- Pediatrics, General
- Health Service Area
Vice President for Quality, Lucile Packard Children's hospital (1995 - 2000)
Residency:Mount Zion Medical Center (1974) CA
Medical Education:University of Illinois College of Medicine (1972) IL
Residency:Stanford University School of Medicine (1975) CA
Board Certification: Pediatrics, American Board of Pediatrics (1978)
Internship:Strong Memorial Hospital (1973) NY
Fellowship, Stanford University, RWJ Clinical Scholar (1977)
MD, University of Illinois, Medicine (1972)
BA, Yale University, Psychology (1968)
Community and International Work
Asthma care in the schools, East Palo Alto, CA
Ravenswood Unified School District
School Children K-8
Opportunities for Student Involvement
Current Research and Scholarly Interests
My research has involved the use of new technologies to create different types of patient-doctor transactions. I am also interested in how these new transactions impact clinical care processes. Current work includes the evaluation of a patient portal for children with cystic fibrosis, the use of telemedicine to bring asthma experts into the schools and the attitudes of teens and parents about the use of a secure patient portal for teens.
- Independent Studies (5)
Graduate and Fellowship Programs
Continuing education needs of pediatricians across diverse specialties caring for children with medical complexity.
2015; 54 (3): 222-227
Objective. Care for children with medical complexity (CMC) relies on pediatricians who often are ill equipped, but striving to provide high quality care. We performed a needs assessment of pediatricians across diverse subspecialties at a tertiary academic US children's hospital about their continuing education needs regarding the care of CMC. Methods. Eighteen pediatricians from diverse subspecialties were asked to complete an online anonymous open-ended survey. Data were analyzed using modified grounded theory. Results. The response rate was 89% (n = 16). Of participants, 31.2% (n = 5) were general pediatricians, 18.7% (n = 3) were hospitalists, and 50% (n = 8) were pediatric subspecialists. Pediatricians recognized the need for skills in care coordination, giving bad news, working in interprofessional teams, and setting goals of care with patients. Conclusions. Practicing pediatricians need skills to improve care for CMC. Strategically incorporating basic palliative care education may fill an important training need across diverse pediatric specialties.
View details for DOI 10.1177/0009922814564049
View details for PubMedID 25561699
Challenges and Potential Solutions to Educating Learners About Pediatric Complex Care
2014; 14 (6): 603-609
View details for Web of Science ID 000344966800013
- Palliative care is critical to the changing face of child mortality and morbidity in the United States. Clinical pediatrics 2014; 53 (11): 1030-1031
Internet-Based Developmental Screening: A Digital Divide Between English- and Spanish-Speaking Parents
2011; 128 (4): E939-E946
Internet-based developmental screening is being implemented in pediatric practices across the United States. Little is known about the application of this technology in poor urban populations.We describe here the results of focus groups, surveys, and in-depth interviews during home visits with families served by an urban safety-net organization to address the question of whether it is possible to use Internet or e-mail communication for medical previsit engagement in a population that is majority Hispanic, of low socioeconomic status, and has many non-English-speaking families.This study included families in 4 clinics within a safety-net health care system. The study design included the use of (1) parental surveys (n = 200) of a convenience sample of parents whose children received primary care in the clinics, (2) focus groups (n = 7 groups) with parents, and (3) in-depth interviews during home visits with 4 families. We used χ(2) and multivariate analyses to compare Internet access in English- and Spanish-speaking families. Standard qualitative methods were used to code focus-group texts and identify convergent themes.In multivariate analysis, independent factors associated with computer use were English versus Spanish language (odds ratio: 3.2 [95% confidence interval: 1.4-6.9]) and education through at least high school (odds ratio: 4.7 [95% confidence interval: 2.3-9.7]). In focus groups, the concept of parental previsit work, such as developmental screening tests, was viewed favorably by all groups. However, many parents expressed reservations about doing this work by using the Internet or e-mail and stated a preference for either paper or telephone options. Many Spanish-speaking families discussed lack of access to computers and printers.In this economically disadvantaged population, language and maternal education were associated with access to the Internet. Given the potential power of previsit work to tailor well-child visits to the needs of individual families, alternative strategies to using the Internet should be explored for populations without reliable Internet access.
View details for DOI 10.1542/peds.2010-0111
View details for Web of Science ID 000295406800020
View details for PubMedID 21911347
Moving From Research to Large-Scale Change in Child Health Care
2011; 11 (5): 360-368
There is a large and persistent failure to achieve widespread dissemination of evidence-based practices in child health care. Too often studies demonstrating evidence for effective child health care practices are not brought to scale and across different settings and populations. This failure is not due to a lack of knowledge, but rather a failure to bring to bear proven methods in dissemination, diffusion, and implementation (DD&I) science that target the translation of evidence-based medicine to everyday practice. DD&I science offers a framework and a set of tools to identify innovations that are likely to be implemented, and provides methods to better understand the capabilities and preferences of individuals and organizations and the social networks within these organizations that help facilitate widespread adoption. Successful DD&I is dependent on making the intervention context sensitive without losing fidelity to the core components of the intervention. The achievement of these goals calls for new research methods such as pragmatic research trials that combine hypothesis testing with quality improvement, participatory research that engages the target community at the beginning of research design, and other quasi-experimental designs. With the advent of health care reform, it will be extremely important to ensure that the ensuing large demonstration projects that are designed to increase integrated care and better control costs can be rapidly brought to scale across different practices settings, and health plans and will be able to achieve effectiveness in diverse populations.
