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Cardiac management by pediatricians versus pediatric cardiologists in an inpatient academic center

AMERICAN HEART JOURNAL 2003年第3期145卷 424-429页

作者： Benun, J Fisher, SD Orav, EJ Schwartz, ML Exil, V Messere, C Lipschultz, SE Univ Rochester Med Ctr Div Pediat Cardiol Rochester NY 14642 USA Boston Med Ctr Dept Pediat Boston MA USA Boston Univ Sch Med Dept Pediat Boston MA 02118 USA Univ Rochester Med Ctr Dept Med Cardiol Unit Rochester NY 14642 USA Brigham & Womens Hosp Dept Med Boston MA 02115 USA Childrens Hosp Dept Cardiol Boston MA 02115 USA Harvard Univ Sch Med Dept Pediat Boston MA 02115 USA Golisano Childrens Hosp Strong Rochester NY USA Univ Rochester Sch Med & Dent Dept Pediat Rochester NY 14642 USA

Background Limited resources;managed care, and advances in technology have led to the suggestion that physicians other than cardiologists be further empowered to perform the initial cardiac evaluation in children with suspected heart disease. To study this strategy, we compared the management decisions of pediatricians with the recommendations of pediatric cardiologists who reviewed the records of the same patients. Methods Sixty-nine patients aged <23 years with suspected heart disease were referred by pediatricians (n = 40) on the inpatient service at Boston Medical Center, for either a cardiology consultation or echocardiography. Two pediatric cardiologists who were blinded to the management decisions and clinical outcomes later reviewed the patient records. Recommendations between the 2 pediatric cardiologist reviewers and the managing pediatricians were compared. Results Pediatricians scheduled significantly fewer cardiology follow-up visits, instituted cardiac medications significantly less often, arranged significantly fewer family meetings to review cardiac findings, and ordered significantly fewer additional cardiac procedures than the pediatric cardiologists. This result was consistent regardless of whether the pediatrician's management decisions were made on the basis of the echocardiogram results only or on the recommendations of a cardiology consultant. The 2 pediatric cardiologist reviewers agreed more often with each. other than either did with the managing pediatricians. Conclusions Pediatricians have different management styles than-pediatric cardiologists for patients with suspected cardiac disease. The effect of these differences on outcome is unknown, and further investigation is warranted.

关键词：医学科学研究中心心脏病学/统计学和数值数据超声心动描记术/统计学和数值数据随访研究心脏缺损先天性/诊断心脏缺损先天性/治疗心脏病/诊断心脏病/治疗心脏杂音/诊断心脏杂音/治疗住院儿科学/统计学和数值数据医师的作用职业家庭关系转诊和会诊/统计学和数值数据青少年成年人儿童儿童学龄前女(雌)性人类婴儿婴儿新生男(雄)性

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Extension of academic pediatric radiology to the community setting: experience in two sites

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PEDIATRIC RADIOLOGY 2000年第1期30卷 3-6页

作者： Ecklund, K Share, JC Childrens Hosp Dept Radiol Boston MA 02115 USA Harvard Univ Sch Med Boston MA 02115 USA

Background. Children are better served by radiologists and technical personnel trained in the care of pediatric patients. However, a variety of obstacles may limit the access of children to dedicated pediatric imaging facilities. Objective. We designed and implemented two models for providing community-based imaging by academic pediatric radiologists. Materials and methods. The first site was an outpatient clinic staffed by physicians from the university-affiliated children's hospital. Imaging services included radiography, fluoroscopy, and ultrasound. The second site was a full-service community hospital radiology department staffed by a group practice, with pediatric imaging covered by the children's hospital radiologists. Facility, equipment, and protocol modifications were required to maintain quality standards. Success of these models was determined by volume statistics, referring physician/patient satisfaction surveys, and quality-assurance (QA) programs. Results. The outpatient satellite had a 48 % increase in total examinations from the first year to the second year and 87 % the third year. Pediatric examinations in the community hospital increased over 1000 % the first 7 months. Referring physicians reported increased diagnostic information and patient satisfaction compared to previous service. QA efforts revealed improved image quality when pediatric radiologists were present, but some continuing difficulties off-hours. Conclusion. We successfully implemented pediatric imaging programs in previously underserved communities. This resulted in increased pediatric radiologist supervision and interpretation of examinations performed on children and improved referring physician and patient satisfaction.

