Exploring the scope for advocacy by paediatricians. (33/2521)

AIMS: To ascertain the type and extent of problems requiring advocacy in paediatrics. To develop an approach for analysing problems according to their root causes and the level of society at which advocacy is needed. METHODS: Nine paediatricians kept detailed clinical diaries for two weeks to identify problems. Classifications were developed to categorise problems by cause and the level of society at which they needed to be addressed. The press was surveyed for one week for childhood issues attracting media attention. RESULTS: 60 problems requiring advocacy were identified. Root causes included failures within agencies, between agencies, and inadequate provision. In addition to advocacy required individually, "political" action was needed at the community level (16 issues), city level (16 issues), and nationally (15 issues). 103 articles were found in the press, these did not relate closely to issues identified by clinicians. CONCLUSIONS: Many opportunities for advocacy arise in the course of daily work. A systematic way of analysing them has been developed for use in planning action. To optimise the health and health care of children, there is a need to train and support paediatricians in advocacy work for local as well as national issues. Ten issues were identified that might be prioritised by paediatricians working on an agenda for action.  (+info)

Changes in the scope of care provided by primary care physicians. (34/2521)

BACKGROUND: Strategies to control medical costs and improve the quality of care often translate into decisions affecting the range of services primary care physicians provide to patients, which patients are referred for specialty care, and the points in disease processes at which referrals are made. This study focused on physicians' assessments of changes in the scope of care provided by primary care physicians and their assessments of the appropriateness of the scope of the care that primary care physicians are expected to provide. METHODS: We analyzed data from the 1996-1997 Community Tracking Study Physician Survey. Telephone interviews were conducted with 12,385 physicians (reflecting a response rate of 65 percent) who were drawn from a representative random sample of physicians providing direct patient care in the continental United States and not employed by the federal government. The analysis was based on responses from the 7015 primary care physicians and 5092 specialists who had been in practice for at least two years. RESULTS: Thirty percent of the primary care physicians and 50 percent of the specialists reported that the scope of care provided by primary care physicians had increased during the previous two years. Twenty-four percent of the primary care physicians and 38 percent of the specialists reported that the scope of care expected to be provided by primary care physicians was greater than it should be. According to multivariate analysis, primary care physicians other than general or family practitioners (i.e., pediatricians and general internists), those who were in one- or two-physician practices, those who received revenues from capitation, and those who served as gatekeepers for their patients' care were significantly more likely to report that the scope of care they were expected to provide was greater than it should be. CONCLUSIONS: The finding that nearly one in four primary care physicians reported that the scope of care they were expected to provide was greater than it should be arouses concern about the potential impact of changes in the delivery of health care. The associations we found between financial and administrative aspects of managed care and physicians' concern about the scope of care they provide to their patients deserve careful consideration.  (+info)

Empirically supported treatments in pediatric psychology: bedtime refusal and night wakings in young children. (35/2521)

OBJECTIVE: To review the literature for empirically supported treatments for bedtime refusal and night wakings in young children. METHODS: An extensive review of the literature resulted in the inclusion of 41 studies that were evaluated according to the criteria established by the Task Force on Promotion and Dissemination of Psychological Procedures (1995). RESULTS: Evidence exists indicating that extinction and parent education on the prevention of sleep problems can be considered well-established treatments. Furthermore, graduated extinction and scheduled awakenings are probably efficacious treatments, with positive routines a promising intervention. CONCLUSIONS: A discussion of effectiveness, treatment feasibility, cost-effectiveness, and methodological limitations of the studies is provided. Recommendations for future directions for research in the treatment of these two common sleep disorders are presented.  (+info)

Psychotherapeutic practice in paediatric oncology: four examples. (36/2521)

Psychotherapy, often used with children treated for a solid tumour, is seldom described. We present four examples of such therapies: a mother who refused enucleation for her 7-month-old boy; a boy's jealousy towards his sister who was being treated for a brain tumour; a teenager troubled by his scar; a 7-year-old boy embarrassed by the unconscious memory of his treatment when he was 5 months old. All names have been changed, for reasons of privacy. Psychotherapies aim to help children and parents to cope with the violent experience of having cancer, to recover their freedom of thought and decision-making concerning their life, their place in the family, their body image, their self-esteem, their identity. These descriptions of brief psychotherapy could help paediatricians to gain a more thorough understanding of the child's experience, to improve collaboration with psychotherapists and to confront clinical skills of psychotherapists.  (+info)

Attitudes toward managed care and cost containment among primary care trainees at 3 training sites. (37/2521)

