Factors associated with emergency department utilization for nonurgent pediatric problems.

OBJECTIVE: To identify specific caretaker and utilization characteristics predictive of the use of the emergency departments (EDs) for nonurgent reasons. Each year more than 20 million children in the United States seek medical care in EDs. Between one third and one half of these visits are for nonurgent reasons. DESIGN: A descriptive study conducted during a 6-month period. SETTING: Two urban hospital EDs. MEASURE: A questionnaire was designed to elicit information about specific caretaker characteristics and their reasons for using the ED for their child's nonurgent medical care. SUBJECTS: Two hundred caretakers and children brought to the ED for nonacute medical care. Caretakers in this study included mothers (82%) with a mean age of 30 years, single caretakers (70%), and unemployed caretakers (60%). The average age of the children was 6.2 years. RESULTS: Most caretakers (92%) reported having a continuity physician for their children. Caretakers who reported being taken to the ED when they were children (P<.002) and those with Medicaid insurance (P<.001) were more likely to view the ED as the usual site of care. Being a single parent was a predictor for nonurgent visits (P<.05). CONCLUSIONS: Predicting which caretakers are at risk for using the ED for nonurgent care when their children are sick provides the primary care physician a means of identifying specific patients who may benefit from interventions designed to promote a more cost-effective approach to using medical resources. Arch Fam Med. 2000;9:1086-1092

Residency orientation: what we present and its effect on our residents.

BACKGROUND AND OBJECTIVES: This study describes the content of family practice residency orientation programs, presents data about resident satisfaction with orientation, and determines if residents feel prepared for residency duties. METHODS: We surveyed program directors and first-year residents at 100 family practice residency programs. We used questionnaires to collect data about orientation activities; program demographics; and resident characteristics, satisfaction, and preparation. RESULTS: Sixty-nine percent of directors and 68% of their residents responded. The activity most frequently presented was a social event with faculty, while the least frequently presented was an assessment of cognitive knowledge. Even though residents desire orientation to clinical programs, and directors wish to promote group cohesion, the greatest number of orientation activities were presented to introduce hospital services and administration. Eighty-seven percent of residents were at least "somewhat satisfied," and 83% felt at least "somewhat prepared" for clinical duties after completing orientations. Residents from military programs were more likely not to be satisfied with their orientations. Extreme satisfaction was associated with residents in community-based programs. Being totally prepared was associated with having had prior graduate medical education. CONCLUSIONS: While residents had previously reported having clinical needs from an orientation, the most frequently reported activities were nonclinical. Most residents reported having been satisfied with their orientations and having felt prepared for their new duties. Directors should consider increasing the clinical content of their orientations, including an assessment of residents' knowledge and clinical skills.

Practices of family physicians and pediatricians in administering poliovirus vaccine.

BACKGROUND: When the Advisory Committee on Immunization Practices added the sequential schedule to the poliovirus vaccine (PW) recommendations in 1997, primary care physicians expressed concern about its implementation. This study examines the practices and factors influencing the administration of sequential, oral, or inactivated PW schedules by family physicians and pediatricians. METHODS: A random sample of Ohio family physicians and pediatricians was surveyed between January and April 1998. Primary outcome measures included physicians' awareness of the 1997 recommendations, their recommendations to parents and caregivers, administration of current PW options, and the factors influencing their practices. RESULTS: All physicians who immunize children (n = 263) reported awareness of the 1997 PW recommendations. Family physicians were more likely to recommend and administer oral polio vaccine than pediatricians (50% and 63% vs 17% and 28%; P < .001). Pediatricians were more likely to recommend and administer the sequential schedule than family physicians (66% and 67% vs 31% and 28%; P < .001). Choice of sequential schedule was related to the risk of vaccine-associated paralytic poliomyelitis and liability (P < or = .05). Choice of an all oral polio vaccine schedule was related to cost of inactivated PW and increased number of injections (P < or = .05). One hundred eighty-two physicians (69%) indicated that they personally discuss PW options with parents or caregivers; only 41% have them read the required vaccine information sheets. CONCLUSIONS: Differences exist between family physicians' and pediatricians' implementation of the 1997 PW recommendations. Physician choice of PW schedule is influenced by the risk of vaccine-associated paralytic poliomyelitis, increased number of injections, liability concerns, and vaccine cost. Physicians need to inform parents of vaccine benefits and risks to comply with federal regulations.

