The use of parent report to assess the quality of care in primary care visits among children with asthma.

OBJECTIVE: To determine the accuracy of parent report and the accuracy of the medical record in documenting physician performance of elements of pediatric asthma care in the primary care setting. METHODS: A convenience sample of 79 English-speaking parents of 4--12-year old children with asthma presenting to medical center--affiliated inner-city primary care pediatric clinics in the Bronx, Dallas, and Chicago was enrolled, and the office visit was audiotaped. Parents were interviewed 1--16 days after the visit by telephone. OUTCOME MEASURES: Accuracy of parent report was the primary outcome. The "reference standard" was an independent evaluation of the audiotaped record of the primary care visit. The National Asthma Education and Prevention Program was used as a guide to select data elements to assess quality of pediatric asthma care during primary care visits. RESULTS: Sufficient documentation was significantly (P <.001) less likely to be present in the medical record than in the follow-up interview for each element of care. When these elements were combined into a cumulative score, 71% of parent interviews but only 37% of medical records scored > or = 5 (out of a possible 6), with 29% of medical records scoring < 3. Parents were able to accurately report (concordance of parent data with audiotape reference standard) whether or not the visit had included performance of 5 of the 6 elements of care. CONCLUSIONS: Our study suggests that parent telephone interview within 2 weeks after the visit is more accurate than the medical record for documentation of the quality of asthma care in pediatric primary care visits. The medical record was not sufficient to assess the quality of primary care related to asthma, primarily because of missing data. Therefore, our data suggest that assessing quality of care using the medical record will not only bias the findings in the direction of more deficient care but will also make improvement in care more difficult. Further validation of our strategy for using parent report to assess the quality of care in primary care visits will require its application in a variety of other primary care settings.

Successful techniques for retention of study participants in an inner-city population.

The purpose of this work was to describe methods of retaining participants in studies of inner-city populations, including the timing and intensity of contacts; and to describe the characteristics of participants who did not complete all follow-up interviews and/or return all peak flow diaries in the National Cooperative Inner-City Asthma Study. A cohort study design was used involving hospital emergency rooms and community clinics in seven major urban areas. Participants included 1337 4- to 9-year-old asthmatic children and their caretakers. Nearly 89% of participants completed 3-, 6-, and 9-month follow-up interviews. The 15% of participants who completed a baseline interview on the weekends were significantly more likely to complete follow-up interviews on a weekend. The percent of follow-up interviews conducted in person increased over time from 5% to 8%. The percent of participants with complete follow-up increased as the number of contact names increased (86% with zero contacts, 91% with two contracts; p = 0.03, test for trend). Participants who required at least four phone calls to complete the 3- and 6-month assessment were significantly more likely to be black, have higher participant stress, and have a smoker in the household (p < 0.05). Multiple logistic regression suggests that higher social support and lower parental stress were both predictors of completed interviews. Within our study sample of inner-city minority participants with asthmatic children, only a small proportion of participants missed any follow-up interviews. Increased caretaker stress, decreased social support, and inability to provide several alternate contacts were all predictive of retention problems. Having a flexible staff, computer tracking, and face-to-face recruitment appear essential to achieving nearly complete follow-up within a population historically difficult to follow.

Design and methods of the National Cooperative Inner-City Asthma Study.

