The challenge of tetradic relationships in medically interpreted pediatric primary care visits: A descriptive study of communication practices.

OBJECTIVE: To examine spoken interactions between pediatricians and community-based interpreters speaking with adolescents and parents with Limited English proficiency (LEP) in primary care to identify the challenges of interpreting in a four-person or tetradic visit, its sources of co-constructed errors, and specific practices for educational intervention. METHODS: As part of a larger study of vaccine decision-making at six clinical sites in two states, this descriptive study used discourse analysis to examine 20 routine primary care visits in a Latino Clinic in interactions between adolescents, parents, community-based interpreters, and pediatricians. Specific patterns of communication practices were identified that contributed to inaccuracies in medical interpretation RESULTS: Practices needing improvement were tallied for simple frequencies and included: omissions; false fluency; substitutions; editorializing; added clarification, information, or questions; medical terminology; extra explanation to mother; and, cultural additions. Of these speaking practices, omissions were the most common (123 out of 292 total) and the most affected by pediatricians. CONCLUSION: The dynamics of both pediatricians and interpreters contributed to identification of areas for improvement, with more adolescent participation in bilingual than monolingual visits. PRACTICE IMPLICATIONS: These observations provide opportunities for mapping a communication skills training intervention based on observations for future testing of an evidence-based curriculum.

Comparison of continuity in a resident versus private practice.

BACKGROUND: There is widespread agreement among pediatric educators that continuity (following a panel of patients on a first contact basis for all their health care) is an important part of the education of pediatricians. OBJECTIVE: To measure continuity in a pediatric residency practice and to compare this continuity with 2 nearby private general pediatric group practices. We also examined measures of continuity suggested in the literature. DESIGN: Visit data were obtained from the practice billing system for a resident continuity practice and 2 nearby private practices for the 3-year period from July 1, 1992, to June 30, 1995. Visit data used were restricted to patients seen in the office of the practices during regular office hours. Continuity was measured using 5 different indices: 1) the usual provider of care index, visits by the usual clinician/total visits, 2) continuity for patient, the average proportion of visits that an individual patient was seen by his or her own physician, 3) continuity for physician (PHY), the average proportion of visits that an individual physician saw his or her own patients, 4) Continuity of Care Index (COC), and 5) the Modified, Modified Continuity Index. During the period examined, pediatric residents were present in the continuity practice for 1 half-day each week. The resident continuity practice (RCP) had 57 residents and saw 3386 patients for 18 955 visits. Private practice 1 (PP1) had 4 pediatricians who saw 4968 patients for 33 537 visits. Private practice 2 (PP2) had 5 pediatricians who saw 11 953 patients for 75 778 visits. RESULTS: For all visit types, continuity in the RCP was not as high as in the private practices, PHY-RCP versus PP1, PP2; 53% versus 70%, 77%. However, continuity in RCP was greater than 50% for all measures except the COC index, which precipitously decreases as the number of clinicians seen increases. Examining continuity for health maintenance visits (PHY-RCP, PP2 vs PP1; 96%, 96% vs 82%) RCP was equal to the best of the private practices. The percentage of patients not seen for a health maintenance visit during the study period was lowest in the resident practice (RCP/PP1/PP2, 15/22/30). CONCLUSIONS: Although continuity for all visits in this RCP was less than in private practice, it was surprisingly high, considering the limited time residents spend in clinic. In a particularly important area for continuity, health maintenance visits, continuity was identical to one and superior to the other private practice.

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.

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Randomized multicenter trial documenting the efficacy and safety of a lactose-free and a lactose-containing formula for term infants.

OBJECTIVE: To evaluate the efficacy and safety of a new lactose-free infant formula. DESIGN: Randomized, prospective, double-blind, controlled, outpatient, multicenter, parallel 12-week trial. SETTING: Ambulatory-care facilities of the participating centers. SUBJECTS: 137 healthy term infants (approximately 7 days old at the time of study enrollment). INTERVENTION: Healthy term infants, whose mothers had decided not to breast-feed, were randomly assigned 1 of the 2 study formulas. MAIN OUTCOME MEASURES: Weight, length, and occipitofrontal circumference measurements were obtained at baseline and when the infant was 2, 4, 8, and 12 weeks old. Formula acceptance and tolerance were also assessed at weeks 2, 4, 8, and 12. Serum albumin concentration, creatirune level, and blood urea nitrogen were determined at baseline and week 12. Adverse events were assessed throughout the study. STATISTICAL ANALYSES PERFORMED: Each baseline anthropometric and laboratory variable was analyzed for comparability between groups using the Student t test and was also analyzed using a repeated-measures analysis of variance method. Covariance analysis was applied to the final laboratory data using the respective baseline data as covariates. Decisions about equality of mean responses to formula effects were based on the .05 level of significance in all cases. RESULTS: One hundred four infants completed the study. No significant differences between the 2 formula groups were noted for any of the growth and blood parameters. APPLICATIONS: This new formula is an effective and safe lactose-free nutrition alternative for infants who require such a diet.

