Transitional care is an organized effort to provide pediatric patients with the tools and resources they need to assume personal responsibility for their medical care while facilitating their transfer from a pediatrician to an adult practitioner. Since inflammatory bowel disease (IBD) is usually chronic and up to 25% of IBD patients are diagnosed before the age of 18 years, transitional care is an important consideration for adolescent and young adult patients. The importance of transitional care for chronic diseases that begin in childhood has been recognized in a number of published recommendations. However, most of these recommendations arise from intuitive reasoning, as physicians lack information regarding the need for transitional care, optimal delivery protocols, and the efficacy of transition programs. Even fewer studies have been published regarding transitional care in IBD. Current guidelines stress the importance of providing patients with educational resources to help them develop the skills they need to manage their care as independent adults, introducing the concept of transfer to adult care in advance of the actual transfer, and developing routes of communication to facilitate the transfer from pediatric to adult care providers. Future studies should aim to elucidate which programs are effective and how they should be implemented.
Adolescent healthcare; inflammatory bowel disease; pediatrics; transition to adult medicine
To examine the process of transition from pediatric to adult healthcare services from the perspectives of young adults with chronic disease and pediatric and adult healthcare providers.
A qualitative approach using focus group interviews was performed to investigate transition experiences. Novel innovation games were also utilized to generate data. Content and narrative analyses of interview transcripts were performed.
Six focus groups were conducted with 10 young adults with chronic disease and 24 healthcare providers. Content analysis yielded 3 content domains: transition experiences in the context of relationships between patients, parents, and healthcare providers; differences between pediatric and adult-oriented medicine and how these differences inhibit or facilitate transition; and identifying transition services that should be provided to young patients with chronic disease.
This study demonstrates the need for gradual transfer of disease management from parent to child and better communication between adult and pediatric services during the transition process. Pediatric medicine and adult medicine represent different subcultures; acknowledging these differences may improve cooperation during transition from pediatric to adult providers. Young adult patients with chronic disease embrace the use of technology for specific interventions to improve the transition experience.
Cystic fibrosis (CF) is a disease that requires intensive multidisciplinary care, including care by physical therapists (PTs). People with CF are now living well into adulthood, necessitating a transfer of care from the pediatric setting to an adult one. Physical therapists play a large role in the care of the person with CF; however, there is little known about the PT role in transition of care.
To explore transition issues for people with CF from the perspective of PTs.
An 18-question online survey was sent to PTs via an electronic CF listserv. Questions were derived from an analysis of transition literature in CF and other chronic childhood conditions. Physical therapists who reported treating people with CF gave their opinions on issues impacting transition from their perspective as well as their perception of patient and parent concerns. Descriptive statistics were used for data analysis.
A total of 26 PTs completed the survey. A majority, 61.5%, reported that there was a transition program at their facility, with 42.3% involving physical therapy. Common themes for patients and parents included feeling uncertain about: knowledge of the adult physician, acquiring pulmonary infections in the adult setting, and pace of the adult clinic. Physical therapists were concerned about adherence with airway clearance and exercise following transfer to the adult clinic.
The role of PT in transition programs is quite varied. Physical therapists should address common concerns of their patients and families to improve the transition process and possibly impact adherence to the PT plan of care.
transition of care; cystic fibrosis; physical therapy
As an increasing number of patients with chronic conditions of childhood survive to adulthood, experts recommend that young adults with chronic conditions transfer from child-focused to adult-focused primary care. Little, however, is known about how comfortable physicians are caring for this population.
To assess the comfort of general internists and general pediatricians in treating young adult patients with chronic illnesses originating in childhood as well as the factors associated with comfort.
In a random sample, 1288 of 2434 eligible US general internists and pediatricians completed a mailed survey (response rate = 53%).
We measured respondents’ comfort level in providing primary care for a patient with sickle cell disease (SCD) or cystic fibrosis (CF). We also measured levels of disease familiarity, training and subspecialty support, as well as individual physician characteristics.