The National Cooperative Inner-City Asthma Study (NCICAS) was established to identify and then intervene on those factors which are related to asthma morbidity among children in the inner-city. This paper describes the design and methods of the broad-based initial Phase I epidemiologic investigation. Eight research centers enrolled 1,528 children, 4 to 9 years of age, from English- or Spanish-speaking families, all of whom resided in major metropolitan inner-city areas. The protocol included an eligibility assessment and an extensive baseline visit, during which symptom data, such as wheezing, lost sleep, changes in activities of daily living, inpatient admissions, and emergency department and clinic visits were collected. A comprehensive medical history for each child was taken and adherence to the medical regimen was assessed. Access, as well as barriers, to the medical system were addressed by a series of questions including the location, availability, and consistency of treatment for asthma attacks, follow-up care, and primary care. The psychological health of the caretaker and of the child was also measured. Asthma knowledge of the child and caretaker was determined. Sensitization to allergens was assessed by skin-prick allergen testing and exposure to cigarette smoke and the home environment were assessed by questionnaire. For more than a third of the families, in-home visits were conducted with dust sample allergen collection and documentation of the home environment, such as the presence of pets and evidence of smoking, mildew, and roaches. Urine specimens were collected to measure passive smoke exposure by cotinine assays, blood samples were drawn for banking, and children age 6 to 9 years were given spirometric lung function assessment. At 3, 6 and 9 months following the baseline assessment, telephone interviews were conducted to ask about the child's symptoms, unscheduled emergency department or clinic visits, and hospitalizations. At this time, peak flow measurements with 2-week diary symptom records were collected.

Bicycle-riding circumstances and injuries in school-aged children. A case-control study.

OBJECTIVE: To identify bicycle-riding circumstances associated with bicycle-related injury among school-aged children. DESIGN: Case-control. SETTING: One metropolitan emergency department and 3 suburban emergency departments. SUBJECTS: Consecutive sample of children aged 7 through 18 years who experienced bicycle-related trauma and control children seen for non-bicycle-related trauma (matched for age within 1 year, sex, and area of residence [urban vs suburban]). METHODS: Parents and case children were interviewed by telephone about the bicycle ride resulting in their visit to the emergency department. Parents and control children were interviewed about their most recent bicycle ride. The survey instrument addressed the following potential risk factors: helmet use, bicycle speed, road conditions, riding location, bicycle condition, an adult presence, riding destination, bicycle style, and stunt riding. RESULTS: Interviews were completed with 47 (73%) of 64 eligible case children and 42 (69%) of 61 control children with the following age distribution: 27 (30%) of the interviews were completed with children aged 7 to 9 years, 40 (45%) of the interviews were completed with children aged 10 to 14 years, and 22 (25%) of the interviews were completed with children aged 15 to 18 years. Fourteen children (16%) were wearing helmets. There was a high degree of agreement between parent and child responses, higher for case children than for control children. In univariate analyses, injury was associated with riding with other children (vs riding alone or with adults), riding fast or slow (vs normal speed), riding a BMX-style (motocross) bicycle (vs another standard or multispeed style bicycle), playing on the bicycle (vs going to school or other purposeful or nonpurposeful trip), and riding only on the sidewalk (vs in the street). More case children than control children were farther than 3/4 mile (> 1.2 km) from home (38% vs 19%, P = .05). Multiple logistic regression identified' slow riding speed (odds ratio, 10.3;95% confidence interval, 1.6-66.8), distance from home farther than 3/4 mile (> 1.2 km) (odds ratio, 3.7;95% confidence interval, 1.1-12.5), and riding on the sidewalk (odds ratio, 6.1;95% confidence interval, 1.8-20.5) as independent risk factors for injury. CONCLUSIONS: This study identifies 3 counterintuitive but apparently strong behavioral risk factors for bicycle injuries treated in an emergency department in children aged 7 through 18 years in the Chicago (III) area. These findings will need to be confirmed in larger samples from a wider range of locales. In addition to stressing the importance of wearing a helmet when riding a bicycle, it may be desirable to include the findings of this study in anticipatory guidance discussions with school-aged children.

Growth of Chicago-area infants, 1985 through 1987. Not what the reference curves predict. Pediatric Practice Research Group.

