they have their surgical repair. Their parents are understandably fearful about caring for these infants. Parents need to be adequately prepared for the task and need to establish an adequate support system. Ideally, discharge planning which include teaching the parents the skills that they will need should begin at the time of diagnosis. The overall goal for the parents is confidence and ,competency without undue anxiety or overconcern. Those involved in the care of these infants and families are usually the primary nurse or nurse specialist, the cardiologist, the social worker, the dietitian, the community health nurse, and, if possible, the private pediatrician. The nurse who has consistently cared for the infant is in the best position to establish a trust relationship with the parents and to coordinate the involvement of the other team members. In the beginning, the care plan for discharge teaching must consider the parents' needs and their anxiety level. Shock and anxiety over their baby's heart defect may block out information and instructions at first. Often, their guilt feelings have to be alleviated before they can cope successfully. Such feelings are indicated by the frequently asked question, Did we do anything to cause our baby's problem? We tell parents that the heart is

Bacterial colonization of human milk.

Because human milk is being used more and more for feeding neonates, many hospitals are struggling with the issue of culturing. The literature indicates that human milk is hardly ever sterile. Since there has been much debate concerning protocols and frequency of culturing milk specimens, we evaluated our facility's protocol, the aim of which was to assure clean collection and transportation of the mothers' milk. We studied two large sectors of patients; private and nonprivate (service). Both sectors had a similar contamination rate with the same type of organisms. Private pediatricians generally ordered more cultures per patient than did the service (nonprivate) pediatrician. We challenge the need for all these cultures, which increase the patients' cost.

674 THE ROLE OF THE PRIVATE PEDIATRICIAN IN FOLLOW-UP OF NEONATAL INTENSIVE CARE GRADUATES

Although mortality and morbidity statistics are continually improving, benefits of NICU care for the infant weighing less than 1,500 grams will be measured in long term follow-up. Compliance rates in hospital-based follow-up programs are poor due to geographic limits, financial considerations, ethnic adjustments, and poor communication. Since most births occur in the community hospital settings, and parents will gravitate to private pediatricians, it seems natural that the pediatrician be involved in the care of NICU graduates in a well-defined program. The pediatrician oftentimes has intimate knowledge of the family, its goals and attitudes. Knowledge about referral centers, financial aid, and counseling within the community point to a more direct role for the private pediatrician. An organized approach includes a program for the first and subsequent well child visits and a protocol for recording growth data, nutritional information, laboratory data, Denver Developmental Testing, psychological evaluations, auditory and visual evoked potentials, photographs, and subspecialty referrals. If the neonatologist at the tertiary center organizes this “private pediatric group”, a program can evolve which will service more physicians and patients. The pediatrician will remain interested in the total spectrum of NICU care, and will insure continuity of total care.

Hyperactivity and pediatrician diagnoses, parental ratings, specific cognitive abilities, and laboratory measures.

Children diagnosed as hyperactive and treated for hyperactivity by private pediatricians were compared to a large unselected sample of children on parental ratings of behavioral problems (Conners Symptoms Rating Questionnaire), laboratory measures (a week-long assessment of locomotion as measured by pedometers, sustained attention, selective attention, fidgeting, and aggressiveness), and 10 tests of specific cognitive abilities (verbal reasoning, spatial reasoning, memory, and perceptual speed). Test-retest reliability was obtained for all measures. The results indicated that pediatrician diagnoses of hyperactivity are related to parental ratings but not to laboratory assessments. Diagnoses by private pediatricians may include more heterogeneous and nonspecific behavioral problems than diagnoses made in most research contexts. Pediatrician diagnoses were related to deficits in specific cognitive abilities, most notably perceptual speed and verbal ability. Hyperactivity as diagnosed by private pediatricians may reflect deficits in skills necessary to pace oneself appropriately in school-related tasks. In general, these results suggest that the criteria and methods used to diagnose hyperactivity deserve greater attention.