Fifteen percent of general internists reported being comfortable as the primary care provider for adults with CF and 32% reported being comfortable providing primary care for adults with SCD, compared with 38% of pediatricians for CF ( < .001) and 35% for SCD ( > 0.05). Less than half of general internists felt that their specialty should take primary care responsibility for adult patients with CF and SCD.
A majority of general internists and pediatricians are not comfortable providing primary care for young adults with chronic illnesses of childhood origin, such as CF and SCD. Efforts to increase treatment comfort among providers may help with the transition to adult-focused care for the growing numbers of young adults with complex chronic conditions.
transitional care; cystic fibrosis; sickle cell disease; young adults; adolescents; children with special health care needs; primary care; childhood diseases; health care transitions
Despite their significance, little is known about diagnostic errors in general pediatric practice other than data from malpractice claims. We surveyed pediatricians to elicit their perceptions about frequency, contributing factors and potential systems and provider-based solutions to address diagnostic errors.
Academic, community, and trainee pediatricians at three tertiary care institutions and affiliated 109 clinics (N=1,362) were invited to complete the survey anonymously via an Internet survey administration service between November 2008 and May 2009.
Overall response rate was 53% (N=726). Over half (54%) of respondents reported that they made a diagnostic error at least once or twice per month; this frequency was markedly higher (77%) among trainees. Almost half (45%) reported diagnostic errors that harmed patients at least once or twice per year. Failure to gather information through history, physical examination or chart-review was the most common reported process breakdown, whereas inadequate care coordination and teamwork was the most common system factor reported. Viral illnesses being diagnosed as a bacterial illness was the most commonly reported diagnostic error followed by misdiagnosis of medication side-effects, psychiatric disorders, and appendicitis. Physicians ranked access to electronic health records and close follow-up of patients as strategies most likely to be effective in preventing diagnostic errors.
Pediatricians reported making diagnostic errors relatively frequently and patient harm from these errors was not uncommon. Our survey provides new data about the types of diagnostic errors and their causes and lays the groundwork for a concerted, multifaceted approach to reduce these errors in children.
diagnostic errors; children; patient safety; missed and delayed diagnosis; misdiagnosis; malpractice
When epilepsy does not remit in childhood, transition and transfer to adult care is eventually required. Youth must leave the family-centered approach of pediatric care for the individual focus of adult medicine. Evidence from population-based studies indicates that many of those with childhood-onset epilepsy have major social difficulties in adulthood even if their epilepsy has resolved. Epilepsy may have major effects on normal adolescent development, and societal attitudes confound this difficult period in the lives of young people with epilepsy. Very little objective data are available to assist in the designing of models of care for youth with epilepsy; however, based on our clinical experience and the limited available literature, it appears that a transition program to prepare children for adult care is best started during childhood and adolescence. The formal transfer to adult services may be assisted by a transition clinic jointly attended by pediatric and adult epilepsy specialists.
Few national data exist to assess primary care physicians’ (PCP) clinical practices with regard to childhood obesity.
To survey pediatricians and family practice physicians regarding their assessment, counseling, and management of diet, physical activity, and weight status among pediatric patients in the primary care setting.
A nationally representative cross-sectional survey of pediatricians and family practice physicians sampled from the American Medical Association (AMA) Masterfile was conducted in 2008 and analyzed in 2010. Outcomes included: Physicians’ self-reported practice behaviors regarding assessments of pediatric patients’ weight status, counseling of diet and physical activity, and referrals and follow-ups.
Response rate excluding physicians listed as “no-contact” by the AMA was 73.7% among pediatricians and 66.9% among family physicians. Less than 50% of all PCPs assessed BMI percentiles regularly in children. Eighteen percent of all PCPs reported referring children for further evaluation or management. Fifty-eight percent of all PCPs reported never, rarely, or only sometimes tracking patients over time concerning weight or weight-related behaviors. Pediatricians were more likely than family physicians to assess weight status and provide behavioral counseling (Ps<0.001).