关键词：儿童保健服务/统计学和数值数据医院社区门诊部医院儿科学/统计学和数值数据放射学/统计学和数值数据放射科医院专业医学儿童人类

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Influence of the unit of analysis on the studies of the factors of primary care resource utilization

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Gaceta sanitaria / S.E.S.P.A.S 1999年第1期13卷 53-61页

作者： Juncosa, S. Bolíbar, B. Roset, M. Martínez, C. Unitat d'Investigació Centre Institut Català de la Salut Terrassa España. Barcelona 08027 Spain

OBJECTIVE: To identify the characteristics of the patient that influence a different cost of his care, specifically, the different behaviour of these factors depending on the unit considered: encounter, episode or patient. METHODS: Observational study with the voluntary participation of 13 physicians (9 general practitioners and 4 paediatricians) and nursing staff. During 7 months all diagnoses and interventions to a sample of attended patients were gathered. The cost of care was calculated and aggregated depending on the three units, and four models of multiple lineal regression were built with the following explanatory variables: age, gender, morbidity (ambulatory diagnosis groups), comorbidity and psychosocial conditions. RESULTS: 1,868 adult patients (more than 14 years) made 11.146 consults which belong to 4,772 episodes. The 895 paediatric patients made 6,254 consults that belonged to 3,416 episodes. Morbidity is the variable that shows a major increase in all units. Overall, the capacity to explain cost variations are: 0.03 for the encounter, 0.14 for the episode and 0.44 for the patient. CONCLUSIONS: The patients variables considered in the study explain very little the resource utilization of the encounter, more the episode, and rather more the patient. Those results indicate that the assessment or comparison of the effectiveness, efficiency, or quality of the encounters will be very difficult considering only the commonly used variables to control the patient factors. The patient classification systems that group with a similar complexity that use the visits as the unit, should, consequently, consider additional variables of the process of care in contrast with the others units. This have implications in the collection and availability of the information.

关键词：门诊医疗/经济学门诊医疗/利用共病现象数据收集/方法诊断相关患者组家庭医学/统计学和数值数据卫生保健费用/统计学和数值数据卫生资源/经济学卫生资源/利用模型理论年患病率/发展趋势多元分析诊室就医/经济学诊室就医/利用病人/分类病人/心理学儿科学/统计学和数值数据初级卫生保健/经济学初级卫生保健/利用回归分析研究设计社会经济因素西班牙/流行病学青少年成年人老年人老年人 80以上儿童儿童学龄前女(雌)性人类婴儿婴儿新生男(雄)性中年人

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Paediatric intensive care

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ANAESTHESIA 1999年第12期54卷 1227-1228页

作者： Bennett, NR Stack, C Sheffield Childrens Hosp Sheffield S10 2TH S Yorkshire England

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Immunization practices and beliefs of physicians in suburban Cook County, Illinois

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JOURNAL OF COMMUNITY HEALTH 1999年第1期24卷 1-11页

作者： Smith, SW Connery, P Knudsen, K Scott, KL Frintner, MP Outlaw, G Weingart, S Cook Cty Dept Publ Hlth Div Communicable Dis Oak Pk IL 60301 USA Univ Illinois Maternal & Child Community Hlth Sci Consortium Chicago IL 60680 USA

This study was conducted to ascertain the vaccination beliefs and practices of physicians who provide care for low income children. Sixty-two (56.9%) of a sample of 109 physicians in suburban Cook County, Illinois responded to a mail survey. A majority of physicians reported a willingness to immunize during well child care, follow-up, and chronic illness visits;yet, a substantial lack of willingness to immunize given certain acute mild illnesses was reported. Twenty-six percent of providers did not routinely identify children who were behind in immunizations and only 16% had completed a chart audit in the past three years. Seventy-four percent were willing to provide all shots needed at a single visit. Misconceptions regarding true contraindications was found among the group. Missed well child visits were identified as the greatest barrier to complete immunization. Improvements in vaccination rates are expected if physicians utilize all types of medical encounters to monitor the immunization status of patients and provide vaccines using only true medical contraindications.