OBJECTIVE: To determine if the National Center for Health Statistics (NCHS) growth curves (including 867 white infants, born between 1929 and 1975, in the Yellow Springs, Ohio, area) reflect contemporary infant growth in pediatric practices. DESIGN: Observational cohort study of healthy term infants. Office personnel obtained standardized measurements at health maintenance visits. SETTING: Ten pediatric community practices that were members of the Chicago, III, area Pediatric Practice Research Group (PPRG). METHODS: Measurements of 1574 PPRG infants, seen on at least 5 occasions between 2 and 54 weeks of age, generated sex-specific growth curves using a 3-parameter mathematical model fitted to the serial data for each infant. Values from the computed curves were compared with NCHS growth references at 1, 3, 6, 9, and 12 months. The birth weights of PPRG and NCHS cohorts were compared. RESULTS: Mean birth weight of PPRG infants was significantly greater than a similar NCHS measure. Compared with the NCHS reference curve, PPRG infants were heavier at 1, 3, and 6 months, longer on all comparisons, and had greater head circumferences, particularly in the early months of age. CONCLUSIONS: The NCHS growth curves do not accurately reflect infant growth in this cohort. Nationally representative data are needed to revise the NCHS growth curves.

Infant and toddler feeding patterns and problems: normative data and a new direction. Pediatric Practice Research Group.

To fill information gaps, predominantly non-Hispanic white parents in five Chicago-area pediatric offices were surveyed concerning infant (n = 130) and toddler (n = 151) feeding times and behaviors. Feeding time distributions did not differ by age. Percentiles (in minutes) were: 10th, 9.4; 50th, 17.7; and 90th, 29.3. The most common infant problematic feeding behavior (PFB) was "not always hungry at mealtime" (33%). Toddler PFB included "not always hungry at mealtime" (52%), "trying to end meals after a few bites" (42%), "picky eating" (35%), and strong food preferences (33%). Toddler picky eaters ate more slowly (means 23.3 vs 19.7 minutes, p < .04). Toddlers with recalled PFB at 6 and 12 months ate most slowly (mean 37.5 minutes). We conclude that: (1) infants and toddlers who take >30 minutes to feed are slow feeders; (2) reports of behavioral feeding problems are common in toddlers and are related to slow feeding; (3) and these data can guide clinical care and future studies.

Gun storage patterns in US homes with children. A pediatric practice-based survey. Pediatric Practice Research Group.

OBJECTIVE: To describe gun storage patterns in gun-owning families with children. DESIGN: Survey of parents attending participating offices. SETTING: Twenty-nine urban, suburban, and rural pediatric practices in Chicago, Ill; New Jersey; Houston, Tex; Utah; Georgia; Iowa; and South Carolina. SUBJECTS: Parents of children attending offices for well- or sick-child care. SELECTION PROCEDURE: Consecutive sample of families seen during the 1-week study period. MEASUREMENTS AND ANALYSES: Logistic regression models were constructed to identify sociodemographic factors associated with keeping guns loaded. RESULTS: Of 5233 surveys, 1682 (32%) indicated ownership of at least one powder firearm. Of the gun-owning families, 61% reported at least one gun unlocked, and 15% reported at least one gun loaded. Rifles were more often stored unlocked (62% rifles vs 52% handguns, P<.001, z=4.60; two-proportion z-test), but handguns were more likely to be kept loaded (3% rifles vs 27% handguns, P<.001). Seven percent of gun-owning families reported at least one gun unlocked and loaded (handguns 12 times more likely than rifles). Only 30% of households reported all guns stored unloaded and locked up. The best-fit logistic regression model for keeping a gun loaded identified four predictor variables: owning a gun for self-protection, work-related gun ownership, owning a handgun, and no men in the home. CONCLUSIONS: Because most gun-owning families store guns loaded, unlocked, or both, anticipatory guidance should address gun storage in all such families. Interventions designed to alter the way work guns are dealt with after work, and to provide safe and effective means of self-protection might affect these storage patterns.

Sampling issues in a regional pediatric practice-based network.

