Changes in the proportion and volume of care provided to children by generalists and subspecialists

Understanding Caregiver Perspectives on an Electronic Consultation and Referral System

This study examined caregiver impressions of an electronic consultation and referral (ECR) system. Participants included 56 caregivers of primary care patients referred through the ECR system. Semistructured interviews and surveys were conducted between August 2018 and April 2019. Transcripts were coded and themes developed using thematic content analysis. A total of 51% of caregivers stated that they would prefer to see their child's primary care provider (PCP) for a specialty issue if they could receive the same quality of care. All caregivers who received an electronic consult (n = 28) said that they would utilize that process again. Three themes emerged: (1) caregivers expect immediate action prior to or instead of a specialty referral; (2) caregiver preferences for PCP versus specialist are mediated by both child and provider characteristics; (3) caregiver attitudes toward the ECR system are influenced by external considerations and experiences with the system. Results suggest caregivers value enhanced communication and immediate access to specialty input facilitated by the ECR system.

Development and Assessment of a Pictographic Pediatric Constipation Action Plan

OBJECTIVE

To assess the Uniformed Services Constipation Action Plan (USCAP) as an evidence-based, personalized, clinical action tool with pictograms to aid clinicians and families in the management of functional constipation.

STUDY DESIGN

The USCAP facilitates the management functional constipation by using a health literacy-informed approach to provide instructions for pharmacotherapies and lifestyle modifications. This study included part 1 (pictogram validation) and part 2 (assessment). For part 1, pictogram transparency, translucency, and recall were assessed by parent survey (transparency ≥85%, mean translucency score ≥5, recall ≥85% required for validation). For part 2, the USCAP was assessed by parents, clinical librarians, and clinicians. Parental perceptions (n = 65) were assessed using the Consumer Information Rating Form (17 questions) to gauge comprehensibility, design quality and usefulness. Readability was assessed by 5 formulas and a Readability Composite Score was calculated. Clinical librarians (n = 3) used the Patient Education Materials Assessment Tool to measure understandability (19 questions) and actionability (7 questions) (>80% rating was acceptable). Suitability was assessed by clinicians (n = 34) using Doak's Suitability Assessment of Materials (superior ≥70% rating).

RESULTS

All 12 pictograms demonstrated appropriate transparency, translucency, and recall. Parental perceptions reflected appropriate comprehensibility, design quality, and usefulness. The Readability Composite Score was consistent with a fifth-grade level. Clinical librarians reported acceptable understandability and actionability. Clinicians reported superior suitability.

CONCLUSIONS

The USCAP met all criteria for clinical implementation and future study of USCAP implementation for treating children with chronic functional constipation.

Shared Care: Using an Electronic Consult Form to Facilitate Primary Care Provider-Specialty Care Coordination

OBJECTIVE

The quality of children's health is compromised by poor care coordination between primary care providers (PCPs) and specialists. Our objective was to determine how an electronic consultation and referral system impacts referral patterns and PCP-specialist communication.

METHODS

The primary care clinic at Boston Children's Hospital piloted an electronic referral and consultation system with the neurology and gastroenterology departments from April 1, 2014, to October 31, 2016. PCPs completed an electronic consult form, and if needed, specialists replied with advice or facilitated expedited appointments. Specialist response times, referral rates, wait times, and completion rates for specialty visits were tracked. PCPs and specialists also completed a survey to evaluate feasibility and satisfaction.

RESULTS

A total of 82 PCPs placed 510 consults during the pilot period. Specialists responded to 88% of requests within 3 business days. Eighteen percent of specialty visits were deferred and 21% were expedited. Wait times for specialty appointments to both departments significantly decreased, from 48 to 34 days (P < .001), and completion rates improved from 58% to 70% (P < .01), but referral volumes remained stable (25 per month to 23 per month; P = .29). Most PCPs said the Shared Care system facilitated better communication with specialists (89%) and enabled them to provide superior patient care (92%). Specialists reported that the system required a minimal amount of time and enabled them to educate PCPs and triage referrals.

CONCLUSIONS

Implementation of an electronic referral and consultation system was feasible and provided timely access to specialty care, but did not affect referral volume. This system could serve as a model for other health care organizations and specialties.

General Pediatrician-Staffed Behavioral/Developmental Access Clinic Decreases Time to Evaluation of Early Childhood Developmental Disorders

OBJECTIVE

To describe and evaluate the effectiveness of a quality improvement project to decrease wait time to evaluation for children referred to Developmental Behavioral Pediatricians (DBPs).

