Reinterpreting disability: changes in supplemental security income for children.
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Adolescent↗
Biomedical subjects
J M Perrin
Publications and source records attributed to J M Perrin.
Children with special health needs: a United States perspective.
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Adolescent↗
Variations in rates of hospitalization of children in three urban communities.
Hospitalization accounts for a large portion of the expenditures for child health care, and differences in the rate of hospitalization may produce important variations in the cost of that care. We studied the rates of hospitalization in Boston, Rochester (N.Y.), and New Haven (Conn.) in 1982. We assigned the risk of hospitalization in Rochester a score of 1.00. Boston children were hospitalized at more than twice the rate of Rochester children for most medical diagnostic categories (relative risk, 2.65; 95 percent confidence interval, 2.53 to 2.78), and the rate for the New Haven group was intermediate (relative risk, 1.80; 95 percent confidence interval, 1.68 to 1.93). Rates of inpatient surgery differed less (Boston relative risk, 1.12; New Haven relative risk, 0.93). The relative risks of hospitalization (as compared with Rochester children) for Boston and New Haven children, respectively, were 3.8 and 2.3 for asthma, 6.1 and 2.9 for toxic ingestions, and 2.6 and 2.7 for head injuries. Fractures of the femur, appendicitis, and bacterial meningitis (conditions uniformly treated in the hospital) had similar rates of hospitalization across the three cities, but the relative risk of hospitalization for aseptic meningitis was 3.7 in Boston. The rates of hospitalization of children in all three communities were below the national averages in 1982. Although this study does not define the reasons for the variation in rates of hospitalization, it is possible that they were related in part to differences in socioeconomic status or access to primary care. The implications of these data for the cost and quality of pediatric care therefore remain to be determined.
Adolescent↗
The effect of 2-[(aminopropyl)amino] ethanethiol on fission-neutron-induced DNA damage and repair.
The effect(s) of the radioprotector 2-[(aminopropyl)amino] ethanethiol (WR 1065) on fission-neutron-induced DNA damage and repair in V79 Chinese hamster cells was determined by using a neutral filter elution procedure (pH 7.2). When required, WR1065, at a final working concentration of 4 mM, was added to the culture medium, either 30 min before and during irradiation with fission spectrum neutrons (beam energy of 0.85 MeV) from the JANUS research reactor, or for selected intervals of time following exposure. The frequency of neutron-induced DNA strand breaks as measured by neutral elution as a function of dose equalled that observed for 60Co gamma-ray-induced damage (relative biological effectiveness of one). In contrast to the protective effect exhibited by WR1065 in reducing 60Co-induced DNA damage, WR1065 was ineffective in reducing or protecting against induction of DNA strand breaks by JANUS neutrons. The kinetics of DNA double-strand rejoining were measured following neutron irradiation. In the absence of WR1065, considerable DNA degradation by cellular enzymes was observed. This process was inhibited when WR1065 was present. These results indicate that, under the conditions used, the quality (i.e. nature), rather than quantity, of DNA lesions (measured by neutral elution) formed by neutrons was significantly different from that formed by gamma-rays.
Animals↗
Effect of iodinated contrast media on blood clotting.
Recently, blood clot formation in catheters used for the injection of nonionic contrast media (CM) during angiography has been reported as being due to activation of hemostasis in the catheter. However, CM exhibit inhibitory properties regarding coagulation and platelet functions. The effect on blood clotting of iohexol, iopamidol, ioxaglate, diatrizoate, and ioxitalamate at a ratio of 10% v/v with nonanticoagulated human whole blood was evaluated using the kinetics of fibrinopeptide A (FpA) generation. Blood aliquots were taken every 2 minutes until blood clot occurred. Two groups of contrast media were identified: (1) iohexol and iopamidol, which increased the clotting time, and (2) ioxaglate, diatrizoate, and ioxitalamate, for which all clotting times were over 30 minutes and no FpA generation occurred.
Blood Coagulation↗
Parental perceptions of health status and psychologic adjustment of children with asthma.
