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In this issue of Pediatrics , Catenaccio et al1 examined the impact of completing a pediatric fellowship on lifetime financial returns (expressed as net present value) compared to pursuing a general pediatrics private practice and the effect of eliminating medical school debt, shortening fellowship, and loan repayment on the return. The authors also compared these results to a similar study they conducted 10 years ago.2 The main finding is that for all but 3 subspecialties (cardiology, critical care, and neonatology), the net present value is lower for trainees that pursue a fellowship compared with those who enter private practice general pediatrics. The authors also found that the difference between the highest and lowest paying subspecialties has widened over time, as has the gap between most subspecialties with general pediatrics. To calculate net present value, the authors use 3 well-recognized databases and assume that all subspecialists are practicing in an academic medical center, whereas general pediatricians are in a private practice. However, these assumptions are not entirely accurate. Freed et al3 reported that, although the majority of recent fellowship graduates are initially employed by universities or … Address correspondence to Richard B. Mink, MD, MACM, Harbor–University of California, Los Angeles Medical Center, 1000 W Carson St, Box 491, Torrance, CA 90502. E-mail: rmink{at}ucla.edu

Title Improving Oral Health Risk Factor Assessment in a Private Practice Setting – a Preventative Care Quality Improvement Project Authors Andrew Lee, DO, Ayesha Mirza, MD, Randolph Thornton, MD Background and Objective The American Academy of Pediatrics (AAP) recommends fluoride varnish in the primary care setting every 3-6 months starting at tooth emergence, as an important component to preventing dental caries in children. Only 4.3% of nondental healthcare providers, however, incorporate oral preventative services into their routine well-child checks (WCC). Our SMART AIM was three-fold: 1. Increase the percentage of …

BACKGROUND: The American Academy of Pediatrics recommends literacy promotion and developmental assessment during well-child visits. Emergent literacy skills are well defined, and the use of early screening has the potential to identify children at risk for reading difficulties and guide intervention before kindergarten. METHODS: The Reading House (TRH) is a children’s book designed to screen emergent literacy skills. These are assessed by sharing the book with the child and using a 9-item, scripted scoring form. Get Ready to Read! (GRTR) is a validated measure shown to predict reading outcomes. TRH and GRTR were administered in random order to 278 children (mean: 43.1 ± 5.6 months; 125 boys, 153 girls) during well-child visits at 7 primary care sites. Parent, child, and provider impressions of TRH were also assessed. Analyses included Rasch methods, Spearman-ρ correlations, and logistic regression, including covariates age, sex, and clinic type. RESULTS: Psychometric properties were strong, including item difficulty and reliability. Internal consistency was good for new measures (rCo-α = 0.68). The mean TRH score was 4.2 (±2.9; range: 0–14), and mean GRTR was 11.1 (±4.4; range: 1–25). TRH scores were positively correlated with GRTR scores (rs = 0.66; high), female sex, private practice, and child age (P < .001). The relationship remained significant controlling for these covariates (P < .05). The mean TRH administration time was 5:25 minutes (±0:55; range: 3:34–8:32). Parent, child, and provider impressions of TRH were favorable. CONCLUSIONS: TRH is a feasible, valid, and enjoyable means by which emergent literacy skills in 3- and 4-year-old children can be directly assessed during primary care.

BACKGROUND: Concerns exist regarding the adequacy of the pediatric subspecialty workforce in the United States. Data on practice patterns and job characteristics are necessary to help develop policies to ensure availability. METHODS: We performed survey data analysis of all pediatric subspecialists enrolled in Maintenance of Certification in 2013 and 2014, assessing demographic information, characteristics of current positions, plans for retirement, and satisfaction with allocation of professional and clinical responsibilities. Four logistic regression models examined the independent association of demographic variables collected along with variables of practice ownership and academic appointment with the outcome variables of pediatric subspecialists reporting match of desired with current actual professional duties, match of desired with current actual clinical responsibilities, current part-time employment, and expected age of retirement RESULTS: Data from 5100 subspecialists were analyzed (response rate 87.2%). Most (83%; N = 4251) reported their current allocation of professional time was what they desired in their current position; similarly, 93% (N = 4755) reported likewise for clinical responsibilities. Differences by gender and years in subspecialty were evident, with women much more likely to work part time than men (odds ratio 6.22); those >20 years in practice were less likely to retire before the age of 65 compared with those CONCLUSIONS: This study is the largest to date of practicing pediatric subspecialists. Variation in work patterns found between genders, with time in practice, and between subspecialties suggests that future research should focus on these issues.

OBJECTIVE: The goal of this study was to identify the rationale by parents/guardians and providers for delaying or administering human papillomavirus (HPV) vaccination to girls. METHODS: Qualitative interviews were conducted with parents/guardians accompanying their vaccine-eligible 11- to 17-year-old daughters to medical visits. Interviews were conducted in 1 public clinic and 3 private practice settings to ascertain why girls did or did not receive HPV vaccination. Questions probed vaccine decision-making from the point of view of parents/guardians and providers. RESULTS: A total of 124 parents/guardians and 37 providers participated. The most common reasons parents reported for not vaccinating their daughters was the lack of a physician recommendation (44%). Both parents and providers believed that HPV vaccination provided important health benefits, but the timing of vaccination with relation to sexual activity was an important theme related to vaccine delay. Providers with lower self-reported vaccination rates delayed vaccine recommendations in girls perceived to be at low risk for sexual activity, and several parents reported that their providers suggested or supported delaying vaccination until their daughters were older. However, parents/guardians and providers agreed that predicting the timing of sexual debut was extremely difficult. In contrast, providers with high vaccination rates presented HPV vaccination as a routine vaccine with proven safety to prevent cancer, and parents responded positively to these messages. CONCLUSIONS: Although most parents and providers believe that HPV vaccination is important, missed opportunities result from assumptions about the timing of vaccination relative to sexual activity. Routinely recommending HPV vaccination as cancer prevention to be coadministered with other vaccines at age 11 years can improve vaccination rates.

BACKGROUND AND OBJECTIVE: Despite a thorough history and comprehensive testing, many children who present with recurrent symptoms consistent with allergic reactions elude diagnosis. Recent research has identified a novel cause for “idiopathic” allergic reactions; immunoglobulin E (IgE) antibody specific for the carbohydrate galactose-α-1,3-galactose (α-Gal) has been associated with delayed urticaria and anaphylaxis that occurs 3 to 6 hours after eating beef, pork, or lamb. We sought to determine whether IgE antibody to α-Gal was present in sera of pediatric patients who reported idiopathic anaphylaxis or urticaria. METHODS: Patients aged 4 to 17 were enrolled in an institutional review board–approved protocol at the University of Virginia and private practice allergy offices in Lynchburg, VA. Sera was obtained and analyzed by ImmunoCAP for total IgE and specific IgE to α-Gal, beef, pork, cat epithelium and dander, Fel d 1, dog dander, and milk. RESULTS: Forty-five pediatric patients were identified who had both clinical histories supporting delayed anaphylaxis or urticaria to mammalian meat and IgE antibody specific for α-Gal. In addition, most of these cases had a history of tick bites within the past year, which itched and persisted. CONCLUSIONS: A novel form of anaphylaxis and urticaria that occurs 3 to 6 hours after eating mammalian meat is not uncommon among children in our area. Identification of these cases may not be straightforward and diagnosis is best confirmed by specific testing, which should certainly be considered for children living in the area where the Lone Star tick is common.

