Just-in-time coding of the problem list in a clinical environment.

Clinically useful problem lists are essential to the CPR. Providing a terminology that is standardized and understood by all clinicians is a major challenge. UNMC has developed a lexicon to support their problem list. Using a just-in-time coding strategy, the lexicon is maintained and extended prospectively in a dynamic clinical environment. The terms in the lexicon are mapped to ICD-9-CM, NANDA, and SNOMED International classification schemes. Currently, the lexicon contains 12,000 terms. This process of development and maintenance of the lexicon is described.

Strategies for problem list implementation in a complex clinical enterprise.

Although the Institute of Medicine states that a patient problem list should have a prominent place in the computer-based patient record, the design and function of the problem list is not a matter of universal agreement. Developer experience with implementation has been inconsistent, in part because of confusion on data standards, uncertain user acceptance of data entry, and minimal rewards for the clinician. I propose that necessary features of the problem list include: 1) clinical focus, 2) codification of problems, 3) support for problem resolution, 4) historicity of problems, 5) support for multiple clinical views, 6) integration of maintenance functions with workflow, 7) support for administrative reporting, and 8) integration with useful clinical tools. I describe the strategies that we employed to meet these goals while implementing the problem list in a computerized patient record serving a large, complex clinical enterprise. I further report the successful achievement of those goals based upon audits six months after implementation.

Childhood lead poisoning and managed care.

Childhood lead poisoning is a problem that disproportionately affects impoverished children. Many aspects of affected children's lives may be involved in the prevention and treatment of this disease. Changes in child health services are occurring in the context of fundamental changes of virtually all human services. Managed care changes may alter the sites where children get primary care services, the content of that care, and linkages of medical services to public health, nutrition support, housing, mental health, education, and social services. This article discusses the opportunities and the dangers that managed care changes may pose to the prevention and treatment of childhood lead poisoning.

Cost-effectiveness in diagnosing infantile hypertrophic pyloric stenosis.

PURPOSE: The purpose of this study was to determine which imaging study, upper gastrointestinal series (UGI) or abdominal ultrasonography (US), is more cost-effective in diagnosing infantile hypertrophic pyloric stenosis (IHPS) using a decision analysis model. METHODS: Probabilities were calculated from a review of the records of all infants less than 6 months of age referred for UGI or US to rule out IHPS over a 3-year period from January 1992 to December 1995. Cost-effectiveness was determined from hospital charges for each imaging study and its possible outcomes. RESULTS: The positive predictive value of UGI was 1.0 and US was 0.98 in the 246 infants evaluated for possible IHPS. In patients who had an initially normal study finding (UGI or US), 25% of patients undergoing US first required a second study for persistent symptoms, whereas only 6% of patients who had a negative initial UGI finding required a second study. CONCLUSIONS: Cost analysis found UGI to be more cost-effective than US because fewer secondary studies were required. UGI provides information regarding other pathological conditions as compared with US.

A comparison of screening strategies for elevated blood lead levels.

OBJECTIVE: To calculate and compare the average expected cost per child screened (hereafter referred to as COST) among various screening strategies. DESIGN: A decision analysis of 5 strategies: (1) conduct risk assessment and screen high-risk children by venipuncture, low-risk children by fingerstick; (2) screen all children by fingerstick; (3) screen all children by venipuncture; (4) conduct risk assessment, screen high-risk children by fingerstick; and (5) conduct risk assessment, screen high-risk children by venipuncture. We assumed all fingerstick blood lead levels of 0.72 mumol/L or higher (> or = 15 micrograms/dL) would be confirmed by venipuncture. Baseline variables taken from the literature included prevalence of elevated blood lead levels in the pediatric population (2%), sensitivity and specificity of fingerstick blood lead assay (90% each), specificity of risk assessment (50%), sensitivity of risk assessment at blood lead levels of 0.48 to 0.68 mumol/L (10-14 micrograms/dL) and 0.72 mumol/L or higher (> or = 15 micrograms/dL) (65% and 85%, respectively), cost of blood lead assay ($6), cost to obtain blood by venipuncture ($4) and fingerstick ($2), and cost to get a child who has a fingerstick blood lead level of 0.72 mumol/L or higher (> or = 15 micrograms/dL) to return ($0.18). Sensitivity analysis determined whether selected variables affected the COST. RESULTS: The COSTs for strategies 1 through 5 were $9.07, $8.16, $10, $4.13, and $5.04, respectively. Among the universal strategies, screening children by fingerstick had the lowest COST at a prevalence of less than 38% and fingerstick blood lead assay a specificity of greater than 62%. Among the selective strategies, screening high-risk children by fingerstick had the lowest COST at a prevalence of less than 38% and fingerstick blood lead an assay specificity of greater than 63%. CONCLUSION: At a readily attainable specificity of the fingerstick blood lead assay, practices serving a patient population with a prevalence of elevated blood lead levels of less than 38% will have the lowest COST when a fingerstick screening strategy is used.

The new CDC and AAP lead poisoning prevention recommendations: consensus versus controversy.

