Effectiveness of a rural pediatric diabetes management program.

BACKGROUND: Children with type 1 diabetes living in rural areas may have limited access to specialty diabetes care compared to children living in urban areas. To address this issue, providers have developed outreach services in which specialists travel periodically to rural communities. OBJECTIVE: To determine whether the care of children with type 1 diabetes treated by pediatric endocrinologists in a rural outpatient clinic is comparable to the care of children treated in an urban medical center by the same diabetes team. METHODS: We carried out a retrospective cohort study comparing the number of patient visits with physicians, behavioral specialists, and dietitians and the frequency of hemoglobin A1c (HbA1c) measurements over a 12-month period treated in a rural clinic with a matched group treated in an urban children's hospital clinic. RESULTS: We found that urban patients (n = 38) were more likely to complete four visits per year compared to a matched group (n = 19) at the rural clinic (55.3% vs. 15.8%; p < 0.004), were significantly more likely than those in the rural clinic to have had four HbA1c measurements per year (55.3% vs. 21.1%; p < 0.014), and more likely to have had an assessment by a behavioral specialist (31.6% vs. 0%). Children at the rural clinic site were more likely to have had a visit with a nutritionist during the year (89.5% vs. 36.8%; p < 0.005). CONCLUSION: We conclude that diabetes care provided using a rural outreach model closely approximates, but does not entirely duplicate, care provided in the urban setting.

Characteristics and financial performance of a pediatric faculty inpatient attending service: a resource-based relative value scale analysis.

OBJECTIVES: In many children's hospitals, inpatient attending physician services are provided by academic faculty who function as part-time inpatient specialists or hospitalists. Although some have claimed that hospitalist care can reduce length of stay and total hospital resource use and expenses, there are few benchmarks or data regarding physician productivity or the characteristics and financial performance of these programs. The resource-based relative value scale (RBRVS) is a valuable tool for developing national benchmarks and comparing the financial performance of inpatient programs at varying daily census and reimbursement levels. The objectives of this study were to 1) describe physician productivity on an inpatient service as measured by total relative value units (TRVUs) and professional charges, 2) determine whether inpatient collections were adequate to support faculty salaries for the time spent attending, and 3) develop a model to evaluate financial performance of inpatient programs at varying census and TRVU reimbursement levels. METHODS: A retrospective review of hospital discharge and faculty practice billing data between June 1997 and July 1998 was conducted in a general medical service in a regional, 208-bed, university-affiliated children's hospital in the Pacific Northwest. RESULTS: Of 4113 patients who were admitted to the children's hospital general medical service during a 12-month period, faculty part-time hospitalists (N = 28) served as the attending physician for 1738 (42%). On an annual basis, faculty attended for an average of 29.1 days (median: 21.0; range: 7.0-97.0), with an average daily patient census (ADC) of 7.2 (median: 6.5; range: 2.8-12.0). Inpatient attendings billed for 1738 initial visits and 3957 subsequent visits. Total physician productivity for the inpatient attending group during 1 year included 12 085 TRVUs and gross professional charges of $777 743. The average payment, or conversion factor (CF), was $24.46/TRVU (71% of Medicare CF). The cash collection rate was 38%, reflecting a payor mix that included 54% Medicaid, 28% commercial payors, 12% health maintenance organization, and 6% other payors. On a weekly basis, physicians generated an average of 109 TRVUs and collected $2665 in cash. The average salary cost per RVU was $23.40, and weekly faculty salary and benefit expenses were $2550. After operating expenses and academic taxes totaling 24% were deducted ($5.87/TRVU), RBRVS-based payments and cash collections covered 79% of average faculty weekly salaries. Financial modeling showed that either an average CF of $31/TRVU or an ADC of 9 patients per day on the inpatient service would be required to generate sufficient revenue to support physician salaries and operating expenses. CONCLUSIONS: For a faculty inpatient attending service in a children's hospital with an ADC of 7, a $24.46 RBRVS-based CF payment is inadequate to support faculty salaries and operating expenses for the time spent attending. Inpatient services in similar payor environments with comparable expenses and staffed by faculty who care for fewer than 9 patients per day will not cover typical faculty salary costs and operating expenses.

Computerized pediatric telephone triage and advice programs at children's hospitals: operating and financial characteristics.