METHODS

The authors created a Behavioral/Developmental Access Clinic (BDAC) staffed by a general pediatrician (GP) and pediatric psychologist. Clinicians in the BDAC provided comprehensive developmental evaluations for children in a discrete age range (<5 yr old). We describe the establishment of the BDAC along with referrals, diagnoses, and recommended follow-up for patients seen by the GP. We used 2-tailed t tests to compare the mean time with initial evaluation for patients seen in BDAC versus a DBP.

RESULTS

Sixty-three children were seen in BDAC over 6 months. Referrals from the BDAC included: physical/occupational/speech therapy (71%), psychology (35%), audiology (25%), genetics (14%), and neurology (8%). Five patients (8%) were diagnosed with autism spectrum disorder (ASD). Compared with time to appointment with a DBP (327 d), mean time to developmental assessment was shorter for the 45 patients who accepted earlier appointments in the BDAC (159 d), and for the 18 children seen in the BDAC as new referrals (11 d), p < .001. Follow-up with a DBP was recommended for 9 (50%) of the new patient referrals evaluated in BDAC.

CONCLUSION

The BDAC allowed for earlier developmental assessment of young children, with potential for earlier diagnosis and treatment of developmental disorders, including ASD. Opportunity for initial evaluation in BDAC decreased the number of patients requiring evaluation by DBPs, improving access to this subspecialty in our institution.

Referral pattern of children with short stature to a pediatric endocrine clinic in Kuwait

BACKGROUND

The aim of the study was to describe the referral pattern, baseline characteristics, and etiological profile of children referred with short stature in Kuwait.

METHODS

This is a cross-sectional retrospective review of children referred to the Endocrine Clinic with short stature. Short stature was defined as height or length below the 3rd centile or <-2 standard deviation score (SDS).

RESULTS

A total of 221 children were referred with no gender difference (p=0.346). Almost one fifth of these children had normal stature. Median (interquartile) age was 7.7 (4.7, 10.3) years and mean height SDS was -2.67 (0.68). The most common diagnoses were normal variants of growth, growth hormone deficiency (GHD).

CONCLUSIONS

Our study highlights the need to improve the referral process in order to avoid unnecessary investigations and alleviate parental anxiety. There is no gender bias in short stature referrals in Kuwait. There is a need of further investigation of short stature in the region.

The natural history of skin-limited Langerhans cell histiocytosis: a single-institution experience

INTRODUCTION

Prior reports of Langerhans cell histiocytosis (LCH) suggest that isolated skin involvement is rare and often progresses to systemic disease. More rapid access to pediatric subspecialty care has likely led to more frequent representation of this condition. The purpose of this study is to characterize the natural history of skin-limited LCH in an era of increased access to pediatric subspecialty care.

MATERIALS AND METHODS

A retrospective chart review was performed on all patients newly diagnosed with LCH between 2001 and 2012 at the Children's Hospital of Wisconsin. Extensive review of laboratory, physical examination, and imaging reports was performed and data collected for patients with biopsy-proven skin LCH.

RESULTS

Sixteen individuals with skin-limited LCH were identified. The median age at onset of skin eruption was birth (range, birth to 6 mo), and median duration of follow-up was 19.5 months (range, 2 wk to 10 y) from diagnosis. One patient (6%) developed pituitary disease and 1 patient (6%) had refractory skin involvement. All others experienced complete resolution. For patients without progressive or refractory disease, resolution of skin findings occurred within 7 months from onset.

DISCUSSION

Progression of skin-limited to multisystem LCH likely may be less frequent than previously described.

A new model to decrease time-to-appointment wait for gastroenterology evaluation

OBJECTIVE

To describe the implementation and evaluation of a quality improvement intervention to increase new-patient access and decrease time-to-appointment wait for gastroenterology care.

METHODS

We used a new model of care for gastroenterology evaluation. For specified clinical complaints, we offered new-patient appointments that were scheduled with a general pediatrician as an alternative to a subspecialist. A nurse navigator assisted in triaging patients. We analyzed all patient encounters over an 8-month period. To verify decreased time-to-appointment wait, mystery shoppers made semimonthly calls to centralized scheduling. We surveyed parents/families after visits with the pediatrician or subspecialists regarding satisfaction.

RESULTS

The "access" pediatrician evaluated and treated ∼40% of all new patients presenting to the division during the study period. Approximately 10% of new patients evaluated by the pediatrician (4% overall) were referred on to the subspecialist; fewer patients were reevaluated by the pediatrician in follow-up. The pediatrician ordered a minimal number of procedures. Semimonthly sampling revealed that overall new-patient access improved from an average time-to-appointment wait of 25 days to <1 day. Parent/family satisfaction was high for the patients evaluated by the pediatrician.

CONCLUSIONS

Embedding a general pediatrician within a subspecialty division, and navigating patients to this provider, can increase access to treatment of new low- to moderate-complexity patients. The access pediatrician can maintain patient satisfaction, provide high-quality care, and decrease need for subspecialist evaluation. The model, in the setting of a large academic medical center, may provide a solution for barriers to patient care such as lengthy time-to-appointment wait.