A considerable body of evidence has surfaced over the past several decades indicating that low-level lead exposure has detrimental effects for young children. As neurocognitive deficits have increasingly been found to be associated with lead levels as low as 10 micrograms/dL, the CDC has progressively lowered the threshold lead level designated as elevated to the present level of 10 micrograms/dL. The CDC also has recommended universal screening of all children for lead. These recommendations have engendered much controversy. After independently reviewing the relevant literature, the AAP and the National Academy of Science concurred with the CDC's conclusions and recommendations. As additional prevalence information becomes available, a more targeted approach to screening based on local prevalence data eventually may replace universal screening. However, as long as lead is found everywhere in the environment, children will continue to develop lead poisoning and suffer from its adverse effects. The problem of lead poisoning can be summarized best by a quote from a report of the Agency for Toxic Substances and Disease Registry to Congress, "Lead is toxic wherever it is found, and it is found everywhere."

Patient-specific reminder letters and pediatric well-child-care show rates.

The objective of this study was to determine whether patient-specific letters, which describe the content of an upcoming well-child appointment, improve the show rate of well-child appointments better than postcard reminders. In this prospective clinical trial conducted at a pediatric continuity clinic in a teaching hospital, 288 newborns were randomized to a letter, postcard, or control group. For every well-child appointment, families were sent either a letter pertaining to the particular well-child appointment or a postcard; the control group received no reminders. There were no differences in demographics among the groups. The show rates between the letter and postcard groups were not different, but were significantly higher than the show rate for the control group (75.0%, 73.7%, and 67.5%, respectively; P < .05). A cost comparison between the use of postcards versus not using postcards revealed a benefit in the former. We concluded postcard reminders are effective in improving show rates for well-child-care visits, and that patient-specific letters have no additional benefit above that of postcard reminders.

Immunization practices of primary care practitioners and their relation to immunization levels.

OBJECTIVES: To assess variations in immunization practices and attitudes among primary care providers and to relate these characteristics to the immunization levels of their patients. SETTING: Monroe County, New York. DESIGN: Survey of pediatricians (n = 96) and family practitioners (n = 44) to assess immunization practices and attitudes and medical chart reviews for 1884 patients of 32 physicians who practice in the city of Rochester to measure immunization levels. ANALYSIS: Tabular analyses for survey responses (chi 2 test and Fisher's Exact Test); logistic regression to assess the relation between provider responses and measured immunization levels. RESULTS: Responses by pediatricians and family practitioners were similar. Most providers did not routinely immunize during acute-illness visits but did immunize during follow-up or chronic-illness visits. Few used tracking systems to identify underimmunized children. Most practitioners immunized children who had colds but withheld immunizations from children who had fevers or otitis media. Most providers agreed with expanding immunization programs to include sick visits, health department clinic visits, and community site visits, but most thought that they should not be provided at emergency department visits, except for very-high-risk children. Immunization levels at 10 months of age were positively correlated with private practice setting (P = .001) but negatively correlated with immunizing at acute- (P < .01) or chronic-illness (P < .05) visits, Medicaid coverage (P < .05), and high rates of appointments that were not kept (P < .001). CONCLUSIONS: Primary care providers' immunization practices and attitudes vary and do not always follow established guidelines for immunization delivery. Many providers of high-risk children are already attempting to improve immunization delivery by using patient reminders and by immunizing children at acute- or chronic-illness visits. Improving provider immunization practices to deliver childhood immunizations more effectively must be part of our efforts to resolve this nation's childhood immunization problem.

The school-based immunization survey: an inexpensive tool for measuring vaccine coverage.

A school-based immunization survey was conducted among the 36 Rochester, NY, elementary schools (n = 5584 children) to determine (1) the vaccination rates at 2 years of age by type of primary care provider and (2) the accuracy of school immunization records (by comparing them with medical charts for children attending hospital-based clinics). These rates varied by provider type from 58% to 86% and were all below the national goal of 90%. In comparison with medical chart review, the school data had error rates of 15%; however, these errors occurred in both directions and were thus unbiased. School-based surveys include children who lack connections to the primary care system. With minimal effort these surveys can help identify populations in need of intervention.

Acute appendicitis in children: factors affecting morbidity.

Appendicitis is a disease that continues to be characterized by a high morbidity rate that has changed little over the past 50 years. A significant proportion of patients (39 percent in this study) still present with advanced disease (gangrene, perforation, or abscess), as determined at operation. Duration of symptoms was the factor most closely associated with advanced disease. Patients with advanced disease had 88 percent of the morbidity. Primary care physicians referred patients who had symptoms for a longer period of time and who ultimately were found to have a more advanced stage of disease compared with patients who were referred from emergency rooms. This difference did not correlate with third party insurance coverage, as both referral groups exhibited a similar profile of coverage. In this study, the number of normal appendices removed was 5 percent. Early intervention remains the most promising means to reduce morbidity, mortality, and discomfort for the child and expense to the family or insurance carrier of a child with suspected appendicitis.

Contribution of angiography to the diagnosis, staging and assessment of radiation and chemotherapy of solid abdominal malignancies in children.

Sequential angiographic studies were done in six children to stage and assess the results of radiation and/or chemotherapy of solid abdominal malignancies: one bilateral Wilms' tumor, two neuroblastomas, two hepatoblastomas and one hepatocarcinoma. Angiography was of value in demonstrating the tumor, its location, extent and vascular characteristics, as well as its regression and recurrence. Wilms' tumor and neuroblastoma responded and well to radiation and chemotherapy with substantial decrease in tumor size and regression or disappearance of tumor neovasculature. Resceted tumors revealed this to be due to tumor necrosis, hemorrhage and/or cystic degeneration. Hepatoblastoma and hepatocarcinoma did not respond as well to chemotherapy, with only mild decrease in size and neovasculature of the tumor.