Children's immunizations: the gap between parents and providers.

Children's immunizations have been a part of our health care practice for many years. While immunizations have reached record highs in recent years, there is a fear that complacency may cause a drop in immunization rates and thus increases in disease rates. This study explored immunizations from two perspectives. First, focus groups with parents examined immunization information acquisition, practices, and barriers. Next, a physician survey examined immunization provider perceptions of parents' information acquisition, barriers and immunization practices. Several gaps were discovered between these two groups controlling the immunization of our children. Suggestions are made as to possible paths to begin addressing these gaps in order to increase immunization rates.

Recent changes in residency requirements for pediatrics: who agrees?

The purposes of this study were to determine the opinion of private and academic pediatricians about changes in pediatric residency requirements proposed by the Residency Review Committee (RRC) in October 1994 and to compare the results with the requirements finalized in February 1996 and implemented in February 1997. Surveys were mailed to all Fellows of the American Academy of Pediatrics in South Carolina. Those surveyed were asked to agree or disagree with 57 proposed changes. The level of agreement among all groups of pediatricians was very high; however there were significant differences between groups of pediatricians. Many controversial items were modified or deleted in the final version.

Evaluation of bivalent live attenuated influenza A vaccines in children 2 months to 3 years of age: safety, immunogenicity and dose-response.

1126 children, 2 months to 3 years old, received a single intranasal dose of 10(4), 10(6), or 10(7) TCID50 of cold adapted (ca) A/Kawasaki/9/86 (H1N1) and A/Beijing/352/89 (H3N2) or placebo, in a double blind, placebo-controlled, safety and immunogenicity trial. No reactogenicity attributable to vaccine was demonstrated. A single bivalent 10(6) or 10(7) dose produced high rates of seroconversion to H1N1 (77%) and H3N2 (92%) in seronegative children > 6 months old; serologic responses were lower to H1N1 (P < 0.001) and H3N2 (P = 0.01) in younger infants. A single 10(6) dose of bivalent ca influenza A vaccine can be immunogenic in children, but response is age dependent.

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.

OBJECTIVES: 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. STUDY DESIGN: Retrospective and cross-sectional surveys of immunization data. SETTING: 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. PATIENTS: Children 2 to 3 years old followed by the participating physicians. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Prenatal care and infant lead exposure.

OBJECTIVE: The objective of the study was to determine the relation between prenatal care of mothers and blood lead concentrations in their offspring in the first year of life. METHODS: A retrospective survey was conducted of 200 predominantly black infants between the ages of 6 and 22 months (mean age, 13.4 months). The infants had been screened for the first time since birth at the Charleston County (South Carolina) Health Department. They resided in a neighborhood with the highest prevalence of lead poisoning in Charleston. Prenatal care use data were obtained after matching birth records with lead-screening records. RESULTS: Seventy-three infants (37%) had blood lead levels 0.48 micromol/L (> or = 10 microg/dl) or higher. Adequacy of prenatal care, defined by the Modified Kessner Index, showed 11% with intensive care (26% of these with high lead levels), 39% with adequate care (35% high blood lead levels), 35% with intermediate care (40% with high blood lead levels), 13% with inadequate care (42% with high blood lead levels), and 2% with no prenatal care (25% with high blood lead levels). With the exception of the small group with no prenatal care (n = 4), the proportion of infants with a high blood lead level was inversely proportional to the level of care. The logistic regression model that best fit the data included age at screen for lead and birth weight. Low birth weight babies (<2500 gm) were more likely to have a high blood lead level at primary screen than babies who were heavier at birth (odds ratio, 2.60; p = 0.04), and the older the baby at screening, the greater the likelihood of a high blood lead level (odds ratio, 1.23; p = 0.01). There was a trend for black infants to have a high blood lead level more often than white infants (odds ratio, 3.05; p = 0.06). CONCLUSIONS: Less than adequate use of prenatal care may reflect an increase in risk factors contributing to lead exposure in infancy. Low birth weight also was related to high blood lead levels. Further studies are required to differentiate among several hypotheses for this effect. Intrauterine lead exposure, which is known to reduce birth weight, may contribute to measured blood lead levels at first screen. Alternatively, low birth weight may increase lead absorption and retention in infancy or may increase risk of lead exposure.

Methodological issues in determining rates of childhood immunization in office practice. A study from pediatric research in office settings (PROS).