This paper explores various approaches to achieving representative and generalizable practice-based data. The data used were derived from original research conducted by the Pediatric Practice Research Group (PPRG), a research consortium including full-time staff at Children's Memorial Hospital and 132 practitioners in 35 Chicago-area practices in a variety of settings ranging from Chicago's inner city to rural northwest Indiana. Sampling issues addressed include sampling frame, source (population or practice), geographical representation, seasonal representation, survey instrument design, socioeconomic diversity, and contact and response rates.

Children's household exposure to guns: a pediatric practice-based survey.

Guns in the home are a factor in pediatric unintentional and intentional firearm injuries, yet the patterns of ownership and use are unclear. OBJECTIVES. To describe the prevalence of firearms in households containing children who go to pediatricians, the types of firearms owned, the purposes of such ownership, the conditions of firearm storage, and the social correlates of ownership. METHODS. Survey of parents attending 29 (urban, suburban, and rural) pediatric practices in Chicago, New Jersey, Houston, Utah, Georgia, Iowa, and South Carolina for well or sick child care during a 1-week study period. The main outcome measure was ownership of rifle/shotgun and/or handgun. RESULTS. Gun ownership was reported by 37% of 5233 respondent families: rifles (26%), handguns (17%), and powder firearm (32%). Ownership varied significantly across practices and geographical locations. Thirteen percent of 823 handguns and 1% of 1327 rifles were reported both unlocked and loaded. Recreation was the most common reason for both rifle (75%) and handgun (59%) ownership; 48% of handguns were kept for self-protection versus 21% of rifles. In logistic regression models, predictor variables for firearm ownership included rural area, single family dwelling, at least one adult male, and fewer preschool children (for handgun and rifle); mother with at least 12 years education (for handgun), and white mother (for rifle). CONCLUSIONS. The data presented suggest that US pediatricians routinely see children in families that own firearms, including a worrisome number that keep loaded and unlocked handguns. Until more detailed information becomes available, it is reasonable for pediatricians to be guided by these data, and so to counsel routinely about gun exposure.

Exposure corrected risk estimates for childhood product related injuries.

This study assesses the effect of exposure correction on injury risk estimates for children, using Chicago-area survey data on age-specific exposure of children to seven products: amusement park rides, sleds, bunkbeds, skateboards, fireworks, toboggans, and air guns and rifles. National Electronic Injury Surveillance System estimates for 1987 were used as numerators with two denominators: (i) uncorrected age-specific U.S. Census estimates for 1987 and (ii) these estimates corrected for exposure. Except for bunkbeds, skateboards and sleds, corrected injury risk decreased as age increased. Uncorrected population injury rates underestimated the risk posed to product-using children, especially those who are youngest and those who use skateboards.

In-office survey of children's hazard exposure in the Chicago area: age-specific exposure information and methodological lessons. Pediatric Practice Research Group.

Anticipatory guidance on injury prevention should reflect the risks children face, yet hazard exposure information is generally unavailable. The objectives of this study were (1) to obtain information on age-specific exposure of Chicago-area children to amusement park rides, sleds, snow discs, bunkbeds, skateboards, fireworks, toboggans, and air guns and (2) to assess methodological issues in gathering exposure information by parental survey in pediatric practices. Questionnaires were received from 679 families, including 1469 children. The proportion of families with at least one exposed child varied: amusement park rides (94%), sleds (67%), snow discs (25%), bunkbeds (24%), skateboards (22%), fireworks (17%), toboggans (15%), and air guns and rifles (6%). Use of skateboards, air guns and rifles, and bunkbeds was highest in males. Use of skateboards, air guns and rifles, and snow discs peaked among young adolescents (ages 10 to 14), whereas use of sleds, toboggans and amusement park rides peaked among young children (ages 5 to 9) and young adolescents. Use of bunkbeds peaked among young children. Log linear analyses found: the likelihood of exposure to sleds and snow discs was highest in rural communities and for families owning their own home; toboggan exposure was highest among home owners; air gun and rifle exposure was highest in rural areas; fireworks exposure decreased with increased paternal education; exposure to skateboards was highest in single family dwellings and suburban home owners. This study generates the only available current estimates for use of these products, and demonstrates that in-office parental surveys concerning exposure are feasible. The findings can help guide future hazard exposure research and may affect anticipatory guidance in some settings.(ABSTRACT TRUNCATED AT 250 WORDS)

Children fathered by men treated with chemotherapy for testicular cancer.