BACKGROUND AND OBJECTIVES: A near vacuum exists for credible information regarding specialty-specific demography, including gender, years since training completion, current employer, academic affiliation, and hours worked in specific tasks. Understanding the current status and changes to the medical workforce and its work patterns is essential to assessing whether the supply and distribution meets the needs of patients, institutions, society, and educational programs. METHODS: A self-administered electronic survey sent to all pediatricians at the time of their enrollment in the Maintenance of Certification program in 2013–2014. The survey focused on exploring trends associated with career choice, career paths, time spent in professional activities, and current practice characteristics. Logistic regression and χ2 analyses were conducted. RESULTS: The response rate was 87.2% (N = 15 351). Of those who completed the survey, 9253 (64%) self-identified as general pediatricians. An increased likelihood of working part-time was seen among women (odds ratio [OR]: 12.21), those without an academic appointment (OR: 1.32), and those not working in a private/independent practice (OR: 1.15). Overall, 89% (n = 8214) of respondents stated that their current allocation of professional time was approximately what they wanted. Those more likely to be involved in quality improvement in the past year did not work in independent/private practices (OR: 1.78) and worked full-time (OR: 1.16). CONCLUSIONS: Understanding the current nature of the pediatric workforce is a first step in providing data to guide future workforce planning and the training experiences required to maintain and shape the workforce to meet the current and future needs of children.

OBJECTIVE: Historically, most pediatric subspecialists have conducted their clinical work in academic health centers. However, increases in the absolute numbers of pediatric subspecialists in past decades, combined with greater concentrations of children in urban and suburban settings, might result in more opportunities for pediatric subspecialists to enter private practice. Our goal was to assess the proportions of subspecialists in private practice. METHODS: We surveyed a stratified, random, national sample of 1696 subspecialists from 5 subspecialties and assessed the ownership of their current clinical practice settings. RESULTS: The response rate was 77%. Two-thirds of respondents (65% [n = 705]) reported that they work in academic hospitals or outpatient clinics. Compared with other subspecialists, greater proportions of neonatologists (38% [n = 92]) and critical care physicians (19% [n = 44]) reported that they work in community hospitals. Larger proportions of cardiologists (27% [n = 58]) and gastroenterologists (24% [n = 47]) reported that they work in private outpatient practices. CONCLUSIONS: There were significant proportions of pediatric subspecialists in private practice in most of the 5 subspecialties studied. Ensuring children's access to pediatric subspecialists likely will require a robust workforce in both academic and private clinical settings. Ongoing studies of the career trajectories of pediatric subspecialists with respect to their venues of practice will be essential for future workforce planning.

Geographic circumstances: Hurricane Katrina destroyed my private practice on the Mississippi Gulf Coast. After strong attempts to reestablish practice, I moved to Florida. About the author: In 2004 I opened a solo pediatric private practice in the town of Bay St Louis, Mississippi. In 2005 Hurricane Katrina produced a storm surge up to 30 ft that damaged or destroyed 90% of the buildings. I returned to practice 1 month after the storm and continued there until June 2007, when I relocated to Naples, Florida, to work for a community health center. My experiences, thoughts, and advice were incorporated into the American Academy of Pediatrics “Disaster Preparedness for Pediatric Practices: An Online Tool” (available at http://practice.aap.org/disasterpreptool.aspx). In July 2007 I was asked to testify before Congress regarding elevated formaldehyde levels in Federal Emergency Management Agency trailers. Since 2007, I have been a member of the academy's Disaster Preparedness Advisory Council. Hurricane Katrina was the costliest disaster in US history.1 The storm mobilized an unprecedented relief effort, both official and organized (state and federal authorities including the Federal Emergency Management Agency [FEMA] and National Guard troops) and impromptu volunteer (countless churches, nonprofit organizations, and kind-hearted people). Local capacity to cope was overwhelmed even before the storm came through. However, all responses must start locally, because all disasters start locally, and to understand a disaster's true impact, you must also start locally, hearing how individual communities and neighborhoods experienced it. My family and I evacuated our home in coastal Waveland, Mississippi, ahead of the approaching storm. When I returned 10 days later, I saw a cross between a Third World country and the post–atomic bomb landscapes of Hiroshima and Nagasaki. Soldiers armed with M-16 rifles patrolled the streets and manned checkpoints. The community hospital was cordoned behind a military encampment. Dark helicopters … Address correspondence to Scott Needle, MD, Creekside Pediatrics, 1265 Creekside Pkwy, 208, Naples, FL 34108. E-mail: sneedlemd{at}gmail.com

* Abbreviation: EPA — : entrustable professional activity Within this compendium of perspectives and expert consensus about the education of subspecialty fellows, we are told that “ Recent advances in medical education allow the question of required duration of training to be examined using the metric of the pediatrics milestones.…” The consensus also reinforces that “Training should remain at three years for now, but over time the Board could allow a shorter or longer period to demonstrate expertise in a particular subspecialty. ” 1 Here we have the setting for 2 fundamental, but potentially conflicting, metrics, time versus maturation, that can collide and put substantial strain on resources intended to educate and certify fellows. If time is used as the gating mechanism for the advancement of fellows, it stands to reason that there will be heterogeneity of skills, knowledge, and maturity upon completion of the requisite time. Alternatively, if maturation is used as the gating mechanism, then there will likely be heterogeneity in the time to completion. It is worth exploring some of the consequences of these options. To the extent that the milestones (such as the Denver Developmental Screening Test) and entrustable professional activities (EPAs; such as the driver’s road test) will provide a blueprint for assessing the maturation of a fellow, the potential benefit is a rigorous, reproducible, and logical method to recognize what competencies have been achieved throughout the course of education and clinical practice. In addition, this method should provide a means to track a fellow’s progress in real time, which would permit formative feedback and potential for midcourse adjustments and, even more importantly, for self-directed learning and development. This approach requires validation of the evaluation, establishment of confidence intervals, measurement of interrater agreement, certainty that the maturational schema is properly ordered, and assessment of ease of application. It is essential to recognize that … Address correspondence to George Lister, MD, Department of Pediatrics, Yale School of Medicine, PO Box 208064, New Haven, CT 06520-8064. E-mail: george.lister{at}yale.edu

OBJECTIVES: The goals were to estimate nationally representative pediatric practices' costs of providing influenza vaccination during the 2006–2007 season and to simulate the costs pediatric practices might incur when implementing universal influenza vaccination for US children aged 6 months to 18 years. METHODS: We surveyed a stratified, random sample of New York State pediatric practices (N = 91) to obtain information from physicians and office managers about all practice resources associated with provision of influenza vaccination. We estimated vaccination costs for 2 practice sizes (small and large) and 3 geographic areas (urban, suburban, and rural). We adjusted these data to obtain national estimates of the total practice cost (in 2006 dollars) for providing 1 influenza vaccination to children aged 6 months to 18 years. RESULTS: Among all respondents, the median total cost per vaccination was $28.62 (interquartile range: $18.67–45.28). The median component costs were as follows: clinical personnel labor costs, $2.01; nonclinical personnel labor costs, $7.96; all other (overhead) costs, $10.43. Vaccine purchase costs averaged $8.22. Smaller practices and urban practices had higher costs than larger or suburban practices. With the assumption of vaccine administration reimbursement for all Vaccines for Children (VFC)-eligible children at the current Medicaid median of $8.40, the financial loss across all US pediatric practices through delivery of VFC vaccines would be $98 million if one third of children received influenza vaccine. CONCLUSION: The total cost for pediatric practices to provide influenza vaccination is high, varies according to practice characteristics, and exceeds the average VFC reimbursement.

