Suburban Private Practice Research Articles

Clarifying Parents' and Pediatricians' Views of Partnership.

Given the importance of partnership in improving health care outcomes among children, there is a substantial need to understand better what partnership means to parents and physicians. The goal of this study was to develop a partnership survey that was based on parents' and pediatricians' opinions about the key concepts of partnership. Parents of patients visiting an affluent suburban private practice and a federally qualified health center, and 2 groups of pediatricians, were asked to review 61 partnership concepts and identify those they considered as being important to partnership. Parents and pediatricians from both practices agreed that 42 (68.9%) of the concepts were important to partnership. Sixteen of these concepts were dropped because they were redundant. Parents from both the suburban practice and health center identified 5 (8.2%) concepts that they believed contributed to partnership. Seven (11.5%) concepts were viewed as important to parents and pediatricians from the suburban practice but not to parents from the health center. Significant socioeconomic differences between the 2 parent groups suggested factors that explained the differences between parent groups. The 38 concepts endorsed by parents and pediatricians provided a nuanced view of partnership and formed the Parent Pediatrician Partnership Survey.

Direct Access: Factors That Affect Physical Therapist Practice in the State of Ohio

Direct access to physical therapist services is permitted by law in the majority of states and across all practice settings. Ohio enacted such legislation in 2004; however, it was unknown how direct access had affected actual clinical practice. The purpose of this study was to describe physical therapist and physical therapist practice environment factors that affect direct access practice. A 2-phase, mixed-method descriptive study was conducted. In the first phase, focus group interviews with 32 purposively selected physical therapists were completed, which resulted in 8 themes for an electronically distributed questionnaire. In the second phase, survey questionnaires were distributed to physical therapists with an e-mail address on file with the Ohio licensing board. An adjusted return rate of 23% was achieved. Data were analyzed for descriptive statistics. A constant comparative method assessed open-ended questions for common themes and patterns. Thirty-one percent of the respondents reported using direct access in physical therapist practice; however, 80% reported they would practice direct access if provided the opportunity. Physical therapists who practiced direct access were more likely to be in practice 6 years or more and hold advanced degrees beyond the entry level, were American Physical Therapy Association members, and had supportive management and organizational practice policies. The direct access physical therapist practice was generally a locally owned suburban private practice or a school-based clinic that saw approximately 6% to 10% of its patients by direct access. The majority of patients treated were adults with musculoskeletal or neuromuscular impairments. Nonresponse from e-mail may be associated with sample frame bias. Implementation of a direct access physical therapist practice model is evident in Ohio. Factors related to reimbursement and organizational policy appear to impede the process.

Otolaryngologic Community-Acquired MRSA Infections in a Suburban Private Practice

A retrospective review was conducted of all cases of head and neck community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections seen in the senior author's suburban private practice during a 12-month period. An office and hospital chart review was performed for all patients identified with culture-positive CA-MRSA infections. Several parameters were evaluated, including site of infection, prior therapy, imaging, comorbid disease, culture and sensitivities, surgical and medical management, and long-term results. Of the 10 patients identified, 3 had infections of nasal soft tissues, 3 had infections of the lips, 2 had infections of the paranasal sinus, 1 had an infection of the chin, and 1 had a diffuse, hemifacial infection. All patients were managed successfully with a combination of surgical drainage, wound care, and antibiotics. CA-MRSA is a burgeoning problem in otolaryngology. Appropriate management-including early recognition, appropriate empirical therapy, prompt and thorough surgical drainage with culture and sensitivities, correct antibiotic choice, and meticulous postoperative care-appears to offer excellent results.