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Multivariate analysis of family risk factors in predicting appointment attendance in a pediatric otology and communication clinic

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Journal of Health and Social Policy 1991年第3期2卷 85-102页

作者： Kavanagh, Kevin T. Smith, Theresa R. Golden, Gerald S. Tate, Nellie P. Hinkle, William G. Developmental Disabilities and College of Allied Health University of Tennessee Memphis United States Department of Social Service University of Tennessee Knoxville United States

Parents of pediatric patients attending regional otologic medical clinics were given a questionnaire to document family risk factors predictive of poor appointment attendance, and to determine barriers which caused non-attendance of medical appointments. Family risk factors which affected clinic attendance were. studied using univariate and multivariate analyses. Univariate analyses revealed all factors except patients’ sex and family size to be correlated with attendance. However, multivariate analysis revealed that parental age (p < 0.0153), ownership of car (p < 0.0012), parental education (p < 0.0048), and age of patient (p < 0.0023) were major predictors of clinic attendance. Although ownership of a car was a major independent factor, it was highly correlated with parental age and parental education and only shown to be significant in the subset of patients not having access to public transportation. The identified parental factors which affect pediatric health care delivery underscores the importance of family centered case management in promoting the health care of children and casts doubt on the effectiveness of interventions which are solely centered on the patient or are designed to mitigate only one of these factors. © 1991, Taylor and Francis Group, LLC.

关键词：门诊医疗设施/利用病人预约和时间安排多元分析耳鼻咽喉科学/统计学和数值数据双亲病人依从儿科学/统计学和数值数据问卷调查危险社会经济因素田纳西成年人儿童学龄前人类

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Design and implementation of the North American Pediatric Cardiomyopathy Registry

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AMERICAN HEART JOURNAL 2000年第2期139卷 S86-S95页

作者： Grenier, MA Osganian, SK Cox, GF Towbin, JA Colan, SD Lurie, PR Sleeper, LA Orav, EJ Lipshultz, SE Univ Rochester Childrens Hosp Strong Rochester NY USA New England Res Inst Albany NY USA Harvard Univ Sch Med Childrens Hosp Boston MA 02115 USA Texas Childrens Hosp Baylor Coll Med Houston TX 77030 USA Albany Med Coll Albany NY 12208 USA Harvard Univ Sch Med Brigham & Womens Hosp Cambridge MA 02138 USA

The Pediatric Cardiomyopathy Registry (PCMR) was established to describe the epidemiologic features and clinical course of selected cardiomyopathies in patients aged 18 years or younger and to promote the development of etiology-specific treatments. Sixty-one private and institutional pediatric cardiomyopathy practices in the United States and Canada were recruited to participate in the PCMR. The registry consists of a prospective, population-based cohort of patients in 2 regions (New England and the Central Southwestern United States) and a retrospective cohort of patients diagnosed between 1991 and 1996. Annual follow-up data are collected on all patients. As of June 1999, the PCMR consisted of 337 prospectively identified and 990 retrospectively identified patients. The PCMR has demonstrated the feasibility of establishing a large database of sociodemographic and clinical information on children with pediatric cardiomyopathy. Through this cooperative effort, the PCMR will obtain precise estimates of the incidence of pediatric cardiomyopathy and a better understanding of the natural history of this disease.

关键词：心肌疾病/流行病学数据收集/方法可行性研究发病率北美洲/流行病学儿科学/统计学和数值数据前瞻性研究登记研究设计回顾性研究青少年儿童人类

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