OBJECTIVE. The purpose of this work was to collect data regarding vaccine prices and reimbursements in private practices. Amid reports of physicians losing money on vaccines, there are limited supporting data to show how much private practices are paying for vaccines and how much they are being reimbursed by third-party payers. METHODS. We conducted a cross-sectional survey of a convenience sample of private practices in 5 states (California, Georgia, Michigan, New York, and Texas) that purchase vaccines for administration to privately insured children/adolescents. Main outcome measures included prices paid to purchase vaccines recommended for children and adolescents and reimbursement from the 3 most common, non-Medicaid payers for vaccine purchase and administration. RESULTS. Detailed price and reimbursement data were provided by 76 practices. There was a considerable difference between the maximum and minimum prices paid by practices, ranging from $4 to more than $30 for specific vaccines. There was also significant variation in insurance reimbursement for vaccine purchase, with maximum and minimum reimbursements for a single vaccine differing from $8 to more than $80. Mean net yield per dose (reimbursement for vaccine purchase minus price paid per dose) varied across vaccines from a low of approximately $3 to more than $24. Reimbursement for the first dose of vaccine administered ranged from $0 to more than $26, with a mean of $16.62. CONCLUSIONS. There is a wide range of prices paid by practices for the same vaccine product and in the reimbursement for vaccines and administration fees by payers. This variation highlights the need for individual practices to understand their own costs and reimbursements and to seek opportunities to reduce costs and increase reimbursements.

OBJECTIVE. We sought to examine whether pediatric clinicians in private, non–health maintenance organization practices could implement the national asthma guidelines and whether, when implemented, these guidelines would decrease medical services utilization and improve asthma care for children. METHODS. A trial of a disease management program (Easy Breathing II) involving 20 private pediatric practices in the greater Hartford, Connecticut area was conducted between January 1, 2001, and December 31, 2003. Demographic data on participating practitioners and patients were obtained from questionnaires. Medical services utilization data from claims were obtained from ConnectiCare, a regional managed care organization. RESULTS. Of the 16750 children enrolled in Easy Breathing II, 2458 were enrolled in ConnectiCare and 490 had asthma. Inhaled corticosteroid use increased in the community overall during the study period. After enrollment in Easy Breathing II, with adjustment for age, gender, ethnicity, asthma severity, season, and calendar year, children with persistent asthma experienced an additional 47% increase in inhaled corticosteroid use, a 56% reduction in outpatient visits, and a 91% decrease in emergency department visits for treatment of asthma. Adherence to national asthma guidelines for prescribing inhaled corticosteroids was 95%. Seventeen of the 20 practices are still using Easy Breathing, 5 years after program implementation. CONCLUSIONS. Pediatric primary care clinicians in private practice settings can implement an asthma management program patterned after the national asthma guidelines. When implemented, this program is successful in reducing medical services utilization for children with asthma. Just as differences in patterns of medical services utilization exist in private practices, compared with urban clinics, the impact of disease management on medical services utilization differs in private practices, compared with urban clinics.

OBJECTIVE. Several studies have found decreased cost and length of stay for patients who are cared for by pediatric hospitalists compared with traditional faculty models. The objective of this study was to compare cost and length of stay between a faculty group and 2 separate hospitalist groups in a community teaching hospital. This study differs from previous ones in that both the traditional faculty and hospitalist models were in place simultaneously, and the traditional faculty group was employed by the hospital, whereas the hospitalist groups were in private practice. METHODS. A total of 1009 pediatric patients with any of the 11 most frequent diagnosis-related groups were analyzed according to the admitting physician group. Total direct costs and length of stay were computed for 3 separate groups (faculty group, hospitalist group 1, and hospitalist group 2). Linear regression models were used to compare total direct costs and length of stay among the groups. Each model accounted for age, severity index, and payer source. RESULTS. Age, severity index, and physician group were predictive in determining total direct costs and length of stay. There was no significant difference in patient age among the groups, but the faculty group had significantly increased severity indices compared with hospitalist groups 1 and 2 (1.6 ± 0.7 vs 1.3 ± 0.6 vs 1.4 ± 0.6, mean ± SD). The faculty group had statistically significantly lower total direct costs compared with hospitalist groups 1 and 2 ($1781 ± $1449 vs $1954 ± $1212 vs $1964 ± $1495, mean ± SD). The faculty group had shorter average length of stay compared with hospitalist groups 1 and 2 (2.6 ± 2.0 vs 3.1 ± 2.6 vs 2.9 ± 2.3, mean ± SD). The readmission rates among the groups were similar. CONCLUSIONS. Traditional faculty models can be as efficient in terms of total direct costs and length of stay as evolving hospitalist models. This study's results may be unique because the traditional faculty model was composed of general pediatricians instead of a blend of generalists and subspecialists. In addition, the traditional faculty physicians concentrated almost entirely on the care of inpatients while engaged in hospital care.

There have been quite a few articles in Pediatrics lately on the general topic of well-child care.1–8 At the risk of seeming presumptuous, I would like to join the discussion from the viewpoint of a private pediatrician. It often seems that many of the authors on pediatric health maintenance concepts these days are academic behavioral pediatricians. I suppose this behavioral approach to health maintenance is appropriate, because the “new morbidity” is now the only morbidity many of us have ever known. But, when all is said and done, it is the general pediatricians, family practitioners, and nurse practitioners who struggle to provide quality well-child care. Actually, I can write with some semblance of authority. I have been in private-practice pediatrics for close to 25 years, and I am honored to be a member of the Bright Futures Users Panel. Looking at pediatric health maintenance and how best to perform it has long been of interest to me. As I see it, we have 4 things to accomplish. We need to spend enough time during the encounter to be thorough and complete. We must do it all in the allotted period of time so as not to keep other families waiting. Yet, we must see enough patients to be productive—pay the bills and make a bit of a profit. Finally, we want to work at a comfortable enough pace that we stay calm and friendly through it all. To do any 3 at the expense of a fourth may be quite feasible, but achieving all 4 can be a profound challenge. Thus, any suggestions toward enhancing pediatric health maintenance become challenges at best and intrusions at worst. The possible topics we can cover for anticipatory guidance can be daunting. I once mentioned to another member of the Bright … Address correspondence to Bruce Bedingfield, DO, FAAP, 2500 W Higgins, #440, Hoffman Estates, IL 60195. E-mail: drbrucebed{at}aol.com

Background. A national shortage of heptavalent pneumococcal conjugate vaccine (PCV7) occurred from September 2001 through May 2003. In December 2001 and January 2002, the Advisory Committee on Immunization Practices and the American Academy of Pediatrics (AAP) issued PCV7-shortage recommendations, emphasizing that all health care providers decrease the number of doses for healthy children so that more children could receive some PCV7. Objectives. We assessed (1) how the PCV7 shortage affected pediatricians, (2) whether children in the public and private sectors were vaccinated differently during the shortage, (3) pediatricians' knowledge of and adherence to the Advisory Committee on Immunization Practices/AAP recommendations, (4) and what factors were associated with nonadherence to the recommendations. Methods. We conducted a cross-sectional mail survey of 2500 US physician-members of the AAP from November 2002 through March 2003; physicians providing childhood immunizations were eligible. We asked about PCV7-shortage experience, assessed recommendation adherence through clinical scenarios, and modeled potential factors associated with reported nonadherence to the recommendation to defer the fourth PCV7 dose. Results. Of 2478 surveys sent to valid addresses, 1412 (57%) completed surveys were received; 946 (67%) of these were from eligible pediatricians. Overall, 79% experienced a PCV7 shortage, 94% reported being aware of the recommendations, and 42% reported barriers to recommendation adherence. Ninety-four percent reported vaccinating 6-month-old infants with private or public insurance in the same manner. As recommended, 91% reported fully vaccinating high-risk patients. Contrary to recommendations, 49% reported sometimes or always administering the fourth PCV7 dose to healthy children 12 to 15 months old; their reasons included recurrent otitis media, childcare attendance, and parental desire. Controlling for other characteristics, pediatricians who had no PCV7 shortage in their practices were significantly more likely to report administering the fourth dose than pediatricians who had a shortage (odds ratio [OR]: 3.67; 95% confidence interval [CI]: 2.40–5.63). Other factors associated with nonadherence were being in solo private practice (OR: 2.18; 95% CI: 1.26–3.77) or being male (OR: 1.51; 95% CI: 1.08–2.12). Among pediatricians deferring PCV7, 36% reported having no system to track children for whom PCV7 was deferred. Conclusions. Many pediatricians, both with and without a PCV7 shortage, administered more PCV7 doses than recommended. Pediatricians without a shortage were less likely to limit use, which suggests that they might have focused on the perceived value of administering the full schedule to their patients in preference to broader public health goals. Providing more information to physicians on the effectiveness of a fewer-dose schedule and the risk of disease when vaccine is deferred and educating parents might increase adherence to recommendations and achieve more equitable coverage during vaccine shortages.