Motivations and future plans of Canadian orthodontic residents

Our purposes were to investigate factors influencing career choice and to identify future plans of Canadian orthodontic residents. All orthodontic residents in the 5 Canadian residency training programs were invited to complete an anonymous online survey in November 2006. Data were categorized by demographic variables, and basic statistics including chi-square comparative analyses were performed. Forty-four of the 54 residents in Canada (81.48%) completed the survey. "Intellectual stimulation/challenge" emerged as the most important factor (40%) influencing the decision to pursue specialty training in orthodontics, followed by a "passion for orthodontics" (29%). The decision to become an orthodontist was made by 42% of respondents while they were in dental school; 33% had decided after completing dental school, and 24% had already decided before starting their dental school studies. Most residents (82%) planned to work in a private practice environment. Only 2 (4.5%) indicated that they will most likely practice primarily in an academic setting. Eighty percent said that they will use self-ligating brackets in private practice, and almost 80% said they will use Invisalign (Align Technology, Santa Clara, Calif). A total of 55% indicated that orthodontic residents should be required to undertake research leading to a masters of science degree as part of their orthodontic program. A total of 77% thought that a 24- to 30-month program was too short to adequately prepare them for private practice. Intellectual stimulation was the major attraction of most applicants to orthodontic programs, and the decision to become an orthodontist was normally made during dental school or even earlier. Most residents intended to enter an urban or suburban private practice after graduation, with few considering academic career choices. Modern techniques such as self-ligating brackets and Invisalign are expected to be popular among future orthodontists in Canada.

Multiresistant Pneumococci in Otitis Media

Multiresistant Pneumococci in Otitis Media

Pediatric Norms for Assessment of Upper Venous Post-Thrombotic Syndrome.

Local collateral vessel formation, increased arm circumference, and upper extremity pain are the most frequently used clinical criteria for upper venous system post-thrombotic syndrome (PTS), a potentially serious complication of central venous catheter-related deep venous thrombosis. However, norms for variation of arm circumferences and vessel prominence have not been established for either children or adults. The objective of this study was to define average arm circumference differences and upper body vein prominence in normal children. Healthy children were recruited for the study at both an inner city continuity care clinic and a suburban private practice office. Efforts were made to include age and race/ethnicity distributions similar to the US population. Children with serious medical conditions or history of central venous catheter use were excluded. After permission was obtained from a parent or guardian, bilateral upper arm circumferences were measured, and data were collected regarding hand dominance, race/ethnicity, gender, age, height, weight, and history of chronic or intermittent arm pain. To evaluate the superficial veins, we developed and utilized an objective 5-point scale of chest, upper arm, neck, and shoulder vein prominence. Two hundred fifteen normal children (age 3–18 yrs, median 7 yrs; 53% female; 47% Caucasian, 21% African American, 26% Hispanic, 6% Asian) were evaluated. The mean variation between arm circumferences was 0.4 ± 0.03 cm (mean± SEM, 95% CI 0.35–0.46), and the mean percent difference between arms was 1.93 ± 0.1% (95% CI 1.7%–2.2%). There was no correlation of arm circumference measurements with age, gender, race/ethnicity, handedness, or body mass index. Of the 215 children examined, 47 (22%) had veins that were more than minimally visible (grade ≥ 2), with 54% of those demonstrating asymmetry in vessel prominence. Race/ethnicity did influence vessel prominence (p = 0.02), with an apparent correlation between vessel prominence and skin pigmentation. Twenty-eight percent of Caucasian and 27% of Hispanic children had veins that were more than minimally visible, while only 9% of African American and 7% of Asian children had veins that were more than minimally visible. There was no correlation between vessel prominence and age, gender, handedness, or body mass index. Although a history of arm pain was reported by 29 children (13%), it was rarely validated by parents. Almost all reports of arm pain were easily explained as muscle strain, sprains, broken bones, or “sleeping wrong,” and only 1 child had parentally confirmed pain of unexplained etiology. In conclusion, arm circumference variation, reports of pain, and prominent superficial veins on the chest wall, neck, shoulder, or arm are encountered frequently in normal children. Caution should be used when applying these criteria for a diagnosis of upper venous system PTS in children with prior or current central venous catheters in place. These data should be employed to develop and validate a scale for more objective diagnosis of PTS.

Children's violent television viewing: are parents monitoring?