Cardiac auscultatory skills of academic family physicians: strength of association with an academic pediatric cardiologist

Aim. Heart murmur is common in children, and it is one of the main reasons for referral among children in primary care. The aim of this study is to evaluate agreement and consistency of normal, innocent, and pathologic murmur decision between academic family physicians and academic pediatric cardiologist. Methods. Seven hundred fifteen primary school children were examined by family physicians and paediatric cardiologist. Auscultatory examination was performed. Intensity, frequency, duration, quality, location, and radiation of the murmur were described if present. Agreement of normal, innocent, and pathologic murmur classification decision between family physician and paediatric cardiologist was analyzed by using kappa statistic. Results. Normal, innocent and pathologic murmurs were reported for 419, 228, and 54 children in family physicians' reports, respectively. Paediatric cardiologist agreed on 383 (91.4%) children as normal, 191 (83.7%) children having innocent murmur, and 19 (35.2%) children having pathologic murmur among family physician's reports. There was good consistency between family physicians and paediatric cardiologist (κ value = 0.679, 95% CI 0.630-0.727, P < .001). They agreed on the majority of normal and innocent murmur decisions. However family physicians reported pathologic murmur more frequently. Conclusion. Cardiac auscultatory skills of academic family physicians may be concordant with paediatric cardiologist.

Routine care provided by specialists to children and adolescents in the United States (2002-2006)

Background

Specialist physicians provide a large share of outpatient health care for children and adolescents in the United States, but little is known about the nature and content of these services in the ambulatory setting. Our objective was to quantify and characterize routine and co-managed pediatric healthcare as provided by specialists in community settings.

Methods

Nationally representative data were obtained from the National Ambulatory Medical Care Survey for the years 2002-2006. We included office based physicians (excluding family physicians, general internists and general pediatricians), and a representative sample of their patients aged 18 or less. Visits were classified into mutually exclusive categories based on the major reason for the visit, previous knowledge of the health problem, and whether the visit was the result of a referral. Primary diagnoses were classified using Expanded Diagnostic Clusters. Physician report of sharing care for the patient with another physician and frequency of reappointments were also collected.

Results

Overall, 41.3% out of about 174 million visits were for routine follow up and preventive care of patients already known to the specialist. Psychiatry, immunology and allergy, and dermatology accounted for 54.5% of all routine and preventive care visits. Attention deficit disorder, allergic rhinitis and disorders of the sebaceous glands accounted for about a third of these visits. Overall, 73.2% of all visits resulted in a return appointment with the same physician, in half of all cases as a result of a routine or preventive care visit.

Conclusion

Ambulatory office-based pediatric care provided by specialists includes a large share of non referred routine and preventive care for common problems for patients already known to the physician. It is likely that many of these services could be managed in primary care settings, lessening demand for specialists and improving coordination of care.

Linking process to outcome: are we training pediatricians to meet evolving health care needs?

The Residency Review and Redesign in Pediatrics (R(3)P) Project began in 2005 and will have been completed in 2009. The purpose was to conduct a comprehensive reassessment of general pediatric residency education. The project convened 3 major colloquia supplemented by numerous meetings of an R(3)P committee and by surveys of residents, subspecialty fellows, and generalist and subspecialty practitioners. A principal conclusion was that resident learning opportunities should be more flexibly directed toward the variety of career choices available to pediatricians. Another conclusion was that reasonable expectations for residency education are most likely if learning is regarded as an integrated continuum, beginning in medical school and continuing throughout a career in practice. The R(3)P Committee declined to create a list of recommendations for immediate changes in residency education; instead, it recommends that changes be based on evidence of education outcomes that are important to improving the health of children, adolescents, and young adults.

Reduction in hospitalizations of children

AIM

The aim of the study was to reduce the number of hospitalizations in a population of children enrolled in the Einstein Program of the Paraisópolis Community, in São Paulo, Brazil, particularly hospitalizations caused by respiratory diseases.

METHODS

All hospitalizations of this paediatric population enrolled in the Einstein Program of the Paraisópolis Community Outpatient Clinic were followed up between 2002 and 2004. The following four strategies to reduce or control respiratory diseases with an impact on hospitalizations were established: specific protocol, educational activities, vaccination against pneumococci and vaccination against influenza.

RESULTS

In 2002, 1025 hospitalizations due to all causes were recorded. This number significantly decreased to 862 hospitalizations in 2004 after implementation of the program, corresponding to a reduction of 15.9% (p < 0.0001). Hospitalizations due to respiratory diseases decreased by 23.37% (p < 0.02), and those due to cases of wheezing bronchitis fell by 51.61% (p < 0.001).