Objective. Violent media exposure has been associated with aggressive behavior, and it has been suggested that child health professionals counsel families on limiting exposure. Effective violence prevention counseling requires an understanding of norms regarding parental attitudes, practices, and influencing factors. Both theories of reasoned action and planned behavior emphasize that subjective norms and attitudes affect people's perceptions and intended behavior. Few data exist on violent television viewing and monitoring from a cross-section of families. By understanding the spectrum of parental attitudes, community-sensitive interventions for violence prevention can be developed. The objective of this study was to assess attitudes about and monitoring of violent television viewing from the perspective of parents.Methods. An anonymous self-report assisted survey was administered to a convenience sample of parents/guardians who visited child health providers at 3 sites: an urban children's hospital clinic, an urban managed care clinic, and a suburban private practice. The parent questionnaire included questions on child-rearing attitudes and practices and sociodemographic information.Results. A total of 1004 adults who accompanied children for health visits were recruited for the study; 922 surveys were completed (participation rate: 92%). A total of 830 (90%) respondents were parents and had complete child data. Of the 830 respondents, 677 had questions on television viewing included in the survey and were the focus of this analysis. Seventy-five percent of families reported that their youngest child watched television. Of these, 53% reported always limiting violent television viewing, although 73% believed that their children viewed television violence at least 1 time a week. Among television viewers, 81% reported usually or always limiting viewing of sexual content on television and 45% reported usually or always watching television with their youngest child. Among children who watched television, parents reported that they spent an average of 2.6 hours per day watching television. Limitation of television violence was associated with female parents and younger children.Conclusions. There was variability in attitudes and practices regarding television violence viewing and monitoring among parents. Attitudes and practices varied on the basis of the age of the child and the gender of the parent.

Background. Personal digital assistants (PDAs) are being increasingly used in medical practice. Although they have been touted as having the ability to improve efficiency and safety, little is known about pediatricians’ use of and attitudes about PDAs. Objective. Our goals were to 1) determine the percentage of pediatricians using PDAs and computers, 2) determine perceived strengths and weaknesses of PDAs, and 3) explore characteristics associated with beliefs and use. Design/Methods. Pediatricians (2130) were selected randomly from the American Medical Association Physician Masterfile of US-licensed physicians. All participants were mailed a survey along with a prepaid return envelope and a $1 incentive. Up to 3 mailings were sent per participant. Results. Of eligible participants, 63.2% returned a survey. There were no significant differences between respondents and nonrespondents with respect to sex, type of practice, and present employment. Thirty-five percent of respondents currently use PDAs at work, and 40% currently use PDAs for personal use. Of those using PDAs, the most commonly used applications were for drug reference (80%), personal scheduling (67%), and medical calculations (61%). Few pediatricians are currently using PDAs for prescription writing (8%) or billing (4%). Users of PDAs were more likely to be male (adjusted odds ratio [AOR]: 2.29; 95% confidence interval [CI]: 1.64–3.19), in an urban community (AOR: 1.81; 95% CI: 1.30–2.55), in training (AOR: 2.64; 95% CI: 1.58–4.42), not in private practice (AOR: 1.47; 95% CI: 1.03–2.11), and a more recent graduate of medical school (AOR: 1.04 per year; 95% CI: 1.02–1.06). When controlling for covariates, those using PDAs were more likely to believe that PDAs can decrease medical errors (AOR: 2.22; 95% CI: 1.46–3.38) and increase efficiency (AOR: 2.40; 95% CI: 1.56–3.71). When compared with nonusers, users were less likely to view the small screen size (AOR: 0.53; 95% CI: 0.37–0.77) or system speed (AOR: 0.47; 95% CI: 0.26–0.84) as a problem but were significantly more likely to view memory as an issue (AOR: 3.48; 95% CI: 2.30–5.25). Conclusions. More than one third of pediatricians are using PDAs in clinical practice. There seems to be a general consensus among users that they have the potential to improve patient safety and streamline care. Future studies should explore means to utilize their potential.

Objective. Strong scientific evidence and national recommendations support the use of reminder and recall messages to improve immunization coverage rates, yet reports have suggested that only a minority of pediatric practices use such messages. Our aims were to 1) determine the proportions of pediatric practices and public clinics that currently use practice-based reminder or recall messages and routinely undergo immunization assessment efforts, 2) evaluate barriers and supports to implementing these practices, and 3) identify predictors of either current use or plans for future adoption of these practices. Methods. This study combined qualitative and quantitative methods in sequential phases. In the qualitative phase, we conducted semistructured, open-ended interviews with a convenience sample of 18 clinician-administrators representing adopters and nonadopters of these messages in both private practices and public health clinics. In the subsequent quantitative phase, we mailed a structured, closed-ended survey to national samples of randomly selected pediatricians (n = 600) and public clinics (n = 600). Results. Response rates were 75% for pediatricians and 77% for public clinics. Among pediatricians, 38% were conducting regular assessments of immunization coverage but only 16% were currently using routine reminder or recall messages. Among public clinics, 85% were conducting regular assessments and 51% were using reminder or recall messages. Among pediatricians’ practices, the most commonly reported barriers to the adoption of reminder or recall messages were lack of time and funding and the inability to identify children at specified ages. For pediatricians’ practices, the strongest predictors of current use of reminder or recall messages were having a champion who led efforts to improve immunization delivery (odds ratio: 1.85; 95% confidence interval: 1.08–3.18) and current use of regular immunization assessments (odds ratio: 2.30; 95% confidence interval: 1.33–3.84). Likewise, for public health clinics, having a champion to lead immunization improvement efforts and believing that their current system needed improvement was associated with current use of reminder or recall messages. Conclusions. Reminder and recall messages remain underused by both pediatricians and public health clinics. Promising strategies to promote adoption of these approaches in both the private and the public sectors include identifying and training champions to promote immunization delivery improvement efforts and helping practices develop methods to identify children at specific ages.