View details for Web of Science ID 000295347100005
View details for PubMedID 21783449
The Use of Internet-Based Technology to Tailor Well-Child Care Encounters
2009; 124 (1): E37-E43
The goal was to evaluate the feasibility and acceptance of a new model for well-child care (WCC) in a large health maintenance organization.We designed a new model of WCC that engages families in Internet-based developmental and behavioral screening, allows for review of the results before the visit, and allows for selection of the appropriate visit type (e-visit, e-visit with brief provider visit, or extended encounter). The new model was pilot-tested in 2 practices within a large health maintenance organization. Seven providers and 70 parents participated in the study. Parents and providers were surveyed regarding their experience and satisfaction with the encounter.Seventy-five percent of parents thought that the online previsit assessment improved or very much improved the WCC visit. However, 12% of parents found the online assessment somewhat or very difficult to use. All of the parents found the e-visit or the e-visit with brief provider visit acceptable or very acceptable, compared with a standard WCC visit. All 7 providers thought that use of the new model helped focus the visit and that they would continue or definitely continue to use the model.We demonstrated the feasibility of a new model of WCC that engaged parents in previsit assessment and used alternative visit types to tailor care to the needs of the family. Future research will be needed to examine the impact of this model on important WCC outcomes.
View details for DOI 10.1542/peds.2008-3385
View details for Web of Science ID 000267448100061
View details for PubMedID 19564267
The use of telemedicine access to schools to facilitate expert assessment of children with asthma.
International journal of telemedicine and applications
Research has shown that access to an asthma specialist improves asthma outcomes. We hypothesized that we could improve access to expert asthma care through a telemedicine link between an asthma specialist and a school-based asthma program. We conducted a prospective cohort study in 3 urban schools to ascertain the feasibility of using an asthma-focused telemedicine solution. Each subject was seen by an asthma expert at 0, 8, and 32 weeks. The assessment and recommendations for care were sent to the primary care physician (PCP) and parents were told to contact their physician for follow-up care. Eighty three subjects participated in the study. Subjects experienced improvement (P < .05) in family social activities and the number of asthma attacks. Ninety four percent of subjects rated the program as good or excellent. This study demonstrates the feasibility and acceptance of a school-based asthma program using a telemedicine link to an asthma specialist.
View details for DOI 10.1155/2008/159276
View details for PubMedID 18369409
Teen use of a patient portal: a qualitative study of parent and teen attitudes.
Perspectives in health information management / AHIMA, American Health Information Management Association
2008; 5: 13-?
We conducted a qualitative study of the attitudes of teens and parents toward the use of a patient portal. We conducted two teen and two parent focus groups, one teen electronic bulletin board, and one parent electronic bulletin board. Videotapes and transcripts from the groups were independently analyzed by two reviewers for significant themes, which were then validated by two other members of the research team. Twenty-eight teens and 23 parents participated in the groups. Significant themes included issues about teens' control of their own healthcare; enthusiasm about the use of a patient portal to access their providers, seek health information, and make appointments; and concerns about confidentiality. In summary, there was considerable support among teens and parents for a patient portal as well as concerns about confidentiality. The teen portal affords an opportunity to negotiate issues of confidentiality.
View details for PubMedID 18923702
Does clinical presentation explain practice variability in the treatment of febrile infants?
2006; 117 (3): 787-795
Previous studies documented considerable variability in the treatment of febrile infants, despite the existence of practice guidelines for this condition. None of those studies documented the extent to which this variability is accounted for by differences in clinical severity.To quantify the individual effects of the patient's clinical presentation, demographic, provider, and practice characteristics, and regional variables on practice variability in the evaluation and treatment of febrile infants.With data collected through the Pediatric Research in Office Settings network, we analyzed data on the treatment of 2712 febrile infants examined by 484 pediatricians located in 194 practices. We analyzed hospitalization, lumbar puncture, urinalysis and/or urine culture, blood work, and initial antibiotic administration. We obtained a summary score for evaluation and treatment intensity (ranging from no tests or treatments to comprehensive testing, hospitalization, and antibiotic therapy) by performing principal-components analysis with these 5 variables. This summary score was regressed with respect to patients' clinical presentation, demographic and practice/practitioner features, and geographic region. Provider fixed effects were also included in the model.Although the overall model explained 46.5% of the variance, the clinical characteristics of the patient alone explained 29.7% of the overall variance. Practice site fixed effects explained nearly 15% of the overall variance. Provider and practitioner characteristics and geographic region had minimal explanatory power.Our results show that measures of the patient's clinical presentation account for nearly one third of the variability that our model explains. This suggests that differences in clinical presentation and severity of illness underlie much of the observed practice variability among pediatricians evaluating and treating febrile infants. These findings demonstrate that the management of this common and potentially serious condition depends more on the clinical presentation of the patient than on the characteristics of the provider/practice and the residential region.