The relationship between severity of illness and psychologic adjustment was evaluated in 46 children with asthma. Two measures of the severity of asthma were used: the first, a composite objective measure based on clinical history and the second, parental estimates of the severity of their child's illness. Psychologic adjustment was measured by the Health Resources Inventory, a parental report of childhood behavior. Parental estimates of severity were correlated significantly with the objective measure of severity (r = .39; P less than .01), although a concordance value of 54% indicated marked lack of agreement between parental and objective ratings. As a group, children in this study achieved apparently normal adjustment scores, although scores ranged widely across all categories of severity. Children whose parents ranked their asthma as mild or severe had significantly lower adjustment scores (F = 3.28; P less than .05) than did those children rated by their parents as having moderate asthma. Children's ranks on the composite objective measure of severity were not associated with their adjustment scores, although children with greater use of medication had lower adjustment scores than did children with little or moderate medication use (P less than .05). The relationship of severity of illness to psychologic adjustment is complex. Children at all levels of severity may demonstrate problems of adjustment, suggesting that attention to psychologic risk should not be limited only to children with severe asthma.
Adolescent↗
The awareness of primary physicians of the psychosocial adjustment of children with a chronic illness.
This study compared primary care physicians' ratings of psychosocial adjustment of their chronically ill pediatric patients with parents' and children's reports. A series of measures of psychosocial adjustment were administered to 63 children with either a seizure disorder or a visible orthopedic condition, and their parents. Each child's physician was asked to rate the presence and severity of psychological adjustment problems in the child, as well as to rate six specific psychosocial domains. Forty-one physicians responded, and relationships between their ratings and child and parent psychosocial measures were determined using Pearson product-moment correlation coefficients. Ratings by physicians correlated with children's reports and parents' judgments about the children, but not with mothers' self-concept or the impact that the illness had on the family. However, physicians' ratings were interdependent. When congruence of physician ratings with child or parent reports was examined for each disease group, we found significant results for the seizure disorder group; however, congruence among ratings for the orthopedically handicapped group was poor. Student's t-tests revealed no statistically significant differences between the two disease groups in any of the demographic variables of the children or physicians, nor in their scores on the criterion measures. Hierarchical multiple regression analysis identified factors that contributed to physicians' significantly different congruence with parents regarding the adjustment of children in the two subsamples. The findings of this study suggested that primary care physicians were moderately aware of the presence and severity of psychosocial adjustment problems in some categories of their pediatric patients with chronic illness.(ABSTRACT TRUNCATED AT 250 WORDS)
Adaptation, Psychological↗
Children with chronic illness. The prevention of dysfunction.
Children with long-term illnesses are at risk of developing problems in psychological adjustment and in functioning in activities of daily life. Their families face increased risks of marital and economic dysfunction, and siblings too face special tasks living with a chronically ill child. A variety of interventions can help children and families to cope effectively with the tasks of chronic illness. Pediatricians should be alert to effects on the family. Children respond to family stress in very predictable ways. Inasmuch as the stress of chronic illness may affect the marital relationship, there is a likelihood of concurrent behavioral and school problems. Relatively sudden changes in behavior may signal family issues that require professional attention. Drotar et al. maintain that professionals should serve as guides or advocates for children with chronic illness and their families. The relationship that develops between families and professionals is based on trust. They believe that "trust appears to evolve from the following principles: (1) continuity of relationship, (2) active participation by professional caregivers, (3) mutual participation of child and family, (4) advocacy, (5) a focus on coping and competence, (6) a developmental perspective, and (7) a family-centered focus." Cadman et al. identified a similar set of elements that characterizes an efficacious preventive intervention approach. In addition, they propose specific programmatic efforts that are associated with less morbidity. These include ongoing education and counseling for the child, family, and community regarding chronic illness and its management, use of stress management techniques to promote mastery and reduce the impact of stressful life events, and facilitation of social support mechanisms for families with chronically ill children. We have added consideration of the child's performance in school.