Violent media exposure has been associated with aggressive behavior, and it has been suggested that child health professionals counsel families on limiting exposure. Effective violence prevention counseling requires an understanding of norms regarding parental attitudes, practices, and influencing factors. Both theories of reasoned action and planned behavior emphasize that subjective norms and attitudes affect people's perceptions and intended behavior. Few data exist on violent television viewing and monitoring from a cross-section of families. By understanding the spectrum of parental attitudes, community-sensitive interventions for violence prevention can be developed. The objective of this study was to assess attitudes about and monitoring of violent television viewing from the perspective of parents. An anonymous self-report assisted survey was administered to a convenience sample of parents/guardians who visited child health providers at 3 sites: an urban children's hospital clinic, an urban managed care clinic, and a suburban private practice. The parent questionnaire included questions on child-rearing attitudes and practices and sociodemographic information. A total of 1004 adults who accompanied children for health visits were recruited for the study; 922 surveys were completed (participation rate: 92%). A total of 830 (90%) respondents were parents and had complete child data. Of the 830 respondents, 677 had questions on television viewing included in the survey and were the focus of this analysis. Seventy-five percent of families reported that their youngest child watched television. Of these, 53% reported always limiting violent television viewing, although 73% believed that their children viewed television violence at least 1 time a week. Among television viewers, 81% reported usually or always limiting viewing of sexual content on television and 45% reported usually or always watching television with their youngest child. Among children who watched television, parents reported that they spent an average of 2.6 hours per day watching television. Limitation of television violence was associated with female parents and younger children. There was variability in attitudes and practices regarding television violence viewing and monitoring among parents. Attitudes and practices varied on the basis of the age of the child and the gender of the parent.

Comparison of laparoscopic-assisted vaginal hysterectomy with traditional hysterectomy for cost-effectiveness to employers

Objective The purpose of this study was to compare the cost-effectiveness of laparoscopic-assisted vaginal hysterectomy to traditional total abdominal hysterectomy and total vaginal hysterectomy with regard not only to direct hospital costs but also to indirect costs. Study design This was a combined retrospective cohort study (Canadian Task Force classification II-2) that was conducted in a suburban private practice. The cases of 268 patients who underwent hysterectomies over a 27-month period were analyzed to include clinical outcomes, direct hospital costs, and indirect costs (time to return to normal function, time to return to work, and time away from work required by other family members). Results For all patients, length of hospital stay and time of return to normal function were shorter for laparoscopic-assisted vaginal hysterectomy than for total abdominal hysterectomy and total vaginal hysterectomy. For working patients, time to return to work and time off for working family members were all significantly shorter after laparoscopic-assisted vaginal hysterectomy when compared with both total abdominal hysterectomy and total vaginal hysterectomy. Operating times were similar for total abdominal hysterectomy and laparoscopic-assisted vaginal hysterectomy, and complications were greater for total abdominal hysterectomy. In a comparison of all procedures, direct hospital costs were greatest for laparoscopic-assisted vaginal hysterectomy and least for total vaginal hysterectomy. Conclusion For most patients, laparoscopic-assisted vaginal hysterectomy provides a minimally invasive way to accomplish a hysterectomy with a lower cost to employers (payers) on the basis of lost work hours.

Community norms on toy guns.

Toy gun play has been associated with aggressive behavior, and it has been suggested that child health professionals counsel families on limiting exposure. Effective violence prevention counseling requires an understanding of norms regarding parental attitudes, practices, and influencing factors. Both theories of reasoned action and planned behavior emphasize that subjective norms and attitudes affect people's perceptions and intended behavior. Few normative data exist on this issue from a cross-section of families. By establishing behavioral norms and understanding the spectrum of parental attitudes, community-sensitive and community-specific interventions for violence prevention can be developed. The objective of this study was to assess community norms on the topic of toy gun play from the perspective of parents. An anonymous self-report assisted survey was administered to a convenience sample of parents/guardians who visited child health providers at 3 sites: an urban children's hospital clinic, an urban managed care clinic, and a suburban private practice. The parent questionnaire included questions on child rearing attitudes, practice, and sociodemographic information. A total of 1004 eligible participants were recruited for the study; 922 surveys were completed (participation rate 92%). The 830 (90%) respondents who were parents and had complete child data were the focus of additional analysis. Regarding toy guns, 67% of parents believed that it was never "OK for a child to play with toy guns," and 66% stated that they never let their children play with toy guns. Parents who thought that it was okay for children to play with toy guns and allowed them to play with toy guns were more likely to be male parents, have male children, and be white. There is variability in norms regarding toy gun play among parents, with most discouraging toy gun play. Norms varied based on gender of the child, gender of the parent, and race. Understanding norms is a first step in designing effective community-sensitive interventions.