Objective. To study the relationship between age at initiation of toilet training, age at completion of toilet training, and the duration of toilet training.Methods. A total of 406 children seen at a suburban private pediatric practice were enrolled in a study of toilet training between 17 and 19 months of age, and 378 (93%) were followed by telephone interviews with the parents every 2 to 3 months until the child completed daytime toilet training. Information obtained at follow-up interviews included how often parents were asking their child to sit on the toilet or potty and where the child urinated and defecated. Parents were considered to have initiated toilet training when they first took out a potty chair and discussed some aspect of training with the child. Intensive toilet training was defined as asking the child to use the toilet or potty >3 times per day.Results. Age of initiation of toilet training correlated with age of completion of training (r = 0.275). The correlation between age at initiation of intensive training and age at completion was even stronger (r = 0.459). Younger age at initiation of intensive toilet training was not associated with constipation, stool withholding, or stool toileting refusal. However, age at initiation of intensive toilet training was negatively correlated with duration of toilet training (r = −0.481), indicating that initiation of training at younger ages was associated with a longer duration of training. In addition, the correlation between age at initiation of intensive toilet training and age at completion of training was not significant for those who began intensive training before 27 months of age (r = 0.107).Conclusions. Early initiation of intensive toilet training correlates with an earlier age at completion of toilet training but also a longer duration of toilet training. Although earlier toilet training is not associated with constipation, stool withholding, or stool toileting refusal, initiation of intensive training before 27 months does not correlate with earlier completion of toilet training, suggesting little benefit in beginning intensive training before 27 months of age in most children.

Objective. State Medicaid programs are obligated by federal law to ensure that enrolled children have access to care and services to the same extent as other children in the same geographic area. Because most children in the United States receive health care from private primary care physicians, participation by private, office-based primary care pediatricians is critical to meeting this equal access obligation. The objective of this study was to document variations in Medicaid participation of private office-based primary care pediatricians across states and to examine the effects of payment levels, prevalence of capitated Medicaid payment, and paperwork concerns on participation.Methods. Survey data collected from 3773 primary care pediatricians who practice in private office-based settings were analyzed with Medicaid physician payment data from other sources. Univariate analyses and a multiple regression were used to examine the effects of payment level, prevalence of capitated Medicaid payment, and paperwork concerns on private primary care pediatricians’ participation in state Medicaid programs.Results. Results revealed substantial state-to-state variation in respondents’ participation in Medicaid. Univariate analyses found that participation increased with state Medicaid payment levels but decreased as the proportion of Medicaid enrollees with primary care capitated payments rose and as paperwork concerns increased. With physician workforce held constant, a regression analysis showed that pediatrician participation in Medicaid increased significantly with Medicaid payment but decreased as the proportion of capitated Medicaid patients increased and as paperwork concerns rose.Conclusions. This study found that low payment, capitation, and paperwork concerns all relate to low Medicaid participation by primary care office-based pediatricians. It behooves state policy makers to address these 3 factors to ensure sufficient primary care physician capacity to serve appropriately children who are enrolled in state Medicaid programs.

Medical malpractice is burdensome to practitioners, patients, and the US healthcare system. The purpose of this study was to perform an epidemiological analysis of the closed medical professional liability (MPL) claims in pediatric orthopaedics using data maintained by the Physician Insurers Association of America (PIAA), a trade association which collects information about malpractice claims for companies that collectively insure over 60% of physicians in private practice in the US. The PIAA registry of all closed MPL claims from 1985-2013 for orthopaedic surgery patients younger than 18 were retrospectively reviewed. The …

Many primary care pediatricians find vaccine hesitancy to be one of the most frustrating situations that they face. Parents who refuse to vaccinate their children implicitly call into question an intervention that most pediatricians see as one of the safest and most effective health care interventions of all time. Many pediatricians respond by refusing to care for children whose parents refuse vaccines, and some may consider that the parent’s refusal warrants referral to child protective services. We present a case in which a pediatrician faces this dilemma, with responses from pediatricians in academia and 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).Conclusion. 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.

Dozens of state Medicaid programs pay pediatricians poorly.1 There have been some successful court challenges to paltry reimbursement rates for pediatric care2; nonetheless, many Medicaid programs manage to get away with extremely low reimbursement levels. These states' unspoken strategy is to rely on subsidized safety-net providers (such as federally qualified health centers and hospital emergency and outpatient departments) and private practitioners who are willing to accept below-market reimbursement rates for appointments not taken by better-paying, privately insured patients. However, recent trends have indicated that the days of Medicaid on the cheap may be waning. Safety-net providers are stretched to capacity,3,4 and an increasing number of young pediatricians value leisure time more than Medicaid's reimbursements. Fortunately for low-income children, pediatricians are greater participants in Medicaid than any other specialty despite its uncompetitive fees. Medicaid accounts for an average of 34% of pediatricians' revenues, more than twice the average for all US physicians,5 and many pediatricians will treat all children regardless of reimbursement level.6 However, when Medicaid rates are too low, strong economic incentives push doctors toward maximizing the number of privately-insured patients in their practice and minimizing the number of Medicaid-insured children that they treat. Historically, state Medicaid programs have counted on the immutable economics of private practice. The vast majority of practice overhead costs are fixed (eg, nonphysician personnel, rent, malpractice insurance premiums), but the marginal cost to treat each … Address correspondence to Samuel S. Flint, PhD, Indiana University Northwest, School of Public and Environmental Affairs, 3400 Broadway, Gary, IN 46408-1197. E-mail: sflint{at}iun.edu

Recent guidelines for adolescent primary care call for the specification of clinical services by three adolescent age subgroups. Yet analyses of office visits have either merged adolescence into one stage or divided it at age 15 years. Objective. To explore the utilization of physician offices in the United States by early (11–14 years), middle (15–17 years), and late (18–21 years) adolescents. Design. Secondary analysis of the 1994 National Ambulatory Medical Care Survey, focusing on visits made by the three adolescent age groups. Setting. Nationally representative sample of 2426 physicians in nonfederal, nonhospital offices. Subjects. A total of 33 598 visits by patients of all ages, representing 681.5 million visits in 1994. Main Outcome Measures. Number of visits, health insurance, providers seen, duration of visits, reasons for visits, resulting diagnoses, and counseling provided. Results. Adolescents aged 11 to 21 years made 9.1% (61.8 million) of the total office visits and represented 15.4% of the total US population in 1994. This underrepresentation in visits held across all three adolescent age subgroups. Within the adolescent cohort, whites were overrepresented relative to their population proportion (78.5% of visits, 67.6% of population) and blacks and Hispanic adolescents were underrepresented (8.3% and 9.3% of visits, 15.5% and 13.1% of population). Middle adolescence signaled a life turning point from male to female predominance in office visits. Peak lifetime uninsurance rates occurred at middle adolescence for females (18.7%) and late adolescence for males (24.0%). Between childhood and early adolescence, public insurance decreased from 24.7% to 15.7% and uninsurance increased from 12.7% to 19.7%. Pediatricians accounted for the highest proportion of early adolescent visits (41.2%), family physicians for middle adolescent visits (35.3%), obstetrician-gynecologists for late adolescent female visits (37.3%), and family physicians for late adolescent male visits (34.8%). Mean visit duration during adolescence was 16 minutes, did not differ by age subgroup or sex, exceeded that of children (14.6 minutes), and was shorter than that of adults (19.3 minutes). Obstetrician-gynecologists spent more time with adolescents than did other physicians. Education or counseling was included in 50.4% of adolescent visits, ranging from 65.1% for obstetrician-gynecologists to 34.8% for internists. During early adolescence, the leading reasons for both male and female visits were respiratory (19.4%), dermatological (10.0%), and musculoskeletal (9.7%). A similar profile was found for middle and late adolescent males. For middle and late adolescent females, the leading reason for visits was special obstetrical-gynecological examination (12.8% and 21.1%), and the leading diagnosis resulting from visits was pregnancy (9.5% and 20.4%). Conclusions. Adolescents underutilize physician offices and are more likely to be uninsured than any other age group. Visits are short, and counseling is not a uniform component of care. As adolescents mature, their providers, presenting problems, and resulting diagnoses change. The data from the National Ambulatory Medical Care Survey support a staged approach to adolescent preventive services, targeted to the needs of three age subgroups.

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.