OBJECTIVE: To describe the operating characteristics, financial performance, and perceived value of computerized children's hospital-based telephone triage and advice (TTA) programs. DESIGN: A written survey of all 32 children's hospital-based TTA programs in the United States that used the same proprietary pediatric TTA software product for at least 6 months. MAIN OUTCOME MEASURES: The expense, revenues, and perceived value of children's hospital-based TTA programs. RESULTS: Of 30 programs (94%) responding, 27 (90%) were eligible for the study and reported on their experience with nearly 1.3 million TTA calls over a 12-month period. Programs provided pediatric TTA services for 1560 physicians, serving an average of 82 physicians (range, 10-340 physicians) and answering 38880 calls (range, 8500-140000 calls) annually. The mean call duration was 11.3 minutes and the estimated mean total expense per call was $12.45. Of programs charging fees for TTA services, 16 (59%) used a per-call fee and 7 (26%) used a monthly service fee. All respondents indicated that fees did not cover all associated costs. Telephone triage and advice programs, when examined on a stand-alone basis, were all operating with annual deficits (mean, $447000; median, $325000; range, $74000-$1.3 million), supported by the sponsoring children's hospitals and their companion programs. Using a 3-point Likert scale, the TTA program managers rated the value of the TTA program very highly as a mechanism for marketing to physicians (2.85) and increasing physician (2.92) and patient (2.80) satisfaction. CONCLUSIONS: Children's hospital-based TTA programs operate at substantial financial deficits. Ongoing support of these programs may derive from the perception that they are a valuable mechanism for marketing and increase patient and physician satisfaction. Children's hospitals should develop strategies to ensure the long-term financial viability of TTA programs or they may have to discontinue these services.

Hospital services for rural children in Washington State.

OBJECTIVE: To examine the current delivery of inpatient hospital services to a statewide population of rural children, define the types of pediatric conditions currently treated in rural hospitals or transferred to urban centers, and explore the role of rural pediatricians and family practitioners in the care of children in rural hospitals. DESIGN: Retrospective review of statewide hospital discharge data. SUBJECTS: All patients younger than 18 years of age with nonsurgical diagnoses discharged from both urban and rural civilian hospitals in Washington State during 1989 and 1990. RESULTS: Of 69690 pediatric hospital discharges during the study period, 16% were rural residents and 10% were from rural hospitals. Rural hospitals cared for 59% of hospitalized rural children. Marked differences were found between urban and rural hospitals in the diagnoses treated; more than two-thirds of all discharges for chemotherapy, psychiatric disorders, and neonates with multiple major problems were from urban hospitals; but the majority of the discharges for gastrointestinal diagnoses, respiratory conditions, or minor problems in the neonatal period were from rural hospitals. Rural hospitals with staff pediatricians had higher annual pediatric discharges, total charges, lengths of stay, and case mix with a higher proportion of neonates with complications, compared to hospitals without pediatricians. However, there was no evidence that these hospitals served as local referral centers for rural pediatric inpatients; the proportion of patients from outside the local hospital catchment areas was similar for rural hospitals with staff pediatricians and for those without. In rural hospitals, pediatricians and family practitioners were listed as the attending physician for 37% and 49% of discharges, respectively. The average rural pediatrician cared for five times as many inpatients as a rural family practitioner. Pediatricians cared for significantly more neonates with birth weights of less than 2500 grams, but otherwise had a similar case mix among inpatient discharges as rural family practitioners. CONCLUSIONS: Most rural children in Washington who require hospitalization for common problems receive their care in local rural hospitals staffed with pediatricians and family practitioners, although those with illnesses requiring a high level of specialty care are predominantly cared for in urban centers. Rural pediatricians make a substantial contribution to the care of rural children, especially in the area of neonatal care, although their presence in rural hospitals does not in itself create local referral centers. Inpatient volumes are higher for pediatricians, but their case mix is similar to that of rural family practitioners, except in the area of neonatology. These data support the recommendations that family practitioners contemplating rural practice receive training in general inpatient pediatrics (regardless of whether they are going to a site with pediatricians) and that pediatricians in rural practice be trained for a high volume of inpatient cases, including problems of low birth weight infants. Because systems of hospital care for rural children depend on regionalized programs, clinical and educational linkages between urban centers and rural providers should be developed and supported.

Physician experience with pediatric inpatient care in Washington State.