View details for DOI 10.1542/peds.2005-0947
View details for Web of Science ID 000235709000050
View details for PubMedID 16510659
Effectiveness of a multicomponent self-management program in at-risk, school-aged children with asthma
ANNALS OF ALLERGY ASTHMA & IMMUNOLOGY
2004; 92 (6): 611-618
Improving asthma knowledge and self-management is a common focus of asthma educational programs, but most programs have had little influence on morbidity outcomes. We developed a novel multiple-component intervention that included the use of an asthma education video game intended to promote adoption of asthma self-management behaviors and appropriate asthma care.To determine the effectiveness of an asthma education video game in reducing morbidity among high-risk, school-aged children with asthma.We enrolled 119 children aged 5 to 12 years from low-income, urban areas in and around San Francisco, CA, and San Jose, CA. Children with moderate-to-severe asthma and parental reports of significant asthma health care utilization were randomized to participate in the disease management intervention or to receive their usual care (control group). Patients were evaluated for clinical and quality-of-life outcomes at weeks 8, 32, and 52 of the study.Compared with controls, the intervention group had significant improvements in the physical domain (P = .04 and P = .01 at 32 and 52 weeks, respectively) and social activity domain (P = .02 and P = .05 at 32 and 52 weeks, respectively) of asthma quality of life on the Child Health Survey for Asthma and child (P = .02 at 8 weeks) and parent (P = .04 and .004 at 32 and 52 weeks, respectively) asthma self-management knowledge. There were no significant differences between groups on clinical outcome variables.A multicomponent educational, behavioral, and medical intervention targeted at high-risk, inner-city children with asthma can improve asthma knowledge and quality of life.
View details for Web of Science ID 000222121500007
View details for PubMedID 15237762
The use of telemedicine access to schools to facilitate expert assessment of children with asthma
NATURE PUBLISHING GROUP. 2004: 203A-203A
View details for Web of Science ID 000220591101198
Management and outcomes of care of fever in early infancy
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2004; 291 (10): 1203-1212
Fever in infants challenges clinicians in distinguishing between serious conditions, such as bacteremia or bacterial meningitis, and minor illnesses. To date, the practice patterns of office-based pediatricians in treating febrile infants and the clinical outcomes resulting from their care have not been systematically studied.To characterize the management and clinical outcomes of fever in infants, develop a clinical prediction model for the identification of bacteremia/bacterial meningitis, and compare the accuracy of various strategies.Prospective cohort study.Offices of 573 practitioners from the Pediatric Research in Office Settings (PROS) network of the American Academy of Pediatrics in 44 states, the District of Columbia, and Puerto Rico.Consecutive sample of 3066 infants aged 3 months or younger with temperatures of at least 38 degrees C seen by PROS practitioners from February 28, 1995, through April 25, 1998.Management strategies, illness frequency, and rates and accuracy of treating bacteremia/bacterial meningitis.The PROS clinicians hospitalized 36% of the infants, performed laboratory testing in 75%, and initially treated 57% with antibiotics. The majority (64%) were treated exclusively outside of the hospital. Bacteremia was detected in 1.8% of infants (2.4% of those tested) and bacterial meningitis in 0.5%. Well-appearing infants aged 25 days or older with fever of less than 38.6 degrees C had a rate of 0.4% for bacteremia/bacterial meningitis. Frequency of other illnesses included urinary tract infection, 5.4%; otitis media, 12.2%; upper respiratory tract infection, 25.6%; bronchiolitis, 7.8%; and gastroenteritis, 7.2%. Practitioners followed current guidelines in 42% of episodes. However, in the initial visit, they treated 61 of the 63 cases of bacteremia/bacterial meningitis with antibiotics. Neither current guidelines nor the model developed in this study performed with greater accuracy than observed practitioner management.Pediatric clinicians in the United States use individualized clinical judgment in treating febrile infants. In this study, relying on current clinical guidelines would not have improved care but would have resulted in more hospitalizations and laboratory testing.