Chlamydia trachomatis (CT) testing practices in a commercially insured population.

Objective: Little data is available on the prevalence of CT in commercially insured female populations. However, it is assumed that the infection is significantly underdiagnosed in this group. A major factor in the underdiagnosis of infection is inadequate behavioral and sexual risk factor ascertainment by clinicians and, possibly, the failure to test patients considered to be high-risk for infection. The purpose of this study is to examine the prevalence of CT testing in a commercially insured female population and to examine factors that may be associated with testing. Design: A retrospective chart review. Materials/Methods: Medical records of 600 commercially insured women ages 15–25 presenting for ambulatory obstetrical and gynecological care to a suburban private practice were reviewed. Information on demographic, reproductive, sexual, and contraceptive practices, as well as risk status for STDs was collected. Patients considered at high-risk for CT infection were those with any of the following characteristics: sexually active women <20 years of age, new or multiple sexual partners in the past 12 months, past history or treatment of a STD, past or current partner with a history of a STD, non-use of condoms, or presenting complaint suggestive of pelvic infection. These risk factors are part of the screening guidelines of the Centers for Disease Control and Prevention (CDC) or the American College of Obstetricians and Gynecologists (ACOG). Univariate and multivariate logistic regression analysis, and chi-square tests were performed to summarize data. Results: The overall rate of testing was 82 of 600 patients (13.6%). Risk factors for CT infection were documented in 165 patients (27.5%), of whom 51 (30.9%) were tested. High-risk women were more likely to be tested than women without documented risk factors (OR = 5.8, p < .0001). Specific risk factors associated with CT testing were: male gender of physician (OR = 2.7, p = .0005), problem-related visit type as compared to routine/annual examinations (OR = 2.8, p = .002), prior pregnancy (OR = 2.3, p = .0007), presenting complaints suggestive of pelvic infection (OR = 9.9, p < .0001), sexual activity in the past 12 months (OR = 12.3, p = <.0001), new sexual partner in past 12 months (OR = 8.8, p = .006), history of STD in past 12 months (OR = 4.1, p = .0007), and sexual activity in women <20 years of age (OR = 4.8, p < .0001). Thirty-six percent of sexually active women <20 years of age were tested as compared to 22% of the entire sexually active study group. The estimated prevalence of infection was 4.9% (4 out of 82 patients) in the study population. Among the 4 patients with positive tests, all had at least one established risk factor for CT. Conclusions: The overall rate of CT testing among commercially insured women is low (13.6%). Although the rate of testing is higher among patients with identified risk factors (31%), testing practices fail to conform to established screening guidelines. The underlying reasons for the failure to test patients identified as high-risk requires further investigation. Supported by: Texas Department of Health.

Vaccine Information Pamphlets: More Information Than Parents Want?

To assess the information needs of parents regarding childhood immunizations, and their satisfaction with the Vaccine Information Pamphlets (VIPs). Verbally administered, forced-choice survey of a representative sample. Urban teaching hospital-primary care center (N = 73), neighborhood health center (N = 75), and a suburban private practice (N = 75). Parents or guardians of children scheduled for routine checkups, aged 1 month to 18 years, presenting for routine health care maintenance visits. Of 227 parents, 223 completed the survey. Almost all (98%) had prior experience with their children's immunizations, and 7% reported a history of a "bad" experience. Most parents stated that it was "very important" to receive information about immunizations regarding: diseases prevented by the immunizations (89%); common side effects (91%); serious side effects (89%); contraindications (91%). Eighty percent of parents indicated they wanted immunization information discussed with each vaccination. Forty-three percent of the parents were familiar with the VIPs; of these, 88% reported that the amount of information was "just right," and 94% thought the VIPs were helpful. However, 29% thought the VIPs were either too long, or somewhat too long. Parents indicate that they want information about many aspects of immunizations, and those familiar with the VIPs report high levels of satisfaction with the pamphlets.

