Disparities in diagnosis and access to health services for children with autism: data from the National Survey of Children's Health.

OBJECTIVE: Earlier assessment of autism improves outcomes. In addition, children with autism have significant need for medical care. Therefore, identification of factors associated with delays in the early diagnosis of autism and with decreased access to care has the potential to lead to interventions that will improve health and well-being. The aim of this study was to determine whether differences occur in the age-specific prevalence of autism or in access to health care in children of traditionally underserved populations. METHOD: Data from the National Survey of Children's Health of 2003/2004 were used. Diagnosis of autism and its severity were based on parental report. RESULTS: The prevalence of autism was lower for Latinos (26/10,000) than for non-Latinos (51/10,000). Whites and blacks had comparable rates. The lowest preschool rate of autism (16/10,000) occurred in poor children. Latinos and poor families rated their children's autism as more severe. Being black, Latino, or poor was associated with decreased access to services, while having Medicaid or State Children's Health Insurance Program was linked with better access to some services. CONCLUSIONS: Disparities in the prevalence and parent-reported severity of autism and in access to health care were found for children with autism. Programs for children in general (e.g., universal screening for autism) and programs that target traditionally underserved groups of children, their families, and their health care providers should be tested and implemented to optimize case finding of children with autism and to eliminate disparities in access to care and to early intervention.

Physical inactivity in adult survivors of childhood acute lymphoblastic leukemia: a report from the childhood cancer survivor study.

PURPOSE: To determine if adult survivors of childhood acute lymphoblastic leukemia (ALL) are less active (and more inactive) than the general population and to identify modifying factors. PATIENTS AND METHODS: Physical activity was assessed by self-report in 2,648 adult survivors of the Childhood Cancer Survivor Study. Participants in the Behavioral Risk Factor Surveillance System (BRFSS) survey administered through the Centers for Disease Control and Prevention (CDC) were used as a comparison group. RESULTS: Survivors had a mean age of 28.7 years (range, 18.0-44.0 years) and were a mean of 23.1 years from their cancer diagnosis (range, 16.0-33.8 years). In multivariate models, ALL survivors were more likely to not meet CDC recommendations for physical activity [odds ratio (OR), 1.44; 95% confidence interval (95% CI), 1.32-1.57] and more likely to be inactive (OR, 1.74; 95% CI, 1.56-1.94) in comparison with the BRFSS general population. Survivors treated with >20-Gy cranial radiotherapy were at particular risk. Compared with BRFSS participants and adjusted for age, race, and ethnicity, survivors were more likely to not meet CDC recommendations (females: OR, 2.07, 95% CI, 1.67-2.56; males: OR, 1.43, 95% CI, 1.16-1.76) and more likely to be inactive (females: OR, 1.86; 95% CI, 1.50-2.31; males: OR, 1.84; 95% CI, 1.45-2.32). CONCLUSIONS: Long-term survivors of childhood ALL are less likely to meet physical activity recommendations and more likely to report no leisure-time physical activity in the past month. This level of inactivity likely further increases their risk of cardiovascular disease, osteoporosis, and all-cause mortality.

What people want from their family physician.

The public wants and is satisfied by care provided within a patient-physician relationship based on understanding, honesty, and trust. If the U.S. health care system is ever to become patient-centered, it must be designed to support these values and sustain, rather than fracture, the relationships people have with their primary physician.

Few people in the United States can identify primary care physicians.

Almost one decade after the Institute of Medicine (IOM) defined primary care, only one third of the American public is able to identify any of the medical specialties that provide it, and only 17 percent were able to accurately distinguish primary care physicians from medical or surgical specialists and non-physicians. This lack of discrimination compromises the goal of achieving primary care for all and merits immediate attention.

Chiropractors are not a usual source of primary health care.

Chiropractors are the largest source of office-based care in the United States that does not involve a physician, but people do not view chiropractors as primary providers of health care or advice. Unlike the care given by primary care providers, the majority of care provided by chiropractors is limited to musculoskeletal problems.

Learning from malpractice claims about negligent, adverse events in primary care in the United States.

BACKGROUND: The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care. METHODS: Physician Insurers Association of America malpractice claims data (1985-2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care. RESULTS: Of 49345 primary care claims, 26126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with "diagnosis error" making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer). CONCLUSIONS: Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations.

The U.S. primary care physician workforce: minimal growth 1980-1999.

Growth in the primary care physician workforce (physicians per capita) in the United States has trailed the growth of the specialist physician population in recent years. This has occurred despite calls during the same period for increased production of primary care physicians and educational reforms focusing on primary care.