View details for Web of Science ID 000220061900020
View details for PubMedID 15010441
Effect of a clinical practice improvement intervention on chlamydial screening among adolescent girls
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2002; 288 (22): 2846-2852
Chlamydia trachomatis infection is a serious public health concern that disproportionately affects adolescent girls. Although annual C trachomatis screening of sexually active adolescent girls is recommended by health professional organizations and is a Health Employer Data and Information Set (HEDIS) performance measure, this goal is not being met.To test the effectiveness of a system-level, clinical practice improvement intervention designed to increase C trachomatis screening by using urine-based tests for sexually active adolescent girls identified during their routine checkups at a pediatric clinic.A randomized cluster of 10 pediatric clinics in the Kaiser Permanente of Northern California health maintenance organization, where adolescent girls aged 14 to 18 years had a total of 7920 routine checkup visits from April 2000 through March 2002.Five clinics were randomly assigned to provide usual care and 5 to provide the intervention, which required that leadership be engaged by showing the gap between best practice and current practice; a team be assembled to champion the project; barriers be identified and solutions developed through monthly meetings; and progress be monitored with site-specific screening proportions.Chlamydia trachomatis screening rate for sexually active 14- to 18-year-old girls during routine checkups at each participating clinic.The population of adolescents was ethnically diverse with an average age of 15.4 years. Twenty-four percent of girls in the experimental clinics and 23% in the control clinics were sexually active. Of the 1017 patients eligible for screening in the intervention clinic, 478 (47%) were screened; of 1194 eligible for screening in the control clinic, 203 (17%) were screened. At baseline, the proportion screened was 0.05 (95% confidence interval [CI], 0.00-0.17) in the intervention and 0.14 (95% CI, 0.01-0.26) in the control clinics. By months 16 to 18, screening rates were 0.65 (95% CI, 0.53-0.77) in the intervention and 0.21 (95% CI, 0.09-0.33) in the control clinics (time period by study group interaction, F(6,60) = 5.33; P<.001). The average infection rate for the experimental clinics was 5.8% (23 positive test results out of 393 total urine tests and a total of 3986 clinic visits) vs 7.6% in controls (12 positive test results out of 157 tests and 3934 clinic visits).Implementation of this clinical practice intervention in a large health maintenance organization system is feasible, and it significantly increased the C trachomatis screening rates for sexually active adolescent girls during routine checkups.
View details for Web of Science ID 000179732600029
View details for PubMedID 12472326
Agreement among measures of asthma status: A prospective study of low-income children with moderate to severe asthma
2002; 110 (4): 797-804
Because no validated "gold standard" for measuring asthma outcomes exists, asthma interventions are often evaluated using a large number of disease status measures. Some of these measures may be redundant, whereas others may be complementary. Use of multiple outcomes may lead to ambiguous results, increased type I error rates, and be an inefficient use of resources including caregiver and patient/participant time and effort. Understanding the relationship between these measures may facilitate more parsimonious and valid evaluation strategies without loss of information.To assess the relationships between multiple measures of asthma disease status over time.We used data from a randomized, controlled trial of a comprehensive disease management program involving 119 disadvantaged inner-city children aged 5 to 12 years with moderate to severe asthma. Spearman correlations were calculated between the following asthma disease status measures: parent-reported disease symptoms, parent-reported health care utilization, functional health status using the American Academy of Pediatrics' validated Child Health Survey for Asthma (CHSA), diary data (symptom scores, night wakings, and bronchodilator use), and pulmonary function tests at baseline, 32 weeks, 52 weeks, and changes from baseline to 52 weeks.Ninety-four (79%) of randomized patients participated at baseline and 52 weeks. Completion rates for outcome measures ranged from 79% (CHSA, spirometry data) to 64% (diary data). At baseline, asthma symptoms, health care utilization, and individual domains from the CHSA were significantly correlated (r = 0.21-0.53). These correlations were stable over the 52-week follow-up. Forced expiratory volume in 1 second and diary data did not correlate to any other measures at baseline, and these measures correlated only inconsistently with other measures at 32 weeks and 52 weeks. Baseline to 52-week changes in asthma symptoms, utilization, and the CHSA domains were significantly correlated (0.22-0.56), as were baseline to 52-week changes in symptom days, night wakings, and the CHSA domains (r = 0.24-0.64). Baseline to 52-week changes in forced expiratory volume in 1 second and diary data did not correlate with other measures.These results suggest that asthma status and change in asthma status over time after introduction of a disease management intervention are best characterized by parent-reported symptoms, parent-reported utilization, and functional health status measures. Asthma diaries and pulmonary function tests did not seem to provide additional benefit, although they may play an important role in individual patient management. Our findings suggest a parsimonious evaluation strategy would include collection of key data elements regarding symptoms, utilization, and functional health status only, without loss of vital response information.
View details for Web of Science ID 000178330200033
View details for PubMedID 12359798
Effect of an evidence-based hand washing policy on hand washing rates and false-positive coagulase negative staphylococcus blood and cerebrospinal fluid culture rates in a level III NICU.
