Delivery of well-child care: a look inside the door.

OBJECTIVE: To describe the delivery of well-child care and its components; to compare that delivery with recommendations in Bright Futures; and to compare delivery of well-child care for children with special health care needs with that for children without special needs. METHODS: Over a 10-week period, 2 medical students observed and documented characteristics of well-child care visits by general pediatricians and midlevel pediatric providers. Parents completed a demographic questionnaire and a screener for children with special health care needs. RESULTS: A total of 483 visits by 43 pediatricians and 9 midlevel providers with patients from 0 to 19 years of age were observed. Adjusted mean visit duration was 20.3 minutes; 38.9% of visits began with an open-ended question about parent/child concerns. A mean of 7.2 health supervision/anticipatory guidance topics were addressed per visit. Clinicians addressed a mean of 42% of Bright Futures-recommended age-specific health supervision/anticipatory guidance topics. Topics addressed less frequently than recommended included family support, parental well-being, behavior/discipline, physical activity, media screen time, risk reduction/substance use, puberty/sex, social-peer interactions, and violence. Shorter visits were associated with asking about parent/child concerns and with addressing greater proportions of recommended health supervision/anticipatory guidance topics. Well-child care visits with children with special health care needs were 36% longer than those with children without special needs and addressed similar numbers of age-specific health supervision/anticipatory guidance topics. More time was spent with children with special health care needs addressing health supervision/anticipatory guidance topics, other conditions (usually their chronic condition), and testing, prescriptions, and referrals. CONCLUSIONS: Utilizing direct observation of visits with pediatric clinicians, we found that solicitation of parent/child concerns occurred less frequently than recommended. Fewer than half of recommended visit-specific health supervision/anticipatory guidance topics were addressed, and there was little congruence with some Bright Futures age group-specific recommendations. Notably, both solicitation of patient/parent concerns and greater adherence to health supervision/anticipatory guidance recommendations were associated with shorter visits. Well-child care visits with children with special health care needs were longer than those with children without special needs; more time was spent addressing similar numbers of health supervision/anticipatory guidance topics as well as their chronic conditions.

An objective means of diagnosing anorexia nervosa and bulimia nervosa using 15N/14N and 13C/12C ratios in hair.

An objective means based on the carbon and nitrogen stable isotope analysis of five hairs per individual is presented for distinguishing between individuals with anorexia nervosa and/or bulimia nervosa from non-clinical individuals (i.e. clinically normal controls). Using discriminant analysis, an algorithm has been developed that provides both sensitivity and specificity of 80% in making diagnoses of individuals with these eating disorders. With further refinements, the results suggest that it may be also possible to distinguish between individuals with anorexia or bulimia. Finally, the study shows the value of conducting blind tests and using larger sample sizes of both control and treatment groups. Both groups are needed to validate the diagnostic value of a method and to provide measures of sensitivity and specificity of any diagnostic test.