Objectives. To measure the proportion of children cared for in private pediatric practices who are fully immunized and have been screened for anemia, tuberculosis (TB), and lead poisoning by 2 years of age. Design. Cross-sectional chart review. Setting. Fifteen private pediatric practices in central North Carolina (11 chosen randomly). Patients. One thousand thirty-two randomly selected 2-year-old children. Main Outcome Measures. Proportion of children immunized and screened for anemia, TB, and lead poisoning by 24 months of age and immunization and screening rates of the practices. Results. Sixty-one percent of the children were fully immunized at 24 months of age; the rates among practices varied widely (38% to 82%). Sixty-eight percent of the children had been screened for anemia, 57% had been screened for TB, and 3% had been screened for lead poisoning. Physicians overestimated the proportions of fully immunized children in their practices by an average of 10% (range, -3% to 17%). The median number of well child visits by 2 years of age was 5 (range, 0 to 14), and only 19% of the entire sample made 8 or more well child visits, the number recommended by the American Academy of Pediatrics in the first 18 months of life. The numbers of well child and non-well child visits were the strongest predictors of complete immunization. Practice characteristics associated with being fully immunized included the use of preventive services prompting sheets (eg, flow sheets) in the medical records, not seeing the same physician for all well child care, and having nurses review patients' immunization status during their visits to the office. Conclusions. Underimmunization and inadequate screening are significant problems in private pediatric practices in North Carolina. Physicians are unaware of the rates of underimmunization in their offices.

BACKGROUND AND OBJECTIVE: There are limited national data on pediatric health information technology adoption rates. Our objective was to determine pediatricians’ adoption rates of electronic health record systems (EHRs), barriers to adoption, and features of the systems adopted. METHODS: A survey of 1620 randomly selected US members of the American Academy of Pediatrics from February to July 2009 addressed use of EHRs and barriers to adoption. Bivariate analysis and logistic regression were used to determine associations between EHR use and various physician and practice characteristics. RESULTS: Six hundred forty-six postresidency pediatric clinicians practicing in office- or clinic-based settings responded (57.2%). Self-reported electronic medical record/EHR use was 54%/41%, but far fewer used systems that met the definition of a basic (25%) or fully functional (6%) EHR. Only 3% used a system that was fully functional and pediatric-supportive. Pediatricians practicing in multispecialty practices and those in hospital-based practices were more likely to use basic or fully functional EHRs than those in solo/2-physician practices. More than half of respondents reported financial barriers to implementing EHRs, and more than one-third were concerned about whether systems could meet their needs and whether an EHR would affect productivity. CONCLUSIONS: Pediatric adoption of fully functional EHRs lags general adoption. Barriers to adoption include financial and productivity concerns, but pediatricians are also concerned about finding systems that meet their needs. Few pediatricians use a system that is pediatric-supportive. To help identify pediatric-supportive systems, EHR certification efforts should include these requirements.

Powerful trends that have influenced pediatric care in recent decades will sweep us into the new century. By looking at the major forces at work today, we can predict where we will be 10 years from now. As infectious diseases continue to decline, psychosocial disorders will take a larger share of the pediatrician's efforts. Technology will allow more effective management, but it will require strong commitment to ongoing education. More children with chronic conditions and more young adults will fall under the care of pediatricians. Prevention will retain a central role in practice. Maintaining an independent practice will become more difficult, and a wide range of delivery schemes will emerge. Relationships among pediatricians and relationships with other health care providers will be influenced significantly by these systems, which carry potential for both positive and negative impact on the quality of care and on the lifestyles of pediatricians. It is crucial that pediatricians take an active and committed role in shaping the evolution of care systems, thereby making the future what it should be for children.

Objective. To assess the information needs of parents regarding childhood immunizations, and their satisfaction with the Vaccine Information Pamphlets (VIPs). Research design. Verbally administered, forced-choice survey of a representative sample. Setting. Urban teaching hospital-primary care center (N = 73), neighborhood health center (N = 75), and a suburban private practice (N = 75). Participants. Parents or guardians of children scheduled for routine checkups, aged 1 month to 18 years, presenting for routine health care maintenance visits. Results. Of 227 parents, 223 completed the survey. Almost all (98%) had prior experience with their children's immunizations, and 7% reported a history of a "bad" experience. Most parents stated that it was "very important" to receive information about immunizations regarding: diseases prevented by the immunizations (89%); common side effects (91%); serious side effects (89%); contraindications (91%). Eighty percent of parents indicated they wanted immunization information discussed with each vaccination. Forty-three percent of the parents were familiar with the VIPs; of these, 88% reported that the amount of information was "just right," and 94% thought the VIPs were helpful. However, 29% thought the VIPs were either too long, or somewhat too long. Conclusions. Parents indicate that they want information about many aspects of immunizations, and those familiar with the VIPs report high levels of satisfaction with the pamphlets.

Objective. To identify potential barriers to the use of oral rehydration therapy (ORT) by pediatric practitioners. Design. Cross-sectional, anonymous, self-administered survey of physicians' ORT knowledge, attitudes, and practice. Setting. A national continuing medical education conference. Participants. One hundred four general pediatricians primarily in private practice (66%) who completed training after 1980 (76%). Measurements and results. Most respondents (83%) reported that ORT plays an important role in their management of dehydration. However, compliance with guidelines from the American Academy of Pediatrics for use of oral therapy is limited: 30% withhold ORT in children with vomiting or moderate dehydration, 50% fail to advise prompt refeeding, and only 3% advise use of a spoon or syringe. The degree of importance of ORT in physicians' practice was negatively associated with reported lack of convenience of ORT administration in the practice setting (P < .001), support staff preference for intravenous versus ORT (P < .001), need for additional training of support staff to implement ORT (P < .01), and likelihood of reimbursement for intravenous versus ORT (P = .07). Notably, degree of importance of ORT was not associated with physician ORT knowledge. Conclusion. Efforts to improve use of ORT should be expanded beyond physician education and focus on such barriers as support staff limitations and financial constraints.

Geographic circumstances: I was on duty 80 miles from flooded hospitals during Hurricane Katrina and remained at the same location. About the author: I am a graduate of the University of Texas Medical School at Houston (UTMSH), and I completed my pediatric residency and neonatology fellowship at the University of Colorado Health Sciences Center. Before moving to Baton Rouge in 1993, I was a faculty member in the department of pediatrics at UTMSH. I am the founder and president of Infamedics, a private practice consisting of 9 neonatologists and 6 neonatal nurse practitioners. I am chief of neonatology at Woman's Hospital and Ochsner Medical Center–Baton Rouge. I serve as clinical faculty for the Our Lady of the Lake pediatric residency program and the department of pediatrics at Tulane School of Medicine. I am active in legislative issues and have served as a chairman of the Advocacy and Medicaid Policy committees for the Louisiana chapter of the American Academy of Pediatrics. I am the current chairman of MedicineLouisiana Inc. Hurricanes Katrina and Rita affected the city of Baton Rouge, Louisiana, as well as many other cities in many ways. For some, it was an increased population, whereas others found a sense of community in helping those less … Address correspondence to Steven B. Spedale, MD, PO Box 45171, Baton Rouge, LA 70895-4171. E-mail: steve.spedale{at}infamedics.com

Study objective. To evaluate the effects of setting, type of supervision, and time in clinic on the resident continuity clinic experience. Design. Prospective cohort with preintervention and postintervention measures. Settings. Pediatric residents selected one of three clinic settings for their continuity clinic experience. These included a traditional, university-based clinic, private practice offices, and publicly funded community-based clinics. Subjects. All pediatric residents at the University of Utah Health Sciences Center, July 1985 through June 1991. Interventions. Using varied clinic sites, matching residents one or two to one with preceptors for their continuity clinic, increasing continuity clinic from 1 to 2 half-days per week. Measurements and main results. Residents in private offices had the most varied experience, seeing more patients, more acute care, and a broader age range of patients than residents at other sites. They were more likely both to be observed by their preceptors during patient visits and to observe their preceptors delivering care. Because the number of patients seen per session rose, increasing continuity clinic time from one to two half-days per week more than doubled the number of patients seen per week. Increased time away from hospital did not affect scores on the Pediatric In-Training Examination. While test scores were similar for incoming residents, those in private offices scored higher on the final Behavioral Pediatrics Examination (P < .05). Conclusions. Clinic setting, time in clinic, and faculty supervision affect the quality of the continuity clinic experience. Increased time in clinic resulted in a broader exposure to patients. Residents placed in private offices had a more varied patient mix, were more closely supervised, and seemed to gain primary care skills more rapidly than residents at other sites.

