The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours.

In December 2008, the Institute of Medicine published new recommendations regarding duty hours and supervision of residents' training in the United States. These recommendations evoked immediate concerns from program directors and leadership in all surgical and medical disciplines, including pediatrics. To address these concerns, the Accreditation Council for Graduate Medical Education convened a Duty Hours Congress in Chicago, Illinois, on June 11 and 12, 2009. This report summarizes the opinions and testimony of the organizations (American Academy of Pediatrics, Association of Pediatric Program Directors, and Council of Pediatric Specialties) that were invited to represent pediatrics at the Duty Hours Congress. The American Academy of Pediatrics, the Association of Pediatric Program Directors, and the Council of Pediatric Specialties supported the basic principles of the Institute of Medicine report regarding patient safety, resident supervision, resident safety, and the importance of effective "hand-offs"; however, the organizations opposed additional reductions in resident duty hours given the potential unintended adverse effects on the competency of trainees, the costs of graduate medical education, and the future pediatric workforce. These organizations agreed that additional changes in graduate medical education must be data driven and consider residents within the broader system of health care. The costs and benefits must be carefully analyzed before implementing the Institute of Medicine recommendations.

Pediatricians' attitudes and practices on ADHD before and after the development of ADHD pediatric practice guidelines.

PURPOSE: The study aims to assess the changes in attitudes and practices about ADHD reported by AAP fellows between 1999 and 2005 during which AAP ADHD guidelines, training, and quality improvement initiatives occurred. METHOD: The study assesses AAP-initiated surveys that were conducted between 1999 and 2005 and involving a random sample of 1,000 and 1,603 pediatricians, respectively. RESULTS: The findings reveal that significant, although modest, increases occurred in pediatric practitioners' self-reported adherence to the guidelines. About 81% of respondents reported routine use of formal diagnostic criteria (up from 67%), and 67% of the respondents routinely use ADHD teacher rating scales (compared to 49% in the 1999 survey). Findings further reveal that treatment with stimulant medications was used extensively by pediatricians from both surveys; more pediatricians in the 2005 survey reported use of a second stimulant if the first did not work, and still more reported almost always providing parent training, although the estimated number remained only about a quarter of the total; and greater familiarity with the initiatives predicted better reported adherence to the guidelines. CONCLUSION: The reported behaviors of practitioners have moved in the direction of greater adherence with the recommended AAP ADHD guidelines, and there was a positive response to, and a greater use of, the materials developed to enhance practice. The authors infer that practice changes may be due to many factors, including AAP guidelines and associated implementation efforts. Changing physician practices needs to be sustained through a continuing process that requires multiple, varying, sustained efforts directed at physicians, other providers, and families.

Outcome measures of Triple Board Graduates, 1991-2003.

OBJECTIVE: To describe program outcomes for the Combined Training Program in Child and Adolescent Psychiatry, Pediatrics, and Psychiatry (Triple Board Program). METHOD: All Triple Board Program graduates to date (1991-2003) were asked to participate in a 37-item written survey from February to April 2004. RESULTS: The response rate was 80.7%. Most graduates go on to careers in child and adolescent psychiatry, spending a mean of 72.3% of their time in the field; however, 24.8% of respondents spend at least one fourth of their time in pediatrics and 8.0% spend one fourth of their time or more in general psychiatry. Many graduates are involved in academics, teaching, and research. Board pass rates (including repeat attempts) were highest for general (95.8%) and child and adolescent psychiatry (91.4%) and lowest for pediatrics (77.2%), and a minority (36.3%) of graduates are fully "triple boarded" (i.e., have completed oral and written boards in all three fields). Of graduates, 93.8% stated they would re-enroll in the Triple Board Program, and satisfaction with the curriculum was high. CONCLUSION: The Triple Board Program is successful in terms of career outcomes, involvement in academics, boards pass rates, and graduate reported satisfaction. These data may help determine the future of this combined program in addressing workforce issues in child and adolescent psychiatry.

Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder.