Active PCP participation in assessing or managing childhood obesity in the primary care setting appears low relative to the frequency of the problem in the U.S.
Since National Immunization Program (NIP) was implemented recently in Korea, public attention on vaccine safety is increasing. This study was aimed to investigate perceptions of pediatricians on the vaccine injury compensation program and to acquire their suggestions to improve the program.
Materials and Methods
Pediatricians working in primary care were surveyed at the sites of the annual Korean Pediatric Society meeting or its regular regional branch meetings during September and October 2012. A questionnaire consisted of 15 items about the Korean National Vaccine Injury Compensation Program (KNVICP) was distributed and collected directly from the pediatricians.
A total of 340 responses were collected. While only 16% of responded pediatricians answered they knew the program well, 11% answered they did not. Twenty-six percent answered a need to expand the types of vaccines and its injuries. Most responders (82%) wished the compensation program to cover the injuries of non-NIP vaccines. On the filing procedures for compensation, they preferred reducing the minimum medical cost limit to claim (94%).
On the basis of this survey, it is suggested to provide more active informative education on KNVICP to primary care pediatricians and to improve the program considering the pediatricians' opinions.
Pediatrics; Data collection; Vaccines
To describe a novel process and present results of formative research to develop a pediatric office intervention that uses available systems of care for addressing parental smoking.
The scientific development of the intervention occurred in three stages. In stage one, we designed an office system for parental tobacco control in the pediatric outpatient setting based on complementary conceptual frameworks of preventive services delivery, conceptualized for the child healthcare setting through a process of key interviews with leaders in the field of implementing practice change; existing Public Health Service guidelines that had been shown effective in adult practices; and adaptation of an evidenced-based adult office system for tobacco control. This was an iterative process that yielded a theoretically framed intervention prototype. In stage two, we performed focus group testing in pediatric practices with pediatricians, nurses, clinical assistants, and key office staff. Using qualitative methods, we adapted the intervention prototype based on this feedback to include five key implementation steps for the child healthcare setting. In stage three, we presented the intervention to breakout groups at two national meetings of pediatric practitioners for further refinements.
The main result was a theoretically grounded intervention that was responsive to the barriers and suggestions raised in the focus groups and at the national meetings. The CEASE intervention is designed to be flexible and adaptable to the particular practices' staffing, resources, and physical configuration. Practices can choose materials relevant to their own particular systems of care (www.ceasetobacco.org).
Conceptually-grounded and focus group tested strategies for parental tobacco control are now available for implementation in the pediatric outpatient setting. The tobacco control intervention development process might have particular relevance for other chronic pediatric conditions that have a strong evidence base and have available treatments or resources that are underused.
smoking; tobacco; pediatrics; family practice; parent; smoking cessation; secondhand smoke; environmental tobacco smoke; tobacco control; quitline; telephone counseling
The transition process from pediatric to adult health care for adolescents with chronic diseases is always challenging and can be even more so for adolescents with HIV disease. The purpose of this study was to describe characteristics and current practices surrounding the transition of adolescents from the clinics of the Adolescent Trials Network for HIV/AIDS Interventions to adult medical care. This report focuses on the processes of transition, perceived barriers and facilitators, and anecdotal reports of successes and failures. Practice models used to assist adolescents during transition to adult medical care are described. Interviews were conducted with 19 key informants from 14 Adolescent Trials Network clinics. Findings revealed no consistent definition of “successful” transition, little consensus among the sites regarding specific elements of a transition program, and a lack of mechanisms to assess outcomes. Sites that viewed transition as a process rather than an event consistently described more structured program elements.