In a study designed to assess the potential teratogenic effect of paternal chemotherapy, information was obtained on 131 children fathered by 107 men treated for metastatic testicular cancer. Of this group, first born children fathered by 96 chemotherapy patients were compared with 96 children fathered by matched controls. There was no excess of malformations (relative risk 1.0, 95% confidence intervals 0.41 and 2.40). In addition, the rates for specific malformations in the total cohort of 131 children were compared with the general population. There were no significant differences from national rates although the rate for congenital heart disease was higher than expected.

HIV infection in children: sizing up the paediatric problem.

Cases of paediatric AIDS have increased each year in the USA, as the disease has spread to the heterosexual community. In the USA the geographic distribution of perinatal AIDS cases mirrors the distribution of cases in women. To date, 503 HIV antibody positive women have been reported in the UK. It is likely that the increasing number of seropositive women will be reflected in an increase in the number of reports of perinatal HIV infection and AIDS. Although screening of blood donors and blood products has stopped further increase in infections from this route, as transfusion-infected children become symptomatic the burden on paediatric services will increase.

Obstetric and perinatal consequences of human immunodeficiency virus (HIV) infection: a review.

PIP: Pediatric acquired immune deficiency syndrome (AIDS) was known to be a new disease that could be acquired from the mother even before human immunodeficiency virus (HIV) was identified. The suggested routes of transmission of infection are intrauterine, perinatal--from contact with infected maternal genital secretions, or through breastfeeding. At this time the problem in Europe concerns primarily women in high-risk groups: intravenous drug abusers, prostitutes, women from countries where the prevalence of HIV is high, and women whose sexual partners are in a high-risk group. In the future, the infection may extend beyond women in high-risk groups as the disease becomes more prevalent in the community. It has been claimed that pregnancy accelerates symptoms in women who are HIV positive, yet this is based on only a series of case reports of severe infection in pregnancy and on the development of AIDS in asymptomatic women in pregnancy subsequent to the birth of an AIDS child. The only data capable of shedding some light on this issue would be a prospective followup of both pregnant and nonpregnant HIV-positive women from similar high-risk groups. Such a study is ongoing in the US. An increasing number of case reports suggest intrauterine transmission of infection. The following 3 case reports provide clear evidence of intrauterine transmission. Sprecher et al. (1986) detected HIV antigen in amniotic fluid and fetal tissues from a pregnancy termination at 15 weeks gestation in a woman with stage IV AIDS and Kaposi sarcoma. Lapointe et al. (1985) reported an infant born by cesarean section at 28 weeks gestation to a mother with terminal aids. A new dysmorphic syndrome recently has been described in children with symptomatic HIV infection (Marion et al., 1986). HIV has been isolated from cervical secretions (Fogt et al., 1986; Wofsy et al., 1986), which suggests that this cold be another source of infection. There is 1 report of isolation of HIV from the noncellular fraction of breast milk (Thirty et al., 1985). Several case reports have described acquired immunodeficiency in infants for whom the only known risk factor was neonatal transfusion from an individual later found to be suffering from AIDS. The risk of transmission from an infected mother to her infant is unknown, but the best available evidence comes from a study of children born to women who had previously given birth to a child with AIDS (Scott et al, 1985). Of 12 children, 4 developed AIDS or Aids-related complex. Clinical problems among children with AIDS or AIDS-related complex have been fully described. The fatality rate of children with AIDS is high, but the ultimate progress of children with less severe disease or who have asymptomatic infection is known.^ieng