OBJECTIVES: Several guidelines have been published for the care of children with attention-deficit/hyperactivity disorder (ADHD); however, few data describe adoption of practice guidelines. Our study sought 1) to describe primary care diagnosis and management of ADHD, 2) to determine whether the care is in accordance with American Academy of Pediatrics (AAP) practice guidelines, and 3) to describe factors associated with guideline adherence. METHODS: We conducted a mail survey of 1374 primary care physicians in Michigan. Main outcome measures were reported adherence to practices specified in the AAP guidelines; ADHD practice patterns; and other measures, including attitudes about parent, teacher, and community influences on ADHD diagnosis and treatment. Bivariate and multivariate analyses were performed to assess patient and physician factors associated with adherence to guideline components. RESULTS: The overall response rate was 60%. The majority (77.4%) of primary care physicians were familiar with AAP guidelines on ADHD, and many (61.1%) reported incorporating the guidelines into their practice. Differences were apparent by specialty: 91.5% of pediatricians were familiar with the guidelines in contrast to 59.8% of family physicians. The majority of clinicians reported practices consistent with individual components of the diagnostic and treatment guidelines. However, when adherence to multiple components was analyzed together, only 25.8% of clinicians reported routine use of all 4 diagnostic components in the survey. In addition, some physicians continue to use diagnostic modalities that are currently not recommended for routine evaluation of school-aged children with ADHD--continuous performance testing, neuroimaging, and laboratory tests (eg, thyroid, lead, or iron testing). With regard to ADHD treatment, the majority (66.6%) of respondents reported routine recommendation of pharmacotherapy and titration of medications in the first month when prescribed (81.3%). However, just over half (53.1%) reported routine follow-up visits (3-4 times per year) for children who have ADHD and are taking medications. Most (53.4%) clinicians also recommended behavioral therapy for children who had a diagnosis of ADHD. Patterns of specialty differences were less consistent for treatment components: pediatricians were more likely to recommend medications, but family physicians reported more frequent follow-up evaluations for children who receive medications. There were no specialty differences in recommendations for behavioral therapy. In addition to physician specialty variations, differences in management were apparent by practice type and other demographic characteristics. There were few significant associations between adherence to guideline components and physician attitudes about parent, teacher, or community influences. However, these factors were noted by many respondents. Only 32.5% agreed that their community had adequate, accessible mental health resources. Half (50.1%) of the physicians reported that insurers limit coverage for assessment and treatment of ADHD. CONCLUSIONS: Primary care physicians generally report awareness of pediatric ADHD guidelines and follow these clinical practice recommendations. However, some physician variations are apparent, and areas for improvement are noted. Many primary care physicians report poor access to mental health services, limited insurance coverage, and other potential system barriers to the delivery of ADHD care. Additional study is needed to confirm provider-reported data; to determine what constitutes high-quality, long-term management of this chronic condition; and to confirm how reported practices associate with long-term outcomes for children with ADHD.

Receipt of asthma subspecialty care by children in a managed care organization.

BACKGROUND: Although proper outpatient asthma management sometimes requires care from subspecialists, there is little information on factors affecting receipt of subspecialty care in a managed care setting. OBJECTIVE: To determine factors associated with receipt of subspecialty care for children with asthma in a managed care organization. METHODS: We conducted an analysis of the claims from 3163 children with asthma enrolled in a university-based managed care organization from January 1998 to October 2000. We used logistic regression analysis to determine factors associated with an outpatient asthma visit with an allergist or pulmonologist. RESULTS: Of the 3163 patients, 443 (14%) had at least 1 subspecialist visit for asthma; 354 (80%) were seen by an allergist, 63 (14%) were seen by a pulmonologist, and 26 (6%) were seen by both. In multivariate analysis, patients with more severe asthma (odds ratio [OR], 3.81; 95% confidence interval [CI], 2.99-4.86) and older patients (OR, 1.04; 95% CI, 1.02-1.07) were more likely to receive care from a subspecialist. Compared with Medicaid patients, both non-Medicaid patients with copayment (OR, 2.52; 95% CI, 1.85-4.43) and non-Medicaid patients without any copayment (OR, 3.40; 95% CI, 2.35-4.93) were more likely to receive care from an asthma subspecialist. CONCLUSIONS: Children insured by Medicaid are less likely to receive care from subspecialists for asthma. Reasons may be due to health care system-related factors, such as accessibility of subspecialists, to physician referral decisions, and/or to patient factors, such as adherence to recommendations to see a subspecialist. Our findings suggest a need to further investigate health care system barriers, physician referral, and patient acceptance and completion of subspecialty referral.