Journal of perinatology
2002; 22 (2): 137-143
To determine the effect of implementing an evidence-based hand washing policy on between-patient hand washing compliance and on blood and cerebrospinal fluid (CSF) culture rates in a level III neonatal intensive care unit (NICU).An evidence-based hand washing policy, supported by an intensive education program, was introduced in a regional NICU. A total of 2009 preintervention neonates (16,168 patient days) over 17 months were compared to 676 postintervention neonates (5779 patient days) over 6 months. Hand washing compliance and rates of blood and CSF cultures yielding coagulase negative staphylococci (CONS) were compared before and after intervention.Compliance with appropriate between-patient hand washing improved (from 47.4% to 85.4%, p=0.001) after the hand washing policy was introduced. The rate of cultures positive for CONS declined from 6.1+/-2.3 to 3.2+/-1.6 per 1000 patient days (p=0.005). Most of this reduction was attributable to a reduction in false-positive cultures, from 4.2+/-2.4 to 1.9+/-1.8 per 1000 patient days (p=0.042), but there was a trend toward decreased true-positive cultures (from 2.1+/-1.2 to 1.2+/-1.0 per 1000 patient days, p=0.074) as well. Potential confounders and demographics factors were similar between the control and intervention subjects.Implementation of an evidence-based hand washing policy resulted in a significant increase in hand washing compliance and a significant decrease in false-positive coagulase negative staphylococcal blood and CSF culture rates. Exploratory data analysis revealed a possible effect on true-positive coagulase negative staphylococcal blood and CSF culture rates, but these results need to be confirmed in future studies.
View details for PubMedID 11896519
Environmental exposure and sensitization to cockroach, dust mite, and cat allergen: Correlation with asthma symptoms in a population of disadvantaged, inner-city children in the San Francisco Bay Area
MOSBY-ELSEVIER. 2002: S88-S88
View details for Web of Science ID 000173744800231
The effect of inhaled steroids on the linear growth of children with asthma: A meta-analysis
2000; 106 (1)
To determine whether inhaled steroid therapy causes delayed linear growth in children with asthma.Medline (1966-1998), Embase (1980-1998), and Cinahl (1982-1998) databases and bibliographies of included studies were searched for randomized, controlled trials of inhaled steroid therapy in children with asthma that evaluated linear growth.Studies were included if they met the following criteria: subjects 0 to 18 years of age with the clinical diagnosis of asthma; subjects randomized to inhaled beclomethasone, budesonide, flunisolide, fluticasone, or triamcinolone versus a nonsteroidal inhaled control for a minimum of 3 months; single- or double-blind; and outcome convertible to linear growth velocity. English- and non-English-language trials were included.Data were extracted using a priori guidelines. Methodologic quality was assessed independently by both authors. Outcome was extracted as linear growth velocity.Included trials were subgrouped by inhaled steroid. The beclomethasone subgroup, with 4 studies and 450 subjects, showed a decrease in linear growth velocity of 1.51 cm/year (95% confidence interval: 1.15,1.87). The fluticasone subgroup, with 1 study and 183 subjects, showed a decrease in linear growth velocity of.43 cm/year (95% confidence interval:.01,.85). Sensitivity analysis in the beclomethasone subgroup, which evaluated study quality, mode of medication delivery, control medication, and statistical model, showed similar results.This meta-analysis suggests that moderate doses of beclomethasone and fluticasone in children with mild to moderate asthma cause a decrease in linear growth velocity of 1.51 cm/year and.43 cm/year, respectively. The effects of inhaled steroids when given for >54 weeks, or on final adult height, remain unknown.
View details for Web of Science ID 000087990400013
View details for PubMedID 10878177
Beclomethasone for asthma in children: effects on linear growth.
Cochrane database of systematic reviews
Inhaled steroids play a central role in the management of childhood asthma. There is concern about their side effects, especially on growth. However asthma may also cause growth retardation. Growth rates are not stable, so randomised controlled parallel group studies are needed to assess the impact of inhaled steroids on growth. This review is confine to one inhaled steroid, beclomethasone, that is known to have significant levels of systemic absorption.To determine whether inhaled beclomethasone cause significant delay in the linear growth of children with asthma.The Cochrane Airways Group asthma register was searched. Bibliographies from included studies, and known reviews were searched for additional citations. Personal contact with colleagues and researchers working in the field of asthma were made to identify potentially relevant trials.Randomized, controlled trials comparing the effects of beclamethasone to non-steroidal medication (placebo or non-steroidal therapy) on the linear growth of children with asthma.Data related to the clinical outcome "change in growth" were extracted by two reviewers working independentlyOne hundred and fifty-nine citations were identified by the search strategy and bibliography review. Three studies met the inclusion criteria. All used beclomethasone 200 mcg twice daily delivered by dry powder Diskhaler to treat children with mild-moderate asthma. Study duration was 7-12 months. In all three studies, a significant decrease in linear growth occurred in children treated with beclomethasone compared to those receiving placebo or non-steroidal asthma therapy. The average decrease, calculated through meta-analysis, was -1.54 cm per year (95% CI -1.15, -1.94).In children with mild-moderate asthma, beclomethasone 200 mcg twice daily caused a decrease in linear growth of -1.54 cm per year. These studies lasted a maximum of 54 weeks, so it remains unclear whether the decrease in growth is sustained or whether it reverses with 'catch up' after therapy is discontinued. We are unable to comment on growth effects of other inhaled steroids that have potentially less systemic effects. If inhaled steroids are required to control a child's asthma, we recommend using the minimum dose that effectively controls the child's asthma and closely following growth.