OBJECTIVE: To study the attitudes of entering first year (Y1) and graduating third year (Y3) primary care physician trainees from 3 different training program sites (a university hospital system site [UHS], a large staff-model health maintenance organization managed care system site [MCS], and a large public hospital system site [PHS]) toward selected aspects of managed care. DESIGN: A self-administered questionnaire was used in a cross-sectional study. PARTICIPANTS AND OUTCOME MEASURES: Participants were all Y1 and Y3 primary care trainees in internal medicine, pediatrics, and family medicine programs from 3 training program sites. Survey questions dealt with attitudes toward health services, managed care cost containment, and the role of the physician in society. RESULTS: Of eligible primary care trainees (n = 218), 91% completed the instrument. Trainees at the MCS generally held more positive views of managed care systems than trainees at the UHS or PHS. Internal medicine trainees held more negative attitudes towards managed care systems than trainees in pediatrics or family medicine. UHS and PHS trainees more often thought that managed care systems interfere with the doctor-patient relationship and that these systems are more concerned with economics than in providing quality patient care. Approximately one quarter of the Y1 trainees at all sites thought that reducing the cost of healthcare is beyond the control of doctors. No Y3 trainee at the PHS believed that reducing costs was beyond the control of doctors. The majority of trainees endorsed routine peer review of clinical decisions to control healthcare costs. Most trainees believed that managed care systems will eventually predominate and that physician independence is being impaired. CONCLUSION: The data suggest that attitudes of internal medicine, family medicine, and pediatric trainees toward various aspects of managed care vary not only by their year of training but also by their training environment. Thus, managed care educational programs for trainees should consider both the baseline attitudes of trainees and characteristics of the training site itself.  (+info)

Estimates of costs of primary care physician turnover. (38/2521)

OBJECTIVE: To provide estimates of the institutional costs associated with primary care physician (PCP) turnover (job exit). SUBJECTS AND METHODS: A cohort of 533 postresident, nonfederal, employed PCPs younger than 45 years of age, in practice between 2 and 9 years, participated in national surveys in 1987 and 1991. Data from a national study of physician compensation and productivity and data from physician recruiters were combined with PCP cohort data to estimate recruitment and replacement costs associated with turnover. RESULTS: By the time of the 1991 survey, slightly more than half (n = 279 or 55%) of all PCPs in this cohort had left the practice in which they had been employed in 1987; 20% (n = 100) had left 2 employers in that same 5-year period. Among those who left, self-designated specialties and proportions were general/family practice (n = 104 or 37%); general internal medicine (n = 91 or 33%); and pediatrics (n = 84 or 30%). Estimates of recruitment and replacement costs for individual PCPs for the 3 specialties were $236,383 for general/family practice, $245,128 for general internal medicine, and $264,645 for pediatrics. Turnover costs for all PCPs in the cohort by specialty were $24.5 million for general/family practice, $22.3 million for general internal medicine, and $22.2 million for pediatrics. CONCLUSIONS: Turnover was an important phenomenon among the PCPs in this cohort. This turnover has major fiscal implications for PCP employers because loss of PCPs causes healthcare delivery systems to lose resources that could otherwise be devoted to patient care.  (+info)

Investigation and treatment of thyroglossal cysts in children. (39/2521)

Thyroglossal cysts are the commonest midline neck masses in children. To evaluate current practice questionnaires were sent to all ear, nose and throat (ENT) and paediatric surgeons in the UK and 72% responded. The commonest investigation requested was an ultrasound scan (54%) and the commonest operation was a variant of Sistrunk's procedure (78%). Paediatric surgeons did fewer investigations than ENT surgeons and tended to excise more of the thyroglossal tract. Review of the published work suggests that ultrasound scanning and Sistrunk's procedure are the best management policy. The scan can avoid inadvertent excision of an ectopic thyroid gland. Extensive thyroglossal tract excisions give lower recurrence rates.  (+info)

Variation in the use of alternative levels of hospital care for newborns in a managed care organization. (40/2521)

OBJECTIVE(S): To assess the extent to which variation in the use of neonatal intensive care resources in a managed care organization is a consequence of variation in neonatal health risks and/or variation in the organization and delivery of medical care to newborns. STUDY DESIGN: Data were collected on a cohort of all births from four sites in Kaiser Permanente by retrospective medical chart abstraction of the birth admission. Likelihood of admission into a neonatal intensive care unit (NICU) is estimated by logistic regression. Durations of NICU stays and of hospital stay following birth are estimated by Cox proportional hazards regression. RESULTS: The likelihood of admission into NICU and the duration of both NICU care and hospital stay are proportional to the degree of illness and complexity of diagnosis. Adjusting for variation in health risks across sites, however, does not fully account for observed variation in NICU admission rates or for length of hospital stay. One site has a distinct pattern of high rates of NICU admissions; another site has a distinct pattern of low rates of NICU admission but long durations of hospital stay for full-term newborns following NICU admission as well as for all newborns managed in normal care nurseries. CONCLUSIONS: Substantial variations exist among sites in the risk-adjusted likelihood of NICU admission and in durations of NICU stay and hospital stay. Hospital and NICU affiliation (Kaiser Permanente versus contract) or affiliation of the neonatologists (Kaiser Permanente versus contract) could not explain the variation in use of alternative levels of hospital care. The best explanation for these variations in neonatal resource use appears to be the extent to which neonatology and pediatric practices differ in their policies with respect to the management of newborns of minimal to moderate illness.  (+info)