CONCLUSION

The strategies chosen and implemented in the Einstein Program of the Paraisópolis Community Outpatient Clinic over the first 6 months of 2003 were effective in reducing the number of children's hospital admissions due to respiratory disease.

Differences in characteristics among new pediatric neurology patients: the effect of a newly established private pediatric neurology practice

OBJECTIVE

To investigate changes in volume and characteristics of new patients referred when a private pediatric neurology practice (PP) opened in 2004 in an area served primarily by an academic medical center's (AMC) pediatric neurology practice.

METHODS

Retrospective analysis of medical and billing records to examine changes in volume, diagnosis, and sociodemographic factors of new patients at the AMC from July 2004 to June 2005; the PP during the same period; and the AMC during the year before.

RESULTS

One year after the PP opened, 40% more new pediatric neurology patients were seen in this area than the year before. Compared with the AMC, PP saw a greater proportion of seizures (34% vs 26%, P < .05) and headaches (32% vs 17%, P < .001), and a lesser proportion of developmental delay/musculoskeletal disorders (12% vs 19%, P < .001) and congenital/metabolic disorders (<1% vs 2%, P < .001). Fewer PP patients lived >20 miles from the practice (32% vs 64%, P < .001), and fewer had public insurance (4% vs 33%, P < .001).

CONCLUSIONS

The establishment of the PP dramatically increased the volume of new pediatric neurology patients in this area. After the PP opened, the AMC continued to care for most patients with rare diseases and fewer financial resources. Future research should examine whether the increase in volume reflects relief of pent-up demand or increased referral rates due to eased access, and should elucidate how differences in patient populations at academic and private subspecialty practices relate to access to subspecialty care and financial well-being of academic practices.

The regional genetic and newborn screening service collaboratives: the first two years

Newborn screening and genetic technologies are expanding and changing rapidly, increasing the demand for genetic specialty services. Because of the scarcity and geographic maldistribution of genetic specialty services, access to these services is a critical issue. This article discusses some of the efforts initiated by the Maternal and Child Health Bureau of the Health Resources and Services Administration, particularly the establishment of regional genetic and newborn screening collaboratives to improve access to these services and expertise.

Threshold of evaluation for short stature in a pediatric endocrine clinic: differences between boys versus girls?

OBJECTIVES

To determine the height, age, and sex distribution of children evaluated for poor growth or short stature in a pediatric endocrinology clinic.

STUDY DESIGN

Cross-sectional study between March 2001 and July 2003. Sex, age, height, and parental height were abstracted from new patient visits for short stature.

RESULTS

There was a bimodal pattern for the age distribution at presentation. There were no significant gender differences in height z-score or height deficit. Overall, more boys than girls were evaluated.

CONCLUSIONS

More males than females were evaluated, particularly during adolescence. The implications of this differential utilization of subspecialty care remain to be determined.

Family physicians in the child health care workforce: opportunities for collaboration in improving the health of children

Pediatric workforce studies suggest that there may be a sufficient number of pediatricians for the current and projected US child population. These analyses do not fully consider the role of family medicine in the care of children. Family physicians provide 16% to 26% of visits for children, providing a medical home for one third of the child population, but face shrinking panels of children. Family medicine's role in children's health care is more stable in rural communities, for adolescents, and for underserved populations. For these populations, in particular, family medicine's role remains important. The erosion of the proportion of visits to family medicine is likely caused by the rapid rise in the number of pediatricians relative to a declining birth rate. Between 1981 and 2004, the general pediatrician population grew at 7 times the rate of the US population, and the family physician workforce grew at nearly 5 times the rate. The number of clinicians caring for children meets or exceeds most estimates of sufficiency; however, the workforce distribution is skewed, leaving certain populations and settings underserved. More than 5 million children and adolescents live in counties with no pediatrician. Unmet need, addressing health in the context of families and communities, and tackling "millennial morbidities" represent common ground for both specialties that could lead to specific, collaborative training, research, intervention, and advocacy.

Digital rectal examination and the primary care physicians: a lost art?

Digital rectal examination (DRE) in children is crucial to differentiate between simple (habitual) and complicated constipation. Previous experience suggests that primary care physicians (PCPs) avoid DRE in children with constipation before referral. We evaluated the rate of DRE performance by West Virginian PCPs in patients referred to our gastroenterology clinic. Data were collected from the physicians' referral letters and parental reports. We found that the vast majority (85%) of WV-PCPs do not perform DRE before referring their patients, resulting in missed diagnoses and treatment. We concluded that the lack of DRE in children with constipation may result in unnecessary referral to the specialist. To improve standard of care for children with constipation, an educational campaign for PCPs is clearly warranted.