View details for PubMedID 10796632
Evidence-based guidelines and critical pathways for quality improvement.
1999; 103 (1): 225-232
Clinical practice guidelines have a long and distinguished tradition in pediatrics. Currently, the American Academy of Pediatrics has developed more than 15 practice guidelines and more than 250 clinical policy statements. In the past, practice guidelines have been used to improve care through the dissemination of evidence-based, clinically effective practices to pediatric practitioners. In the current environment this purpose has been broadened to include cost reduction, standardization of practice, and reduction of medical liability. This has led to both confusion and distrust on the part of the pediatrician. Practice guidelines are best understood as a tool to insure that children receive evidence-based care. They are best used in association with a set of outcome and performance measures that provide feedback to clinicians and allow for modification of the guidelines to meet the needs of the local patient population. The quality of practice guidelines is directly dependent on the quality of the medical evidence supporting the recommendation. Unfortunately only a small percentage of the evidence supporting practice guidelines comes from randomized clinical trials with the majority of the evidence coming from expert clinical panels. The success of practice guidelines in improving care for children has yet to be convincingly demonstrated. Currently, there is a dearth of well designed studies that document the effectiveness of practice guidelines. Their ultimate effectiveness will depend on both an improved evidence base and effective strategies for rapid dissemination of the recommendations. The development of evidence-based practice guidelines does not insure that it will have a major impact on physician practice. In the past, effective dissemination of new knowledge has been a long process, often taking years. This cycle time can be dramatically shortened through the development of networks of practice sites that share knowledge and experience in the implementation of practice guidelines and the use of strategies that take advantage of key groups in the dissemination process. When used appropriately, practice guidelines can provide an important adjunct to clinical research by facilitating the dissemination of new clinical findings and can provide an important platform for encouraging innovations in patient care.
View details for PubMedID 9917466
Managed care and the quality of children's health services
FUTURE OF CHILDREN
1998; 8 (2): 60-75
Managed care has changed the practice of medicine. The choice of health care providers has been narrowed, physicians are being held financially accountable for the number of services they use, and a new emphasis is being placed on the cost and quality of the care provided. The transition to managed care has occurred with little attention to its impact on access to health care services or the quality of services provided. There is an absence of information about how children fare in these new systems. What little is known indicates that children in managed care arrangements are less likely to be able to be seen by pediatric specialists, and that families and providers are less satisfied under managed care. The impact of these changes on children's health status, however, is yet to be determined. For children with special needs, the problems of coordination of care, coverage of needed services, and the choice of the appropriate pediatric subspecialists, many of which existed in traditional fee-for-service systems, persist under managed care. In spite of all of the negative anecdotes about managed health care, managed care's focus on its population of enrollees and its heightened sense of a need for health care accountability bring exciting new opportunities to measure and improve the health care children receive. A new emphasis is being placed on practicing evidence-based medicine; the focus is on closing the gap between what is known (effective, evidence-based care) and what is done (current practice). Improved health outcomes and reduced health care costs have been documented in demonstration projects in neonatal intensive care units and in pediatric offices. Applying the principles of these learning collaboratives and employing the tools of continuous quality improvement in health care are urgent challenges that deserve to be met. Health plans, physicians, health care purchasers, regulators, families, and their children must work together to assure that children receive the highest-quality care possible--care that is technically excellent and medically appropriate, and that improves the health of our children.