adolescent; AIDS; developmental; HIV; transition
Twenty percent of inflammatory bowel disease (IBD) patients present in the pediatric years, with recent reports suggesting a rising incidence in the pediatric age group. This highlights the need for both pediatric and adult gastroenterologists to better understand issues related to the process of transition from pediatric to adult care. Research from other disciplines outside of IBD provide evidence that the transition period can be associated with poorer health outcomes and that a structured transition program may improve patient compliance and disease control. Recent data from the IBD literature support a need for transition clinics. The ideal model of a transition program has not been established. Controlled trials are not available to measure the impact of a structured transition program on clinically relevant endpoints such as disease control and hospital admissions. As local resources and availability of staffing and funding are highly variable, we have summarized some practical guidelines for the adult and pediatric gastroenterologist that can be used as an aid to help adolescents through the transition process even without the support of an established transition clinic.
inflammatory bowel disease; pediatrics; transition process
Hydrocephalus is a prototypical chronic condition that follows children into adulthood. The objectives of this study were to (1) review how the health care needs of young adults with hydrocephalus are not being met, (2) estimate the numbers of adults with childhood-onset hydrocephalus, (3) describe a novel program to provide care for young adults with hydrocephalus and other chronic pediatric conditions, and (4) propose national strategies to promote successful hydrocephalus transition care.
Adults with hydrocephalus need continuous access to expert surgical and medical providers. Existing care models fail to meet this need. The number of young adults who have hydrocephalus, are aged 18 to 35 and need treatment in the United States is predicted to exceed 40 000 annually within the next 2 decades. We are developing integrated teams of pediatric and adult medical and surgical specialists to provide continuous, coordinated, comprehensive care for individuals with hydrocephalus in a pediatric setting. This setting will train our future physician workforce on optimal transition care. Coordinated national efforts are also needed.
Providers need to implement appropriate management and transition care for individuals with hydrocephalus. We must work at local and national levels to transform the care model, improve the quality of health care delivery, and improve outcomes for young adults with hydrocephalus.
hydrocephalus; health transition; medical education; advocacy
To determine Colorado American Academy of Pediatrics (AAP) pediatricians' involvement in community-based activities and awareness of and interest in the AAP Community Access to Child Health (CATCH) program, a 22-item survey was mailed to all general pediatrician AAP fellows and candidate fellows practicing in Colorado (n = 434). The return rate was 65%. Of the respondents, 73% provide direct patient care as their primary professional activity, 58% reported either current or past involvement in community-based programs outside of their practices, 91% of this community-based work was voluntary, and 80% of the respondents described this work as moderate to very rewarding. Half of the respondents (51%) were aware of the AAP CATCH program, and 68% were interested in attending a statewide CATCH meeting. We conclude that Colorado AAP pediatrician survey respondents participate heavily in community programs outside of their clinical practices and that among this group there is substantial interest in the AAP CATCH program.
Advances in pediatric care have not provided the interdisciplinary support services required by those young adults with pediatric life-threatening conditions (pedLTCs) who live beyond childhood but have limited expectations to live past early adulthood. These young adults, the first generation to live into adulthood, face multiple challenges transitioning from a plethora of pediatric palliative services to scant adult health services. In a case study, using an innovative bulletin board focus group, we describe the complex interplay of the health, education, and social service sectors in this transition. Our descriptions include system deficits and strengths and the young adults' resilience and coping strategies to overcome those deficits and move forward with their lives. Young adults with pedLTC need knowledgeable providers, coordinated and accessible services, being respected and valued, and services and supports that promote independence. We recommend implementation of multidisciplinary solutions that are focused on young adult priorities to ensure seamless access to resources to support these young adults' health, educational, vocational, and social goals. The input and voice of young adults in the development of these services are imperative to ensure that multisystem services support their needs and life goals.