OBJECTIVE: To compare 3 methods for measuring pediatric office immunization rates. DESIGN: Retrospective and prospective cross-sectional surveys. PATIENTS: Children 2 and 3 years old from 15 pediatric practices in 11 states. METHODS: Immunization rates were determined for each practice using 3 methods. The Consecutive method used data from the practice's medical records of patients seen consecutively in the office; the Chart method used data from randomly selected practice medical records; and the Active method (reference standard) used a combination of medical record data with a telephone interview to collect additional immunization data and current patient status, using data only on current patients. Analyses were based on a mean of 57, 62, and 51 (Consecutive, Chart, and Active method, respectively) patients per practice. Patients were considered fully immunized if they had received 4 doses of DTP/DT vaccine, 3 doses of OPV/IPV, and 1 dose of MMR vaccine by their second birthday Comparisons were made using the paired t test. RESULTS: The mean immunization rate by method was Consecutive, 81.5% (range, 51%-97%); Chart, 71.6% (range, 42%-94%); and Active, 79.6% (range, 53%-96%). Within a given practice, the differences between methods varied considerably (0 to 28 percentage points). The mean difference from the reference standard Active method was 8 percentage points (P < .001) for the Chart method and -1.9 percentage points (P = .36) for the Consecutive method. The largest difference was between the Consecutive and Chart methods (mean difference, 9.9 percentage points; P = .003). Practitioners uniformly found the Consecutive method easiest to implement. CONCLUSIONS: Practice-specific immunization rates are one of the few objective measures of the quality of preventive pediatric care. Pediatric practices monitoring their immunization rates should consider using the Consecutive method, a simple, acceptable, and valid measure of practice immunization rate.

Effect of topical adrenergic decongestants on middle ear pressure in infants with common colds.

BACKGROUND: Otitis media is frequently a complication of the common cold. Obstruction of the eustachian tube ostia by nasopharyngeal edema has been suggested as a cause of this complication. OBJECTIVE: To determine the effect of a topical adrenergic decongestant on middle ear pressure in infants with common cold symptoms. METHODS: The study was conducted with a randomized, double blinded, placebo-controlled design. Middle ear pressure was determined in infants 6 to 18 months old who had common cold symptoms. Infants with abnormal middle ear pressure (< or = -100 mm H2O) in either ear were treated with intranasal phenylephrine drops or placebo. The effect of the treatment on middle ear pressure in ears with abnormal pressure at baseline was determined 1 h later. RESULTS: Twenty-three of 44 infants with abnormal middle ear pressures received intranasal phenylephrine drops and 21 received placebo. Middle ear pressure remained abnormal after treatment with phenylephrine in 29 of 33 (88%) ears and after treatment with placebo in 26 of 34 (76%). The mean change in middle ear pressure after treatment was +23 mm H2O in the active group and +40 mm H2O in the placebo group. CONCLUSIONS: Treatment of nasal obstruction with topical adrenergic decongestants does not improve abnormal middle ear pressures during the common cold.

Teaching dietary counseling skills to residents: patient and physician outcomes. The CADRE Study Group.

Our objective was to determine whether an educational intervention and prompting intervention for physicians improved dietary counseling of patients with high blood cholesterol and resulted in beneficial changes in patients' diets and cholesterol levels. We instituted a factorial design, multicenter, randomized, placebo-controlled trial to test two interventions. We tested the trial at continuity care clinics of internal medicine residents at seven community and university medical centers in the northern and eastern United States. Our participants were 130 internal medicine residents and 254 adult outpatients with blood cholesterol levels of 240-300 mg/dL. Interventions included an educational program for resident physicians designed to improve their skills and confidence in dietary counseling (two one-hour sessions with specially prepared printed materials for use in counseling) and a prompting intervention, which was a fingerstick blood cholesterol determination prior to the patient's clinic visit. Resident physicians' knowledge, attitudes, and self-reported behaviors were assessed prior to the intervention and 10 months later using chart audits and questionnaires. Residents' behaviors were also assessed by exit interviews with patients. Patients' knowledge, attitudes, behaviors, and fingerstick blood cholesterol levels were measured at baseline and 10 months later. The educational program increased the percentage of physicians who were confident in providing effective dietary counseling (baseline of 26% to 67%-78%; P < .01). The prompting intervention approximately doubled the frequency of physician counseling (P = .0005) and increased the likelihood that patients would try to change their diets. When both interventions were combined, most outcomes were better, although not statistically significant. Cholesterol levels, however, decreased only marginally and were no different among groups at 10-month follow-up. Despite success in changing physicians' attitudes and behaviors and increasing patients' willingness to change their diets, there was no significant change in patients' cholesterol levels. Medical Subject Headings (MeSH): randomized controlled trial; cholesterol; patient education; behavior therapy; education, medical; diet.