Contraceptive compliance with a triphasic and a monophasic norethindrone-containing oral contraceptive pill in a private adolescent practice

Study Objective: This study was undertaken to assess the impact of a monophasic and triphasic norethin-drone-containing oral contraceptive pill on reported side effects and compliance. Design: Adolescents initiating oral contraceptive use were studied at baseline, 3 months and 12 months, to determine compliance and side effects associated with the use of two oral contraceptive pills. Setting: A suburban private practice of adolescent medicine. Participants: Ninety-nine sexually active adolescent and young adult women were sequentially entered into the study (49 initiating a monophasic pill and 50 a triphasic pill). Outcome Measurements: Compliance with oral contraceptive use at 3 and 12 months was determined for adolescents and young adult women initiating the use of two oral contraceptive pills. Demographic data, sexual history, career goals, and concerns about use were collected before use. Compliance and side effects experienced were determined at 3 and 12 months. Results: There was no significant difference in compliance in the use of the two oral contraceptives at 3 and 12 months of follow-up. At 3 months, there was no difference in reported side effects, but at 12 months, patients taking the triphasic norethindrone pill were more likely to experience breakthrough bleeding than those taking the monophasic pill ( p = 0.001) and to change pills. Despite the common fear among adolescents of weight gain associated with oral contraceptive pill use, mean weight change at 3 months was not different between the two pills and was 0.59 and 0.55 kg for the monophasic and triphasic pill at 3 months and 1.00 kg and 1.24 kg for the monophasic and triphasic pills at 12 months. “Perceived” rather than actual weight gain led to discontinuation of the pill. Conclusion: Adolescents experienced more side effects on the triphasic than the monophasic norethindrone-containing pill but compliance was the same. Weight issues and breakthrough bleeding need to be addressed in suburban practices.

Adolescents' Compliance With the Use of Oral Contraceptives

To elucidate the factors that might influence compliance with oral contraceptive use among sexually active adolescents, we undertook a study of 209 unmarried adolescents initiating use of oral contraceptives in three different settings: an inner-city adolescent clinic, a birth control clinic in a midsized industrial city, and a suburban private practice. At the three-month follow-up visit, factors associated with compliance included older age, suburban residence, white race, health care in the suburban private practice, payment status, prior use of contraception, mother's unawareness of oral contraceptives, married parents, older boyfriend, lack of worry about being pregnant, and satisfaction with pill use. Compliance at long-term follow-up (13.5 +/- 3.7 months) was additionally associated with educational goals, father's education level, and absence of side effects. Ten pregnancies occurred during the study period among noncompliant site I patients. Inner-city clinic patients were at high risk of noncompliance and unplanned pregnancy.

Proportional changes in caries patterns from early to late primary dentition.

A tooth-oriented caries measure has limitations in depicting the caries experience in the primary dentition for a population. Caries patterns based on the child have been presented previously and quantified. The purpose of this study was to explore proportional changes in caries patterns of the primary dentition in two populations. Graphic representation is suggested in developing a model. Children two to five years of age were examined in a city pediatric dental clinic and in a suburban private practice and were categorized as caries-free or as having one of the following etiology-oriented caries experiences associated with lesion sites: Fissures, Hypoplasia, Facial-Lingual, Molar-Approximal, or Facial Lingual/Molar-Approximal. Over 85 percent of children aged 2.5 years or younger were either caries-free or fit the Facial-Lingual category consistent with descriptions of "nursing caries." Trends explored in this study would not be evident using an average for a tooth-oriented caries measure.