A nationwide survey of Canadian pediatricians was undertaken to answer questions about demographic and practice characteristics, perceptions of the quantity and quality of residency training in relation to the realities of practice, and the patterns of use and the value of continuing medical education. The findings included a lower average age of pediatricians from that determined 10 years earlier, a higher proportion of women practising pediatrics, and higher proportions of pediatricians entering practice in smaller communities, doing geographic full-time university work and doing mainly consulting work. Pediatrics is still perceived as an attractive discipline, but there is dissatisfaction with the quantity and quality of training in adolescent medicine, ophthalmology, dermatology, psychosocial pediatrics and orthopedics. The changing patterns of continuing medical education among the most recent certificants suggest a need for journals and professional societies to assess how they can better meet the needs of Canadian pediatricians in this area.
A number of studies published over the past 10 years have examined the long-term health, functional and quality of life outcomes of adults with childhood-onset rheumatic diseases such as juvenile idiopathic arthritis, systemic lupus erythematosus, juvenile dermatomyositis and localized scleroderma. As increasing numbers of patients with these conditions survive into adulthood, understanding the adult outcomes of these pediatric conditions has become ever-more important. Identifying modifiable risk factors for poor outcomes is vital to improving care for these patients. In addition, as these conditions and their treatments can affect cardiovascular health, bone health and fertility, particular attention needs to be paid to these outcomes. Preparing patients and their families for a successful transition from pediatric to adult rheumatology care is an important first-step in the long-term management strategy for this expanding patient population.
Transition of care from pediatric to adult providers is an essential step in the care of young adults with sickle cell anemia. Transition programs should be developed by individual institutions to systematically enhance the transition process for their patients. Prior to transfer, patients must be educated about their disease and personal medical history and develop skill sets required to navigate the adult health care setting. The objective of this literature review is to identify key concepts associated with transition of care for patients with sickle cell anemia. First, transition programs should be developed so that education about transition can begin at an early age. The readiness of patients and families should be assessed and education tailored to meet individual patient needs. Finally, the emotions and fears about transition should be recognized and addressed prior to transition.
anemia; sickle cell; transition to adult care; health transition; adult care
Acute gastroenteritis remains a common condition among infants and children throughout the world. In 1996, The American Academy of Pediatrics (AAP) revised its recommendations for the treatment of infants and children with acute gastroenteritis.
The purpose of this survey was to determine how closely current treatment among Lebanese pediatricians compares with the AAP recommendations and to determine the impact of such management on the healthcare system.
Patients and Methods:
The outline of the study was based on a telephone questionnaire that addressed the management of healthy infants and children below five years of age with acute gastroenteritis complicated by mild to moderate dehydration. In addition, the costs of medical treatment and requested laboratory studies were calculated.
A total of 238 pediatricians completed the questionnaire. Most pediatricians prescribed Oral Rehydration Solutions (ORS) for rehydration (92.4%), advised breastfeeding during acute gastroenteritis (81.5%), and avoided parenteral rehydration for mild to moderate dehydration (89.1%). In addition to ORS, oral fluids such as soda, juices, and rice water were allowed for rehydration by 43.7% of pediatricians. Thirty-one percent of pediatricians delayed re-feeding for more than 6 hours after initiation of rehydration. Only 32.8% of pediatricians kept their patients on regular full-strength formulas, and only 21.8% permitted full-calorie meals for their patients. 75.4% of pediatricians did not order any laboratory studies in cases of mild dehydration and 50.4% did not order any laboratory studies for moderate dehydration. Stool analysis and culture were ordered by almost half of the pediatricians surveyed. Seventy-seven percent prescribed anti-emetics, 61% prescribed probiotics, 26.3% prescribed antibiotics systematically and local antiseptic agents, 16.9% prescribed zinc supplements, and 11% percent prescribed antidiarrheal agents.
Pediatricians in Lebanon are aware of the importance of ORS and the positive role of breastfeeding in acute gastroenteritis. However, they do not follow optimal recommendations from the AAP concerning nutrition, laboratory examinations and drug prescriptions. Consequently, this poses significant financial losses and economic burden.