OBJECTIVE: To determine the frequency with which pediatricians and family physicians in Washington State serve as attending physicians for pediatric inpatients. DESIGN: Retrospective review of statewide hospital discharge data. SUBJECTS: Attending physicians for all patients younger than 18 years of age with nonsurgical diagnoses discharged from civilian hospitals in Washington State during 1989 and 1990. RESULTS: Using medical rosters, the self-identified specialty of the attending physician was determined for 93% (n = 181,581) of discharges. Pediatricians and family physicians were listed as attending for 61% and 28%, respectively, of all eligible patients. Statewide, 97% (n = 555) of all pediatricians and 86% (n = 939) of all family physicians served as attending physicians for at least one inpatient, including healthy newborns, during the 2-year study period. The median annual number of discharges per physician was 78 for pediatricians and 14.5 for family physicians. Excluding healthy newborns, the median annual number of discharges was 25 for pediatricians and 3 for family physicians. Five percent of the physician attending group provided inpatient care for 50% of all children hospitalized with diagnoses other than healthy newborn; 50% of attending physicians cared for 95% of the patients. In rural hospitals, where family physicians served as attending physicians for 44% of pediatric inpatients, children were 3.3 times more likely to receive their care from family physicians than those hospitalized in urban centers. CONCLUSIONS: Most pediatricians and family physicians serve as inpatient attending physicians for hospitalized children only infrequently. These findings question whether the emphasis on inpatient care in many pediatric and family medicine training programs remains an appropriate goal.

The impact of an AIDS symposium on attitudes of providers of pediatric health care.

Following reports of concern among health-care workers regarding the occupational risk of infection with the human immunodeficiency virus (HIV), a symposium was designed in 1987 to demonstrate to health-care providers at three hospitals in The Bronx, New York, the low risk of occupational HIV infection and techniques for avoiding infection. After the symposium, 103 of the health-care providers who had attended it completed a questionnaire assessing the impact of the symposium on their attitudes; the responses from 100 of these providers were used in this study. Twenty-nine of the responding providers reported that the symposium had increased their concerns regarding their risk of HIV infection; this group was composed of seven of the 15 medical students who responded, 12 of the 36 housestaff, seven of the 28 faculty, and three of the 21 other medical staff. The findings of the present study suggest that a symposium designed to decrease concerns of occupational HIV infection among health-care workers may have the opposite effect on some of those who attend it, especially medical students. Education alone may be inadequate to reassure some providers. The authors recommend small-group sessions addressing the emotional aspects of health-care providers' concerns.

Needle injuries among pediatric housestaff physicians in New York City.

Concerns regarding accidental needle puncture wounds, needle injuries among house officers have increased following reports of human immunodeficiency virus (HIV) transmission via this route. Pediatric house officers training in areas with large numbers of children infected with HIV may face a significant risk of occupational HIV infection via needle injury. The cumulative incidence of needle injury among pediatric house officers in New York who completed at least 1 year of training was ascertained. A questionnaire designed to elicit retrospective information regarding needle injuries was completed by 294 house officers in medical school-affiliated pediatric training programs. A total of 205 (69.7%) had stuck themselves or been stuck with a needle contaminated with a patient's blood, and 48 (17%) reported a needle injury involving a needle contaminated with the blood of a patient with suspected HIV infection. Only 11 of the 48 had received counselling or HIV testing following their possible HIV exposure. These data indicate that needle injury among pediatric house officers in New York is common. Reducing occupational risk is an especially compelling policy issue for pediatric training programs in areas where HIV is endemic.

Characteristics of social networks in adolescents with end-stage renal disease treated with renal transplantation.

In adolescents, the establishment of same- and opposite-sex nonfamily peer relations facilitates the normal development of independence and separation from family. Adolescents with end-stage renal disease (ESRD) may be particularly vulnerable to delayed social development and isolation from their peers because of the unique physical and psychosocial aspects of their illness. The characteristics of the social networks of 16 adolescents with ESRD treated with renal transplantation were studied using the Social Networks of Youth Questionnaire. Compared with a matched group of healthy adolescents, these teenagers named fewer significant others in their total social networks, as well as fewer unrelated and opposite-sex peers. Family members comprised a greater proportion of the transplant patients' networks compared to controls. Self-esteem, measured by the Coopersmith Self-Esteem Scale, was similar for transplant and control groups, with the exception of home self-esteem, which was higher in the chronically ill adolescents. Body image was somewhat lower, but not significantly, in adolescents with ESRD. The characteristics of the chronically ill adolescents' social networks suggest that these patients may experience a degree of social isolation. Interventions that promote increased peer contacts and enhance interpersonal skills should be included in the psychosocial management of adolescents with ESRD after renal transplantation.

Thrombocytopenia in a bisexual adolescent male with a history of intravenous drug use.

Immunologically mediated thrombocytopenia has been reported as a manifestation of human T-lymphotropic virus type III (HTLV-III) infection and intravenous (IV) drug abuse. The case report describes thrombocytopenia in a bisexual adolescent male with antibody to the HTLV-III virus and a history of infrequent IV drug abuse. The case underscores the need to consider HTLV-III infection and/or IV drug abuse in the differential diagnosis of thrombocytopenia in an adolescent.