Coding of pediatric behavioral and mental disorders.

BACKGROUND: In response to changing reimbursement and other pressures in the health care environment, many physicians have reported the use of alternate coding to substitute for certain clinical diagnoses. However, very little information is available on how physicians who care for children approach diagnosis and coding dilemmas for behavioral and mental disorders, which often present unique additional challenges. OBJECTIVE: Our study sought to describe the frequency of alternate coding, different approaches to coding, and attitudes toward diagnosis and coding practices by physician specialty. METHODS: We conducted a mail survey of 1492 physicians--497 developmental/behavioral pediatricians (DBP), 500 pediatricians (PED), and 495 child and adolescent psychiatrists (PSY). The main outcomes were survey items on frequency of alternate coding (never, rarely, monthly, weekly, daily), use of different coding strategies (use of somatic symptoms, modifiers, and substitution with other terms), and attitudes on coding practices (Likert scales of agreement). We analyzed outcomes by physician specialty and demographics using Pearson's chi2 and multivariate logistic regression. RESULTS: Overall response rate was 62% (787 of 1269 eligible physicians). The majority of physicians had used an alternate code (DBP 83%, PED 68%, PSY 58%), and many respondents reported monthly-daily alternate coding (DBP 60%, PED 36%, PSY 27%). Physicians used multiple approaches to diagnosis and a variety of coding options, which varied by physician specialty. Financial issues were commonly cited reasons for alternate coding--both to obtain patient services and to receive physician reimbursement. However, challenges of diagnostic classification and coding subthreshold symptoms were cited as frequently as reimbursement issues. Stigmatization, confidentiality, and parental acceptance were mentioned, but reported less frequently. Very few practices and providers have organized administrative methods of alternate coding (26%) or receive feedback on denied claims (46%). Most physicians believe that alternate coding is justified in the present system; however, some physicians expressed concerns that these practices may contribute to stigmatization or lead to improper management decisions. CONCLUSIONS: Alternate coding is commonly reported; however, approaches to diagnostic coding vary by provider specialty. Reimbursement issues are important, but other challenges in diagnosis and classification hold special relevance to children with behavioral and mental disorders. There seems to be a great need to reconsider the separate goals and uses of clinical diagnosis and administrative coding. Additional study is needed to assess how reported coding practices may affect administrative data, patient care, and health care economics.

Primary care referral of children with psychosocial problems.

OBJECTIVES: To examine primary care provider referral patterns for patients with psychosocial problems and to understand the factors that influence whether a mental health referral is made. DESIGN: Secondary analysis of the Child Behavior Study data collected during 1994-1997 from background survey of providers, visit survey of providers and parents, and follow-up survey of parents. SETTING: Two hundred six primary care offices in the United States, Canada, and Puerto Rico. PATIENTS: Four thousand twelve of 21 150 patients aged 4 to 15 years in the Child Behavior Study with a clinician-identified psychosocial problem. MAIN OUTCOME MEASURES: Referral for psychosocial problem at index visit and reported follow-up with mental health care provider within 6 months. RESULTS: Six hundred fifty (16%) of 4012 patients with psychosocial problems were referred at the initial visit. In multivariate analysis, significant factors associated with likelihood of referral included patient factors (severity, type of problem, academic difficulties, prior mental health service use) and family factors (mental health referral of parent); however, none of the provider factors were significant. Clinicians reported frequent barriers to referral and mental health services in the general background survey; however, these factors were rarely reported as influences on individual management decisions. Only 61% of referred families reported that their child saw a mental health care provider in the 6-month period after the initial primary care referral. CONCLUSIONS: Most psychosocial problems are initially managed in primary care without referral. However, referral is an important component of care for patients with severe problems, and many families are not effectively engaged in mental health services, even after a referral is made.

Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force.

PURPOSE: To clarify whether screening adults for depression in primary care settings improves recognition, treatment, and clinical outcomes. DATA SOURCES: The MEDLINE database was searched from 1994 through August 2001. Other relevant articles were located through other systematic reviews; focused searches of MEDLINE from 1966 to 1994; the Cochrane depression, anxiety, and neurosis database; hand searches of bibliographies; and extensive peer review. STUDY SELECTION: The researchers reviewed randomized trials conducted in primary care settings that examined the effect of screening for depression on identification, treatment, or health outcomes, including trials that tested integrated, systematic support for treatment after identification of depression. DATA EXTRACTION: A single reviewer abstracted the relevant data from the included articles. A second reviewer checked the accuracy of the tables against the original articles. DATA SYNTHESIS: Compared with usual care, feedback of depression screening results to providers generally increased recognition of depressive illness in adults. Studies examining the effect of screening and feedback on treatment rates and clinical outcomes had mixed results. Many trials lacked power to detect clinically important differences in outcomes. Meta-analysis suggests that overall, screening and feedback reduced the risk for persistent depression (summary relative risk, 0.87 [95% CI, 0.79 to 0.95]). Programs that integrated interventions aimed at improving recognition and treatment of patients with depression and that incorporated quality improvements in clinic systems had stronger effects than programs of feedback alone. CONCLUSION: Compared with usual care, screening for depression can improve outcomes, particularly when screening is coupled with system changes that help ensure adequate treatment and follow-up.

Epidemiology of depressive symptoms in the National Longitudinal Study of Adolescent Health.

OBJECTIVE: To describe the range of depressive symptoms reported by adolescents in a nationally representative U.S. sample and to examine factors associated with persistent depressive symptoms. METHOD: Secondary analysis was done on National Longitudinal Study of Adolescent Health (AddHealth) data from 13,568 adolescents who completed the initial survey in 1995 and follow-up 1 year later. Main outcomes of Center for Epidemiologic Studies-Depression Scale (CES-D) scores were analyzed by chi2 comparisons and sample-weighted logistic regression. RESULTS: Over 9% of adolescents reported moderate/severe depressive symptoms at baseline (CES-D > or = 24). Females, older adolescents, and ethnic minority youths were more likely to report depressive symptoms at baseline. Only 3% of adolescents with low initial CES-D scores (CES-D < 16) developed moderate/severe depressive symptoms at follow-up. Factors associated with persistent depressive symptoms at 1-year follow-up included: female gender, fair/poor general health, school suspension, weaker family relationships, and health care utilization. Other factors, including race and socioeconomics, did not predict persistent depressive symptoms. CONCLUSIONS: Depressive symptoms are common in adolescents and have a course that is difficult to predict. Most adolescents with minimal symptoms of depression maintain their status and appear to be at low risk for depression; however, adolescents with moderate/severe depressive symptoms warrant long-term follow-up and reevaluation.

Implementing practice guidelines for depression: applying a new framework to an old problem.

We discuss the challenges of implementing clinical practice guidelines for depression in the primary care setting. Multiple potential barriers can limit physician guideline adherence and translation of research into improved patient outcomes. Six primary barriers relate to providers (lack of awareness, lack of familiarity, lack of agreement, lack of self efficacy, lack of outcome expectancy, and inertia of previous practice). In addition, factors related to patient, guideline, and practice environment factors encompass external barriers to adherence. By delineating the underlying barriers to adherence, different interventions that are tailored to improve physician adherence to guidelines can be utilized. We review examples of these barriers, as well as interventions to improve guideline adherence. We also review characteristics of successful interventions to improve physician adherence to guidelines for depression. Since different physicians and practice settings may encounter a variety of barriers, multifaceted interventions that are not focused exclusively on the physician tend to be most effective.