Acute gastroenteritis; Lebanese pediatricians; laboratory studies in acute gastroenteritis in children; oral rehydration solutions
To determine the use of spirometry in family practice, internal medicine, and pediatric outpatient settings.
Data were collected from 45 outpatient offices in the central Pennsylvania area via phone survey that asked a set of four questions: 1) Do you have spirometry in your office? 2) Do you use spirometry for asthma patients? 3) In what situation do you use spirometry for? 4) Do you use spirometry more for chronic obstructive pulmonary disease (COPD) or asthma?
It was found that pediatricians used spirometry 66% of the time, family practitioners 47% of the time, and internal medicine practitioners 60% of the time. Of those who did not use spirometry, 94% stated that they refer to a hospital if they required spirometry and 6% referred to subspecialists if the patient required spirometry. 10% of pediatricians performed the test on each asthma visit, otherwise the others used it only for exacerbations or as a baseline. No internists used spirometry regularly for asthma patients, and 22% used it more for COPD. In family practice only 14% used spirometry routinely at each visit for asthma patients.
Pediatricians used spirometry more often in the outpatient setting than other specialists, followed closely by internal medicine physicians. Family practice physicians were the least likely to use spirometry. Multiple barriers seemed to prevent routine use of spirometry, but no one barrier accounted for the majority.
spirometry; asthma; primary care
It is widely recognised that many patients do not take prescribed medicines as advised.
Research in this field has commonly focused on the role of the patient in non-adherence;
however, healthcare professionals can also have a major influence on patient behaviour
in taking medicines. This study examines the perceptions, beliefs and behaviours of
healthcare professionals—doctors, pharmacists and nurses—about patient
Methods and analysis
This paper describes the study protocol and online questionnaire used in a
cross-sectional survey of healthcare professionals in Europe. The participating
countries include Austria, Belgium, France, Greece, The Netherlands, Germany, Poland,
Portugal, Switzerland, Hungary, Italy and England. The study population comprises
primary care and community-based doctors, pharmacists and nurses involved in the care of
adult patients taking prescribed medicines for chronic and acute illnesses.
Knowledge of the nature, extent and variability of the practices of healthcare
professionals to support medication adherence could inform future service design,
healthcare professional education, policy and research.
A protocol for a cross-sectional survey of healthcare professionals in Europe to
examine the perceptions, beliefs and behaviours of healthcare
professionals—doctors, pharmacists and nurses—about patient medication
The questionnaire used in the survey of healthcare professionals is described in
There is an acute need for evidence regarding healthcare professionals'
beliefs, perceptions and behaviour with regard to patient non-adherence to
This protocol describes a study to address this need.
The results of this study could guide healthcare professionals as they support
patients with taking medicine in their day-to-day clinical practice.
Strengths and limitations of this study
The survey is the largest cross-national survey of healthcare professionals'
approach to medication adherence.
Reliance on self-report data may raise concerns regarding the validity of the
Health care costs and government cutbacks in Canadian training posts have caused concerns about physician manpower. To determine the present pediatric manpower situation a cross-country survey was undertaken of all pediatricians and their practice patterns. Of the 2060 recipients of a questionnaire 5% were found to not be pediatricians. Of the remaining 1960, 69% returned a completed questionnaire. Overall, 70% of the pediatricians were men, although among those less than 35 years of age 49% were women. Across Canada 37% of the pediatricians practised primary care, 25% secondary care and 38% tertiary care. There were wide regional differences in practice patterns, with large numbers of primary care pediatricians in Winnipeg, Toronto, Ottawa and the province of Quebec; few pediatricians in the Maritimes and the remainder of western Canada practised primary care. Non-Canadian graduates accounted for 33% of the pediatricians and represented a considerable proportion of tertiary care pediatricians. Cutbacks in numbers of pediatric training positions and restrictions on immigration of foreign pediatricians may lead to unexpected deficiencies in the availability of some types of pediatric practitioners, especially those in tertiary care.