Observation, history, and physical examination in diagnosis of serious illnesses in febrile children ≤24 months

To determine if observational assessment performed in a systematic manner adds to the efficacy of the traditional history and physical examination in detecting serious illnesses in febrile children, and to determine the sensitivity of the combined evaluation, we studied consecutive patients less than or equal to 24 months of age seen for evaluation of fever at the Primary Care Center-Emergency Room (PCC-ER) of the Yale-New Haven Hospital (n = 143) and a suburban private practice (n = 207). An attending pediatrician performed the observation using the previously reported Acute Illness Observation Scales (AIOS). Subsequently, the history and physical examination were done by an attending pediatrician, and findings were scored as to whether they suggested the presence of a serious illness. Thirty-six patients, 28 in the PCC-ER and eight in the private practice, had a serious illness. The combined AIOS, history, and physical examination had a higher sensitivity and r correlation for serious illness than did the traditional history and physical examination. Three children with serious illnesses, all of whom had no abnormalities on history and physical examination, were identified only by use of AIOS. We conclude that assessment of appearance in a child with fever, when performed in a careful, integrated, stepwise fashion, improves the sensitivity of the history and physical examination in detecting serious illnesses in febrile children.

Supernumerary mandibular premolars: report of cases

Six cases, totaling seven supernumerary mandibular premolars, were seen in a sample population of 4,000 patient records. Four were from a suburban private practice sample of 2,000, the others from a similar group randomly drawn from an urban dental school. Five of seven appeared on the left side, six of seven were impacted or erupted ectopically. Only one patient was female. Four were of Spanish or Hispanic descent, one was white and one was black. The only other supernumerary teeth seen in the population sampled were two paramolars and one mesiodens. The recommended course of treatment is extraction of the supernumerary teeth, unless they may be useful for orthodontic purposes or if the surgery would be unjustifiably hazardous to adjacent structures. Complications could result in resorption of other teeth, malocclusion, and possible cystic degeneration and ameloblastoma formation.

6 CONTRACEPTIVE COMPLIANCE IN THE PRIVATE SECTOR

Erratic contraceptive usage is a major factor in teenage pregnancy. Many studies have addressed the predictors of non-compliance in the use of oral contraceptives in adolescent clinics. This study was designed to focus on the previously ignored private sector, examining their contraceptive behaviors and predictors of their compliance. Patients from a suburban private practice of adolescent medicine were compared to the adolescent clinic population of The Children's Hospital. Profiles commonly associated with contraceptive compliance were recorded at the initial and return visits. Study subjects were randomly assigned to 2 groups receiving either simplified or detailed instructions on pill usage and management of bleeding and amenorrhea. All patients were provided 3 packs of Norinyl 1+35 and scheduled for a 3 month return visit. 51 private and 60 clinic patients (15–22 yrs) were studied. Of the private patients 42 made their own appointments, 29 without parental knowledge; 77% were sexually active before first-visit, 30% having never used contraception. 82% of private and 47% of clinic patients returned at 3 months. Prior completion of a course of antibiotics did not predict O.C. compliance. The type of instruction (simplified vs. detailed) did not affect pill usage (p=.10). The many epidemiologic factors associated with receiving health care in the private sector were major determinants of compliance (p<.001).

Comprehensive outpatient respiratory care: a program conducted in a suburban private practice.

ABSTRACT: ABSTRACT: Fifty‐nine patients (ages, 51–58) with chronic obstructive pulmonary disease took part for nine months in a comprehensive outpatient respiratory program that involved training in various factors of daily living but stressed retraining in breathing, airway hygiene and respiratory efficiency. The patients were followed closely by means of pulmonary function and other tests. Subjectively, 55 patients noted functional improvement and an increased feeling of well‐being. Objectively, 49 patients showed increased endurance and physical capacity. In 7 cases, pulmonary function tests showed an improvement of 30 per cent or more. In general, there was a significant increase in walking distance, chest expansion and body hydration, and a reduction in the use of corticosteroids and the rate of hospital admissions. These results indicate the desirability of having such a program available in every community to patients with chronic obstructive pulmonary disease.