The purpose of this study was to determine (1) whether preschool-age patients who utilize the emergency department (ED) are undervaccinated compared with patients having the same primary care provider and (2) whether reducing missed vaccination opportunities in the primary care office can potentially reduce the differences in undervaccination between the groups. This retrospective cohort study involved two groups: 583 ED patients, aged 4 to 48 months, who had primary care providers; and 583 control subjects randomly selected from primary care sites and matched according to date of birth and primary care site. The major outcome variable was the point prevalence of undervaccination, defined as more than 60 days past due for a vaccine at the time of the ED visit, and for control subjects, at the time of their matched patient's ED visit. Demographic variables, vaccination history, presence of chronic illness, and office utilization history were abstracted from office charts. The mean age of all patients was 20.0 months. Emergency department patients were more likely to be boys (61% vs 50%) and had more chronic illness, but did not differ racially from those in the control group. Primary care sites included a hospital-based clinic (n = 137), neighborhood health centers (n = 172), and private practices (n = 274). The undervaccination rates by primary provider type were for (1) hospital clinic ED patients 21.1%, control subjects 19.7%; (2) neighborhood health center ED patients 29.1%, control subjects 22.7%; and (3) private practice ED patients 26.6%, control subjects 14.9%. Overall, the odds ratio of ED patients' being undervaccinated compared with control subjects was 1.8 (95% confidence interval 1.3 to 2.5). This association was strongest for private practice patients (odds ratio 2.45, 95% confidence interval 1.5 to 4.2), but not significant for hospital clinic or neighborhood health center patients. Emergency department patients had previously missed more vaccination opportunities in the office than had control subjects (25% vs 16% of office visits). Taking advantage of missed vaccination opportunities would have greatly reduced undervaccination differences between ED patients and their controls. An ED visit is a marker for undervaccination, even for children who have primary care providers. These data support efforts to reach out to ED patients with interventions designed to increase their vaccination rates. Interventions in primary care offices, however, are likely to be the most effective.

BACKGROUND: Physician assistants (PAs) are licensed to practice with physician supervision. PAs do not specialize or subspecialize as part of their formal standard training; consequently, their license is not limited to a specific specialty. As such, PAs can, and do, change their practice settings at will. Some researchers have projected plans for the future use of the pediatric PA workforce. However, the information on which those projections have been based is limited. OBJECTIVE: To provide information regarding the current status of pediatric PAs and to inform future workforce deliberations, we studied their current distribution and scope of practice. METHODS: Data from the American Association of Physician Assistants and the US Census Bureau were used to map the per-capita national distribution of pediatric PAs. We conducted a mail survey of a random sample of 350 PAs working in general pediatrics and 300 working in pediatric subspecialties. RESULTS: Most states have CONCLUSIONS: PAs can, and do, play an important role in the care of children in the United States. However, the impact of that role is limited by the relative scarcity of PAs currently engaged in pediatric practice.

OBJECTIVES: Pentavalent rotavirus (RV) vaccine (RV5) was licensed in 2006 and recommended for routine childhood immunization. A significant decrease in the number of RV hospitalizations has been described. The objective of this study was to evaluate the effect of RV5 on acute gastroenteritis (AGE) seen in a primary practice. METHODS: In July 2004, surveillance was initiated among children who were younger than 5 years and seen in a large pediatric practice in New Orleans for those who presented AGE, as determined by International Classification of Diseases, Ninth Revision codes. Primary care physician office visits, emergency department visits, and hospital admissions were identified by review of records. RV testing was performed only on those who were seen at the hospital. RESULTS: Approximately 16 000 children who were younger than 5 years were followed in the practice during each year. For 2006–2007, 2007–2008, and 2008–2009, 11.1%, 40.3%, and 45.6% of age-eligible children, respectively, received ≥1 dose of RV5. As compared with 2004–2005 (before RV5), in 2007–2009, there was a significant decrease in all-cause AGE office visits (23%) and hospitalizations (50%). RV-positive cases (emergency department visits or hospitalizations) decreased by 67%. The decrease in RV-positive cases was more evident among children who were younger than 2 years (81%), with a strong trend among those who were aged 2 to CONCLUSIONS: Increased use of RV5 in a pediatric practice was associated with fewer AGE office visits and hospitalizations. The reduction was specific for RV-positive AGE and seen among children who were targeted for immunization as well as older groups, suggesting a herd-immunity effect.

To determine if experienced primary care physicians are more likely to reach correct decisions on the telephone than their less experienced colleagues, we asked 31 first-year and 29 third-year residents, 21 faculty, and 36 private practitioners in pediatrics and family practice to evaluate three pediatric patients via a telephone interview with a simulated mother and to decide whether each patient needed to be seen that evening. Compared with first-year residents, the third-year residents, faculty and private practitioners decided less frequently to see children who were not severely ill (P < .05) or injured (P < .01); however, less than half obtained histories considered adequate to rule out potential serious illnesses. Faculty did better than either residents or private practitioners in managing a severely dehydrated child; 100% of the faculty, but less than 60% of the residents or private practitioners, chose to see the patient promptly (P < .001). More than one third of all residents and private practitioners reached inappropriate management decisions despite obtaining information that should have altered their decisions. In these simulations, experience in private practice was not associated with improved telephone management of very sick children. Faculty physicians appeared to be better able to identify severely ill children without inappropriately evaluating those who were less ill. In all three simulations, attainment of the correct decision appeared to be determined not by the number or type of questions asked, but rather by the physician's interpretation of the information collected.

OBJECTIVE: The goal was to determine the net return (gain or loss after costs were subtracted from revenues) to private pediatric medical practices from investing time and resources in vaccines and vaccination of their patients.METHODS: A cross-sectional survey of a convenience sample of private medical practices requested data on all financial and capacity aspects of the practices, including operating expenses; labor composition and wages/salaries; private- and public-purchase vaccine orders and inventories; Medicaid and private insurance reimbursements; patient population; numbers of providers; and numbers, types, and lengths of visits. Costs were assigned to vaccination visits and subtracted from reimbursements from public- and private-pay sources to determine net financial gains/losses from vaccination.RESULTS: Thirty-four practices responded to the survey. More than one half of the respondents broke even or suffered financial losses from vaccinating patients. With greater proportions of Medicaid-enrolled patients served, greater financial loss was noted. On average, private insurance vaccine administration reimbursements did not cover administration costs unless a child received ≥3 doses of vaccine in 1 visit. Finally, wide ranges of per-dose prices paid and reimbursements received for vaccines indicated that some practices might be losing money in purchasing and delivering vaccines for private-pay patients if they pay high purchase prices but receive low reimbursements.CONCLUSIONS: We conclude that the vaccination portion of the business model for primary care pediatric practices that serve private-pay patients results in little or no profit from vaccine delivery. When losses from vaccinating publicly insured children are included, most practices lose money.