Right from the start: the family practice orientation study.

BACKGROUND AND OBJECTIVES: Orientation to a residency program introduces residents to the essential functions of their duties, clarifies expectations, and acclimates them to a new social group. This study identified the orientation goals of family practice residency directors and compared those goals to the perceived needs of first-year family practice residents. METHODS: We surveyed program directors and PGY-1 residents at 100 accredited family practice residency programs. Questionnaires obtained descriptive information about orientation programs and resident demographics and assessed directors' goals and residents' needs from orientations. RESULTS: The orientation goal ranked most highly by directors was development of group cohesion. The need ranked most highly by residents was introduction to call duties and inpatient problems. Ranked responses of each group were not well associated. CONCLUSIONS: The orientation goals of program directors and the reported orientation needs of residents were poorly associated. Most directors chose nonclinical areas as their most important goals for orientation. In contrast, most residents valued clinically related information during orientation to residency.

Home-based ventilator-dependent patients: measurement of the emotional aspects of home caregiving.

OBJECTIVE: To explore the concept of caregiving appraisal with the primary family caregivers of home-based ventilator-dependent patients and test the internal consistency of instruments to measure functional dependency of the patient and caregiving appraisal. DESIGN: Nonexperimental, cross-sectional survey. Respondents were reimbursed $25 for the return of a completed questionnaire. SETTING: Caregivers of home-based ventilator-dependent patients residing in southwestern Pennsylvania. SAMPLE: Caregivers of 39 home-based ventilator-dependent patients, 27 responses (69%) were received. MEASURES: Modified Katz Index, Modified Caregiving Appraisal Scale, investigator-developed instrument to assess the health and sociodemographic characteristics of both patients and their caregivers. INTERVENTION: None. RESULTS: The needs of ventilator-dependent patients, as reported by their primary family caregivers, are extensive. Patients require considerable assistance with activities of daily living, with many patients having total care requirements in many functional domains. Caregivers are responsible for numerous pieces of high-tech equipment, as well as other special care requirements unrelated to the patient's ventilatory insufficiency. Although caregivers reportedly spend an average of 8.4 hours each day caring for their family member, the majority continue to maintain full- or part-time employment. Despite the considerable demands placed on caregivers, responses to the Modified Caregiving Appraisal Scale indicate that home placement is not perceived to be a negative experience. Internal consistency of instruments was determined by use of Cronbach's alpha, yielding the following correlation coefficients on the Modified Caregiving Appraisal Scale: burden subscale, 0.87; satisfaction subscale, 0.71; mastery subscale, 0.73; impact subscale, 0.70; and ideology subscale, 0.65. Alpha coefficients for the Katz Indexes measuring patient functional dependence, and consequent caregiver responsibility, were 0.95 and 0.90, respectively.

Health care professionals' characterizations of the system of care for long-term ventilator-dependent patients: a preliminary study.

The purpose of this study was to characterize, from multiple professional perspectives, current management approaches and systems of care for long-term ventilator-dependent patients. This study was preliminary in nature and served to generate questions to be explored with subsequent research. A focus group methodology was used. Three focus sessions were held, with participants representing nursing, social services, and respiratory therapy. Field notes were recorded by two independent observers. The primary themes arising from the narrative data were: (i) caregiver impact, (ii) system barriers to appropriate care, (iii) communication difficulties among professionals and between patients and professionals, (iv) ethical concerns, and (v) patient characteristics that influence medical management and patient outcomes. Implications include the need for systematic research regarding caregiver impact, ethical practice of health care professionals, and the epidemiology of ventilator dependency, as well as evaluative studies of different system approaches to caring for these patients.

Characteristics and health service utilization patterns of ventilator-dependent patients cared for within a vertically integrated health system.