View details for Web of Science ID 000076180400006
View details for PubMedID 9782650
- Hospital-based quality management: A program at the crossroads WESTERN JOURNAL OF MEDICINE 1997; 166 (2): 153-155
Clinical practice guidelines in pediatric and newborn medicine: Implications for their use in practice
1997; 99 (1): 100-114
Clinical practice guidelines are becoming pervasive in pediatrics and newborn medicine. They have spanned a wide range of primary care practice parameters from treating otitis media with effusion, to performing complex surgery for congenital heart disease, and management of respiratory distress syndrome and coordinating discharge from the neonatal intensive care unit. Administrators believe that using clinical practice parameters reduces health care costs, improves quality of care, and limits malpractice liability. Practice parameters and guidelines have grown in use because powerful interests-third-party payers, insurers, and health maintenance organizations, as well as hospital administrators bent on reducing variable costs of care and contracting for capitated care-champion their development, implementation, and monitoring. Economic credentialing of physicians with excessive variances without risk-adjusting for other than average patients is problematic and remains unchecked partly because of the fundamental characteristics of the evolving health care industry in which costs are more easily measured than quality. For highly autonomus physicians this standardization of medical decision making may represent a difficult transition into corporate practice by realigning traditional values of the doctor-patient relationship. However, because guidelines are almost certainly here to stay, pediatricians and neonatologists need to think critically about how their content and method of implementation, monitoring, and modification may influence medical teaching and decision making in the future. If guidelines are introduced primarily as a cost savings or containment tool that ignores the impact on the quality of care and restricts necessary care for infants and children, especially those with chronic illness or who are developmentally at risk, then neonatologists and pediatricians must be quick and determined to challenge the potentially damaging use of practice parameters or guidelines. Furthermore, there are many medicolegal implications of guideline implementation that may not favor physicians and leave to hospitals, insurers, and ultimately the courts decisions regarding evidence-based practice. In this review article, we pay special attention to the guidelines developed in newborn medicine. We discuss why and how guidelines are developed and critically evaluate the available evidence describing potential benefits and drawbacks of guidelines in general. There are legal implications to the implementation of guidelines, and guidelines may increase provider susceptibility to malpractice allegations. Neonatologists and pediatricians should critically analyze the following questions when guidelines are being developed: Are clinical practice parameters the most effective means to reduce the costs of health care, or improve the quality of health care services while reducing the need for and protecting physicians from malpractice suits? Or do clinical practice guidelines more closely resemble an audit system developed by health care organizations, insurers, and others including government-sponsored health care to appease powerful interests-with limited evidence for promise and perhaps potential negative cost, quality, and malpractice liability implications? In pediatric and newborn medicine there is limited evidence that guidelines have achieved the desired goals and further analysis of their process of care and the costs of implementation is warranted.
View details for Web of Science ID A1997WB35000018
View details for PubMedID 8989346
THRIVING IN THE 21ST-CENTURY - OUTCOME ASSESSMENT, PRACTICE PARAMETERS, AND ACCOUNTABILITY
AMER ACAD PEDIATRICS. 1995: 831-835
The past two decades have brought about major health care changes that have been driven by an ever-increasing cost of health care, practice variability, and medical malpractice litigation. These changes pose a challenge to pediatricians to contain costs, to reduce inappropriate use of health care services, and to demonstrate improved health care outcomes. To meet this challenge, a new "clinical tool kit" is required, one that will allow the pediatrician to analyze current practices and to document effective interventions. Two of the major tools in this kit are practice guidelines and outcomes assessment instruments. Practice guidelines are optimal care specifications that provide an analytic framework for defining high-quality care and measuring health care outcomes. Ideally, these guidelines should be developed from scientific evidence. In practice, however, scientific evidence to support the majority of recommendations made in guidelines is insufficient. Consequently, these recommendations are instead developed by expert consensus. Measurement of health outcomes includes clinical outcomes, patient satisfaction, cost and use, and quality of life. Health care organizations have become very sophisticated in measuring cost and use, but considerably less work has been done in the patient-centered areas of satisfaction and quality of life. This is particularly true for children, because measures are dependent on the viewpoint chosen (parent, child, or teacher), the age of the child, and the adjustment for severity of illness. Analyzing practice patterns and improving health outcomes will not be easy tasks to accomplish. For the pediatrician to use these tools in an efficient and effective manner, a new research agenda and new skills will be required.
View details for Web of Science ID A1995RZ55800010
View details for PubMedID 7567366
Quality improvement: buzz words or boon?
Pediatrics in review
1993; 14 (6): 208-213
View details for PubMedID 8327394
- TRAINING PEDIATRICS RESIDENTS TO USE CLINICAL OBSERVATION SCALES JOURNAL OF MEDICAL EDUCATION 1987; 62 (8): 695-697
USING STRUCTURED MEDICAL INFORMATION TO IMPROVE STUDENTS PROBLEM-SOLVING PERFORMANCE
JOURNAL OF MEDICAL EDUCATION
1986; 61 (9): 749-756
In the study reported here, the authors assessed the use of efficient organization of knowledge and of problem-solving strategies to enhance medical students' clinical problem-solving skills. Thirty-five preclinical medical students were randomly assigned to a experimental or control group and given a knowledge base containing information on eight congenital heart diseases to learn. Information for the experimental group emphasized disease groupings (based on their similar clinical presentation), symptom-disease associations, and clinical problem-solving heuristics. The same information for the control group was presented in a textbook format that emphasized the pathophysiology of the diseases. The students then diagnosed three computerized diagnostic problems of varying difficulty while verbalizing their problem-solving strategies. The results showed that the experimental group acquired a higher ratio of diagnostic to nondiagnostic cues, mentioned the correct diagnosis sooner in their workups, and correctly diagnosed the most difficult case more often than the control group. These results provide support for revisions in the organization and presentation of information that are aimed at improving clinical problem-solving skills.