Vaccination in the United States has been and continues to be a great public health success. Many common infectious diseases that were seen during the first half of the 20th century now rarely occur. When isolated outbreaks of mumps or measles occur, these exceptions prompt headlines in national media. Managed-care organizations have long focused on preventive services, and it was through their innovation and expansion after passage of the Health Maintenance Organization Act of 1973 that coverage for many preventive services became a more-integrated part of individuals' health insurance. Additional focus on health plan programs to enhance immunization rates occurred in November 1993, with the inclusion of pediatric immunization rates in the National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set measures,1 which now are used to evaluate the performance of health care organizations and health care providers with respect to important … Address correspondence to Alan B. Rosenberg, MD, WellPoint, Medical Policy, Technology Assessment, and Credentialing Programs, 120 Monument Circle, Indianapolis, IN 46204. E-mail: alan.rosenberg{at}wellpoint.com

OBJECTIVE: The goal was to describe variable costs to providers of delivering childhood immunizations.METHODS: We documented variable costs (costs that vary with the amount of services rendered), including time spent by pediatric staff members and physicians on immunization-related activities, as well as supply costs and medical waste disposal costs. Ten private pediatric practices in the Denver, Colorado, metropolitan area participated in the study. Among the 7 practices that provided us with payment data, 8 health plans were mentioned by ≥2 practices. There were 37 different agreements between the health plans and practices for vaccine administration payments.RESULTS: The total documented variable cost per injection (excluding vaccine cost) averaged $11.51, calculated from the following categories: nursing time, $1.71; billing services, $2.67; nonroutine services, $1.64; registry use, $0.96; physician time, $4.05; supplies, $0.36; medical waste disposal, $0.12. Nonroutine activities primarily included performing vaccine inventory and ordering, providing vaccination records to requesters, and answering parent telephone questions about vaccinations. With the use of a simulation model to compensate for the small number of participating practices, the calculated total variable cost per injection was $11.83. When 2 vaccines were administered, we compared the sum of the 2 payments with the sum of the 2 variable costs ($23.02). More than one third of the payment agreements (13 of 37 agreements) paid the practices less than the combined variable costs for 2 immunizations.CONCLUSION: This study shows that the variable costs of vaccine administration exceeded reimbursement from some insurers and health plans.

The health care system of the US Gulf Coast was severely damaged by Hurricane Katrina in August 2005. Physicians in the region have faced enormous financial and psychological challenges. Pediatricians have been particularly affected, because of the large number of children covered by Medicaid, with its associated low payments, and the failure of children and families to return to affected areas. Federal relief efforts to date have largely benefited nonprofit organizations, community health centers, and hospitals. Private physicians have received little to no governmental assistance, despite their vital role in the health care system. This article explores the many factors threatening the survival of pediatric private practice in the aftermath of Hurricane Katrina and offers some practical governmental solutions. The proposals outlined here aim to provide stability and recovery to health care in the region by enabling residents to obtain care from local preexisting providers on the Gulf Coast and ensuring that physicians are paid adequately for their services. These ideas have applicability beyond Hurricane Katrina and should encourage thought regarding health care delivery after future regional disasters.

OBJECTIVE. National recommendations by the American Academy of Pediatrics and the National Association of Pediatric Nurse Practitioners promote that all children obtain quality primary care through a consistent medical provider who can better assess, diagnose, and monitor a child's health. The purpose of this article was to identify characteristics of children in Florida without a personal health care provider.METHODS. Florida data (N = 2116) from the 2003 National Survey of Children's Health were analyzed by using bivariate and multivariate methods. The dependent, or outcome, variable was a personal health care provider, defined in the National Survey of Children's Health as a personal doctor or nurse.RESULTS. In Florida, 20.1% of children (0–17 years of age) do not have a personal health care provider compared with 16.7% in the United States. Children at greatest risk are those without health insurance. Other significant risk factors include family poverty up to 100% of federal poverty level, poverty level 100% to 199%, poverty level unknown, poverty level 200% to 399%, children aged 5 to 12 years, children aged 13 to 17 years, and Hispanic ethnicity. All the factors in the Florida model were also significant in the national model.CONCLUSIONS. Lack of a personal health care provider is driven by larger community issues of health insurance, socioeconomic status, and ethnicity, including race, on a national level. To achieve the goal of a personal health care provider for children, a multifaceted approach needs to be considered. Knowing which children are without a personal health care provider provides valuable information for state policy-makers, program planners, and evaluators.

OBJECTIVE. The goal was to test the hypothesis that pediatric hospitalists use evidence-based therapies and tests more consistently in the care of inpatients and use therapies and tests of unproven benefit less often, compared with community pediatricians.METHODS. A national survey was administered to hospitalists and a random sample of community pediatricians. Hospitalists and community pediatricians reported their frequency of use of diagnostic tests and therapies, on 5-point Likert scales (ranging from never to almost always), for common inpatient pediatric illnesses. Responses were compared in univariate and multivariable logistic regression analyses controlling for gender, race, years out of residency, days spent attending per year, hospital practice type, and completion of fellowship/postgraduate training.RESULTS. Two hundred thirteen pediatric hospitalists and 352 community pediatricians responded. In multivariable regression analyses, hospitalists were significantly more likely to report often or almost always using the following evidence-based therapies for asthma: albuterol and ipratropium in the first 24 hours of hospitalization. After the first urinary tract infection, hospitalists were more likely to report obtaining the recommended renal ultrasound and voiding cystourethrogram. Hospitalists were significantly more likely than community pediatricians to report rarely or never using the following therapies of unproven benefit: levalbuterol, inhaled steroid therapy, and oral steroid therapy for bronchiolitis; stool culture and rotavirus testing for gastroenteritis; and ipratropium after 24 hours of hospitalization for asthma.CONCLUSION. Overall, in comparison with community pediatricians, hospitalists reported greater adherence to evidence-based therapies and tests in the care of hospitalized patients and less use of therapies and tests of unproven benefit.

August 29: Hurricane Katrina Landfall: I am a neonatologist in private practice and had been at the hospital for >24 hours along with 40 other physicians. I had volunteered to take care of the patients at Memorial Medical Center (MMC) during Hurricane Katrina. There were 16 infants in the NICU, ∼260 patients in total at the hospital, 500 essential employees, and >1200 family members of the patients and employees with their pets taking refuge from the storm. An additional 50 patients were in an acute care ward for adults with chronic conditions run by LifeCare within the hospital premises. Like most people, I thought Katrina would be just like other hurricanes that had threatened the city in the last few years. We would be at the hospital for a few days, and then we would return home. I had no idea what we were about to encounter. As Katrina approached New Orleans, Louisiana, the NICU staff moved the infants to an inside room because of the many windows that could endanger their safety. When Katrina made landfall in the early morning, the strong 125-mph winds did blow in several of the hospital's windows, including some in the NICU. As soon as the electrical power was lost, the backup generators started and restored the emergency electrical services. After enduring several hours of severe winds and rain, there was a general feeling of relief because the storm was over. Many windows were shattered, there was glass and water in many places, but apparently there was little structural damage to the main hospital building. In the ensuing hours we heard that the storm surge had breached the levee system, and the waters from Lake Pontchartrain were flooding the city. Still, we had no awareness of the impending severity of the situation. It soon … Address correspondence to Juan J. Gershanik, MD, FAAP, Medical Director, Neonatal Intensive Care Unit, West Jefferson Medical Center, 1101 Medical Center Blvd, Marrero, LA 70072. E-mail: jgershanik{at}aol.com