Who needs an immunization in a pediatric subspecialty clinic?

BACKGROUND: The Standards for Pediatric Immunization Practices recommends that subspecialty clinics screen children's immunization status and ensure the receipt of needed immunizations. OBJECTIVES: To determine the proportion of children presenting to a pediatric subspecialty clinic in whom immunization status can be assessed, and which of those assessed are due an immunization (eligible to receive an immunization on the day of clinic visit). DESIGN: Standardized survey of 196 patients or accompanying children presenting to a pediatric cardiology clinic. Need for immunizations was determined by the Advisory Committee on Immunization Practices recommendations. RESULTS: The reason for visit included 58% return (enrolled in the clinic), 25% initial, and 17% accompanying another patient. Usual immunization provider included 51% health department, 42% primary care physician, and 7% military. We could assess the immunization status of 79 (40%) of 196, and 19 (24%) of these 79 were due an immunization. Logistic regression analysis revealed that children enrolled in the clinic were more likely to be due for immunization than those presenting for initial visits (38% vs 8%; adjusted odds ratio, 7.42; 95% confidence interval, 1.43 to 38.55). CONCLUSIONS: We could not assess the immunization status of most children presenting to this pediatric clinic. Patients enrolled in the clinic were at increased risk for being due immunization. Having a primary care physician as a provider of immunizations did not ensure the receipt of immunizations. Pediatric subspecialists should assess the immunization status of their patients and make sure that they receive needed immunizations.

Adolescent medicine in pediatric practice: a survey of practice and training.

This study was designed to assess the relation between training in adolescent medicine, during and after residency, and self-reported practice of adolescent medicine. This is a cross-sectional study. A questionnaire was mailed to all members of the South Carolina Chapter of the American Academy of Pediatrics. After 2 mailings, 198 (83%) questionnaires were returned. Adolescent medicine training in residency was associated with more adolescent patients enrolled in a practice (P < 0.01) and more adolescent patient visits (P < 0.01) but not with an increase in perceived competence in the practice of adolescent medicine. Adolescent medicine continuing medical education was associated with seeing more adolescent patients and with increased competence in many areas, including contraceptives, suicide, and school problems (P < 0.05). training in adolescent medicine during and after residency is associated with treating more adolescent patients. Continuing medical education also is associated with increased perceived competence in areas related to adolescents.

Dietary counseling of hypercholesterolemic patients by internal medicine residents.

OBJECTIVE: To assess the knowledge, attitudes, and practices of internal medicine residents concerning dietary counseling for hypercholesterolemic patients. DESIGN: Cross-sectional, self-administered questionnaire survey. SETTING: Survey conducted August 1989 in seven internal medicine residency programs in four southeastern and middle Atlantic states. PARTICIPANTS: All 130 internal medicine residents who were actively participating in outpatient continuity clinic. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Only 32% of the residents felt prepared to provide effective dietary counseling, and only 25% felt successful in helping patients change their diets. Residents had good scientific knowledge, but the degree of practical knowledge about dietary facts varied. Residents reported giving dietary counseling to 58% of their hypercholesterolemic patients and educational materials to only 35%. Residents who felt more self-confident and prepared to counsel reported more frequent use of effective behavior modification techniques in counseling. Forty-three percent of residents had received no training in dietary counseling skills during medical school or residency. CONCLUSION: Internal medicine residents know much more about the rationale for treatment for hypercholesterolemia than about the practical aspects of dietary therapy, and they feel ineffective and ill-prepared to provide dietary counseling to patients.

Effectiveness of computer-generated appointment reminders.

Previous studies of appointment reminders among general pediatric patients have been done exclusively among low socioeconomic populations in clinics with low continuity of care and using block scheduling methods. This study of mailed computer-generated appointment reminders took place in a setting with patient demographics and practice techniques similar to those of many private pediatric practices. During a 6-month period, 901 appointments that were made more than 7 days prior to the scheduled date were randomly assigned to receive reminder postcards or to serve as controls. The overall broken appointment (no-show) rate was reduced from 19% in the control group to 10% in the reminder group, representing a 48% reduction (P = .0002). The magnitude of reduction of no-shows was similar for appointments scheduled more than 14 days prior to the appointment time (39%) as well as those scheduled more recently (58%). Equivalent results were seen with well-child appointments (47%) as with other visits (50%). Both lower and higher socioeconomic groups demonstrated similar results. The mailed postcards cost $0.20 each and were highly cost effective, generating an estimated $7.50 for each $1 spent during the study. With reductions similar to those found in this study, computer-generated appointment reminders are likely to be cost effective in other practices if current no-show rates are greater than 2% to 4%.