View details for Web of Science ID A1986E038600007
View details for PubMedID 3528494
THE IMPACT OF READING A CLINICAL-STUDY ON TREATMENT DECISIONS OF PHYSICIANS AND RESIDENTS
JOURNAL OF MEDICAL EDUCATION
1986; 61 (5): 380-386
The study presented here reports on the impact of newly published clinical research on physicians' decisions. Eighty-three pediatricians, pediatric residents, and family practitioners were presented with a common, potentially serious problem, an infant with a high fever, and were required to estimate the probabilities of bacteremia and of acquiring meningitis and to choose from management options. The participants then read a published scientific report addressing the risks of meningitis in febrile infants and were asked afterward to answer again the questions relating to the clinical problem. After reading the study, the participants significantly increased their probability estimates of the patient acquiring meningitis. Only 14 percent of the participants would have hospitalized the patient before reading the article, but 47 percent would have done so after reading the article. Pediatricians were more likely than family practitioners to use antibiotics after reading the article. These decisions were not based not based on logical processing of information, as there was no correlation between the physicians' estimate of the risk of meningitis and the underlying risk of bacteremia and no correlation between the participants' decisions to hospitalize or use antibiotics and their estimated risk of the patient developing meningitis. Physicians appear to have considerable difficulty in using probability data and appear to base estimates of serious disease and subsequent management on intuition rather than calculation.
View details for Web of Science ID A1986C306400005
View details for PubMedID 3701813
The impact of clinical appearance on pediatric residents' assessment of the febrile infant.
Research in medical education : proceedings of the ... annual Conference. Conference on Research in Medical Education
1986; 25: 135-141
View details for PubMedID 3641558
Training resident physicians to use clinical prediction rules.
Research in medical education : proceedings of the ... annual Conference. Conference on Research in Medical Education
1986; 25: 122-128
View details for PubMedID 3641556
- THE ART AND SCIENCE OF MEDICAL DECISION-MAKING JOURNAL OF PEDIATRICS 1984; 104 (5): 649-656
- THE EFFECT OF THE INTRODUCTION OF A CONTINUITY CLINIC ON SUBSPECIALTY UTILIZATION JOURNAL OF MEDICAL EDUCATION 1983; 58 (9): 744-746
URINARY-TRACT INFECTION IN INFANTS WITH UNEXPLAINED FEVER - A COLLABORATIVE STUDY
JOURNAL OF PEDIATRICS
1983; 103 (6): 864-867
Nine centers collaborated to determine the rate of urinary tract infection in infants with unexplained fever, to determine whether the rate is higher in febrile infants than in asymptomatic infants, and whether the yield justifies urine cultures in febrile infants. Urine cultures were done in 501 infants 0 to 2 years of age. The rate of confirmed urinary tract infections in the 193 febrile infants was 4.1%. All infections were in girls, with a rate of 7.4%. The rate of confirmed urinary tract infections in the 312 asymptomatic infants was 0.3%; again, all infections were in girls, with a rate of 0.7%. The rate in febrile girls was significantly higher than the rate in asymptomatic girls (P less than 0.01). The data support the advisability of culturing the urine of infant girls with unexplained fever.
View details for Web of Science ID A1983RU25100005
View details for PubMedID 6644419
ANALYSIS OF A PROGRAM FOR MENTAL-HEALTH REFERRALS FROM A PEDIATRIC-CLINIC
JOURNAL OF DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS
1982; 3 (4): 232-235
A behavioral evaluation and referral unit (BERU) was established in a Children and Youth Project, to facilitate the referral of children with learning and behavioral problems that were beyond the scope of the general pediatrician. The BERU assessed the need for referral, determined the most appropriate receiving agency, initiated the appointment, and ascertained if the appointment was kept. Results of the program revealed that 48% of referrals to BERU were referred outside the Children and Youth Project. Eighty-four percent of this group completed their referral. Sixty percent received additional care either within or outside the Children and Youth Project. BERU evaluation was required for 25% of behavioral and learning problems presenting in a general pediatric clinic.
View details for Web of Science ID A1982PT93300008
View details for PubMedID 7153369
"The new morbidities," physician competence, and consumer utilization.
Journal of developmental and behavioral pediatrics
1980; 1 (2): 70-73
Results of a questionnaire assessing pediatricians' perceived competence regarding psychosocial, developmental and traditional medical problems were analyzed. The data were compared with a similar questionnaire distributed to seventh grade teachers, youth and parents assessing problems for which pediatricians were utilized. The results reveal that pediatricians rate their competency higher in the area of traditional medical problems. The implications of this study are discussed.
View details for PubMedID 7229050
- SOCIAL-WORK UTILIZATION IN PEDIATRICS - REFERRAL PREFERENCES AMONG TEACHERS, PARENTS, AND PEDIATRICIANS SOCIAL WORK IN HEALTH CARE 1980; 6 (2): 107-110