The objective of this survey was to assess adult primary care physicians’ and pediatricians’ perceptions of asthma exacerbation management, including beliefs concerning the discharge of patients from the emergency department (ED) following asthma exacerbations.
This was a cross-sectional survey of primary care physicians (PCPs) treating adult or pediatric patients. Surveys were mailed to physicians and included questions on how PCPs define an exacerbation, how they are notified and how they followed-up with their patients who experienced exacerbations.
A total of 189 physicians were targeted in this survey, with 124 (65%) returning a completed survey. The majority of physicians agreed that an exacerbation included worsening asthma requiring a course of oral corticosteroids (83%). However, ≥70% of physicians agreed that an exacerbation could also include events which did not require OCS. Overall, 71% of PCPs believed that the majority of their patients’ asthma exacerbations were treated in the doctor’s office with only 6% believing the majority were treated in the ED. Over 90% of PCPs surveyed said they scheduled a follow-up with their patients “all or most of the time” when notified of an ED visit for an asthma exacerbation. Of the adult PCPs surveyed, 20% said they were never notified when one of their patients received treatment in the hospital because of an asthma exacerbation, whereas only 10% of pediatricians said they were never notified. The majority of PCPs surveyed (79%) indicated that if a controller medication was warranted, the ED staff should initiate treatment at time of discharge.
This study showed that healthcare providers may not share a common definition of an asthma exacerbation. In addition, most physicians believe that the majority of exacerbations are treated in their office or at home. Further, most agreed that if a controller medication was warranted, the ED or urgent care staff should initiate treatment.
Asthma; exacerbations; emergency department; primary care.
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.
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.
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.
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.
Kawaski disease (KD) is an acute, self-limited vasculitis that typically occurs in young children and was first described by Japanese pediatrician Tomisaku Kawasaki in 1967. Although originally thought to be a rare condition, KD has become the most common cause of acquired heart disease in the pediatric age group in developed countries. The majority of patients with KD appear to have a benign prognosis but a subset of patients with coronary artery aneurysms are at risk for ischemic events and require lifelong treatment. In the four decades that have passed since the initial recognition of KD, the number of patients reaching adulthood has continued to grow. Adult cardiologists will be increasingly involved in the management these patients. Currently, there are no established guidelines for the evaluation and treatment of adult patients who have had KD. We review here the current literature that may be helpful to clinicians who care for adults who suffered from KD in childhood.
aneurysm; vasculitis; myocardial infarction; myocardial flow reserve; myocarditis
Integrated management of neonatal and childhood illness (IMNCI) is already operational in many states of India, but there are very few studies in Indian scenario comparing its validity and reliability with the pediatricians’ decisions.
1) To compare the IMNCI decision with the decision of pediatricians; 2) to assess the significance of multiple presenting symptoms in the IMNCI algorithm.
Materials and Methods:
The study was conducted among the sick children between 2 months to 5 years presented in pediatric department from January to March 2009. The IMNCI decision was compared with pediatrician's decisions by percent agreement, Kappa and weighted Kappa with the aids of SPSS version 10.
The overall diagnostic agreement between IMNCI algorithm and pediatrician's decisions was 36.64%, (Kappa 0.16 and weighted Kappa 0.29) with 51.15% over diagnosis and 12.21% under diagnosis. The importance given by IMNCI algorithm in cases of multiple presenting symptoms was also reflected as it was evident that 37.50% children presented with three symptoms were categorized as red, whereas it was 28.57% and 11.67% for those presented with two and one symptom, respectively, (P < 0.0001). Pediatricians also gave importance for presence of multiple symptoms by considering 50% as admissible in the group presented with three symptoms, 30.16% in the group presented with two symptoms, and 16.67% in the group presented with only one symptom. The association was also statistically significant (P = 0.018).
Diagnostic discordance is seen mainly due to over diagnosis of all fever cases as malaria. Importance of presence of comorbidities was also reflected.
IMNCI; Kappa; validation study; weighted kappa