The U.S. primary care physician workforce: undervalued service.

Primary care physicians work hard, but their compensation is not correlated to their work effort when compared with physicians in other specialties. This disparity contributes to student disinterest in primary care specialties.

The U.S. primary care physician workforce: persistently declining interest in primary care medical specialties.

A persistent, six-year trend in the choice of specialty training by U.S. medical students threatens the adequacy of the physician workforce of the United States. This pattern should be reversed and requires the attention of policy makers and medical educators.

Family physicians are an important source of newborn care: the case of the state of Maine.

Family physicians (FPs) provided 30 percent of inpatient newborn care in Maine in the year 2000. FPs cared for a large proportion of newborns, especially those insured by Medicaid and in smaller, rural hospitals where FPs also delivered babies. Family medicine's commitment to serve vulnerable populations of newborns requires continued federal, state, and institutional support for training and development of future FPs.

Family physicians make a substantial contribution to maternity care: the case of the state of Maine.

Family physicians provided nearly 20 percent of labor and delivery care in Maine in the year 2000. A substantial proportion of this care was provided to women insured by Medicaid and those delivering in smaller, rural hospitals and residency-affiliated hospitals. As family medicine explores its future scope, research identifying regional variations in the maternity care workforce may clarify the need for maternity care training in residency and labor and delivery services in practice.

Family physicians are an important source of mental health care.

While comprising about 15 percent of the physician workforce, family physicians provided approximately 20 percent of physician office-based mental health visits in the United States between 1980 and 1999. This proportion has remained stable over the past two decades despite a decline in many other types of office visits to family physicians. Family physicians remain an important source of mental health care for Americans.

Family physicians' solutions to common medical errors.

In two U.S. studies about medical errors in 2000 and 2001, family physicians offered their ideas on how to prevent, avoid, or remedy the five most often reported medical errors. Almost all reports (94 percent) included at least one idea on how to overcome the reported error. These ideas ranged from "do not make errors" (34 percent of all solutions offered to these five error types) to more thoughtfully proposed solutions relating to improved communication mechanisms (30 percent) and ways to provide care differently (26 percent). More education (7 percent) and more resources such as time (2 percent) were other prevention ideas.

Consequences of medical errors observed by family physicians.

In two studies about medical errors, family physicians reported health, time, and financial consequences in nearly 85 percent of their error reports. Health consequences occurred when the error caused pain, extended or created illness, or placed patients, their families, and others at greater risk of harm. Care consequences included delayed diagnosis and treatment (sometimes of serious health conditions such as cancer), and disruptions to care that sometimes even resulted in patients needing care in a hospital. Other important consequences were financial and time costs to patients, health care providers, and the health system generally. However, sometimes no consequence was apparent.

Types of medical errors commonly reported by family physicians.

In a group of studies about medical errors in family medicine, the five error types most often observed and reported by U.S. family physicians were: (1) errors in prescribing medications; (2) errors in getting the right laboratory test done for the right patient at the right time; (3) filing system errors; (4) errors in dispensing medications; and (5) errors in responding to abnormal laboratory test results. "Errors in prescribing medications" was the only one of these five error types that was also commonly reported by family physicians in other countries.

Family physicians increase provision of well-infant care despite decline in prenatal services.

Over the past 20 years, family physicians and general practitioners (FP/GPs) and pediatricians have upheld their commitment to preventive care for infants. Non-Metropolitan Statistical Areas (non-MSAs) depend on family physicians for almost one half of their well-infant care. FP/GPs have increased their overall provision of well-infant care despite a decline in delivery of prenatal services. This commitment to child health care demands continued excellence of family physician training in pediatric medicine, preventive care, and child advocacy.

A preliminary taxonomy of medical errors in family practice.

OBJECTIVE: To develop a preliminary taxonomy of primary care medical errors. DESIGN: Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods. SETTING: The National Network for Family Practice and Primary Care Research. PARTICIPANTS: Family physicians. MAIN OUTCOME MEASURES: Medical error category, context, and consequence. RESULTS: Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died. CONCLUSIONS: This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

Title VII funding is associated with more family physicians and more physicians serving the underserved.

Title VII funding of departments of family medicine at U.S. medical schools is significantly associated with expansion of the primary care physician workforce and increased accessibility to physicians for the residents of rural and underserved areas. Title VII has been successful in achieving its stated goals and has had an important role in addressing U.S. physician workforce policy issues.