OBJECTIVE: To describe the characteristics and service utilization patterns of long-term ventilator-dependent patients. DESIGN: Using medical records, a cohort of ventilator-dependent patients was identified and followed. SETTING: A vertically integrated healthcare system in southwestern Pennsylvania. PATIENTS: Forty-nine adults requiring prolonged ventilatory assistance. MEASURES: Demographics, admission date, admission diagnosis, discharge diagnosis, reason for ventilator dependency, level of care to which the patient was admitted, dates of all transfer orders, dates of all transfers between levels of care, discharge destination and subsequent readmissions. RESULTS: The major reason for long-term ventilator dependency was progressive debilitating disease of either a pulmonary or nonpulmonary nature. The mean length of stay within the system was 72.6 days +/- 42.55 (median = 59 days, range = 24 to 267 days). Patients had an average of 3.3 transfers +/- 2.53 within the system (median = 3, range = 0 to 10). No delays in transfer to lower levels of care were found. Health utilization variables were largely unrelated to reason for ventilator dependency. Almost half of the patients (n = 24 or 49.0%) died in the system. Patients who died in the system were significantly older than patients for whom discharge home was possible. CONCLUSIONS: Additional studies are necessary to describe the prevalence, etiology, health status and functional status of ventilator patients at all levels of care; the impact of different system approaches on patient well-being and cost of care; and the process of medical decision making. Economic analyses of costs and outcomes for ventilator-dependent patients using a cost-utility approach are also needed.

Hypoglycemia in children with insulin-dependent diabetes mellitus.

The promotion of normal growth and development and the avoidance of acute and long-term complications are overall goals in the management of a child with insulin-dependent diabetes mellitus. Recent studies provide new and pertinent information about the acute effects of hypoglycemia on such cognitive functioning as learning, memory, reading, and visuospatial skills. The effects of early onset diabetes on school performance are also discussed. This information should be incorporated by diabetes educators into the educational plan for children with IDDM, their families, and schools.

Effect of a hypoglycemic episode on neuropsychological functioning in diabetic children.

The present study investigated neuropsychological functioning in school-age children at various points in time surrounding a hypoglycemic episode using 13 tasks drawn from age-appropriate, standard neuropsychological tests. The results demonstrate the effects of a hypoglycemic episode on neuropsychological functioning even after detectable physical symptoms have subsided. Although we are unable to delineate clearly their temporal course, it appears that the impact of such episodes is transient. In general, the pattern exhibited by these children who have presumably recovered from their mild hypoglycemic episode involved reduced motor performance, attention, and memory. The observed prolonged recovery time of these functions presents important implications for the child in both school and social settings.

Mental efficiency and hypoglycemia.

Cognitive functioning after a mild hypoglycemic episode (MHE) was studied in 24 school-age children with insulin-dependent diabetes mellitus (IDDM). All children were administered a battery of neuropsychological tests which included digit spans, trailmaking tasks, Klove Mathews Maze test, and finger-tapping and handwriting tasks. The experimental group (n = 14) consisted of children who were tested initially after resolution of hypoglycemic symptoms following a documented MHE (Chemstrip bG less than or equal to 60 mg/dl with symptoms). The comparative group (n = 10) consisted of children who were initially evaluated after documentation of euglycemia. Comparison of the comparative group scores with test scores of the experimental group after recovery from the MHE demonstrated statistically significant differences (p less than 0.05 by dependent t-tests) in five of 12 tasks. No differences were noted when second trial scores of both groups were compared when they were retested after documentation of euglycemia. This study suggests that a discrepancy exists between the recovery rate of physical symptoms and cognitive function in children following a MHE.

Mild hypoglycemia associated with deterioration of mental efficiency in children with insulin-dependent diabetes mellitus.

To assess the effects of mild hypoglycemia on cognitive functioning in diabetic children, we used an insulin glucose clamp technique to induce and maintain a hypoglycemic state. Eleven patients, 11 to 18 years of age, completed a series of cognitive tests during a baseline euglycemic state (100 mg/dl (5.5 mmol/L] and repeated those measures at the beginning and end of a hypoglycemic plateau (55 to 65 mg/dl (3.1 to 3.6 mmol/L], and again at restoration of euglycemia. At plasma glucose levels of 60 to 65 mg/dl (3.3 to 3.6 mmol/L), a significant decline in mental efficiency was found. This was most apparent on measures of mental "flexibility" (Trial Making Test) and on measures that required planning and decision making, attention to detail, and rapid responding. Moreover, complete recovery of cognitive function was not contemporaneous with restoration of euglycemia, particularly on those tests requiring rapid responding and decision making (choice reaction time). Not all subjects showed evidence of cognitive impairment during hypoglycemia. The very high degree of intersubject variability suggests that, in addition to plasma glucose values, unknown physiologic variables are responsible for triggering cognitive impairments in school-aged youngsters with diabetes during an episode of mild hypoglycemia.