Adaptation, Psychological↗
Does stress affect bleeding in hemophilia? A review of the literature.
Many bleeding episodes in hemophilia are thought to be related to ambient stress. The evidence in support of this hypothesis comes from a variety of anecdotal and clinical reports. Whether or not stress leads to bleeding has had little direct study in a prospective way, however, and methodological problems affect most of the studies in this field. This paper examines the evidence in support of this hypothesis and suggests ways to improve research relating stress to bleeding.
Child↗
First step in obtaining child health care: selecting a physician.
To investigate the process by which families identified and selected their children's current physicians, a close-ended questionnaire was administered to 750 families in a mail panel. Of 630 responses (84.0%), 244 had children in the home; 229 (93.9%) identified a regular and current physician for their youngest child. However, parents did not spend much time or energy selecting a physician and rarely explored medical expertise in their decisions. Families averaged 1.2 sources of information consulted per decision; few considered more than two physician choices and infrequently considered alternative types of doctors (pediatricians v family or general practitioners). Selection priorities ranked in order of importance concerned parents' perceptions of their doctors' communication skills, accessibility, and quality as determined by recommendations of friends or physicians. Parents appeared less concerned with issues of cost and convenience. Families selecting pediatricians differed from those selecting family and general practitioners in sources of information used and selection priorities. The survey also identified 84 families who had changed or seriously considered changing the physician who was caring for their youngest child. The most frequent dissatisfaction was the perception that an illness was not being managed adequately, followed by believing that the doctor or staff were rude or unconcerned. Families unhappy with pediatricians expressed different reasons from those unhappy with family or general practitioners. The study results provide insight about the first step in obtaining child health care services, a relatively unexplored area of patient decision making.
Adolescent↗
Severity of illness: concepts and measurements.
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Activities of Daily Living↗
A 26-month-old child with Marden-Walker syndrome and pyloric stenosis.
We recently examined a 26-month-old boy with abnormal face, blepharophimosis, hypertelorism, apparently low-set ears, micrognathia, arachnodactyly, talipes equinovarus, and joint contractures. Subsequently he manifested failure to thrive, respiratory infections, and developmental delay. These congenital anomalies and associated findings are consistent with a diagnosis of the Marden-Walker syndrome. He also had mild pyloric stenosis and duodenal bands, not previously reported in this syndrome. This syndrome appears to be an autosomal recessive trait in some families. A summary of findings of the 16 previous published patients is presented.
Abnormalities, Multiple↗
Physician reimbursement by salary or fee-for-service: effect on physician practice behavior in a randomized prospective study.
We used a resident continuity clinic to compare prospectively the impact of salary v fee-for-service reimbursement on physician practice behavior. This model allowed randomization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior. Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians (3.69 visits v 2.83 visits, P less than .01) and saw their patients more often (2.70 visits v 2.21 visits, P less than .05) during the 9-month study. Almost all of this difference was because fee-for-service physicians saw more well patients than salaried physicians (1.42 visits and .99 visits per enrolled patient, respectively, P less than .01). Evaluating visits by American Academy of Pediatrics' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended visits and scheduled visits in excess of those recommendations. Fee-for-service physicians also provided better continuity of care than salaried physicians by attending a larger percentage of all visits made by their patients (86.6% of visits v 78.3% of visits, P less than .05), and by encouraging fewer emergency visits per enrolled patient (0.12 visits v 0.22 visits, P less than .01). Physicians' interest in private practice, as determined by their career plans, correlated significantly with total number of patients enrolled (r = .48, P less than .05) and total clinic patients seen by each resident during the study (r = .40, P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Diffusion of surgical technology. An exploratory study.
The study presents an empirical analysis of the diffusion patterns of five surgical procedures. Roles of payer mix, regulatory policies, physician diffusion, competition among hospitals, and various hospital characteristics such as size and the spread of technologies are examined. The principal data base is a time series cross-section of 521 hospitals based on discharge abstracts sent to the Commission on Professional and Hospital Activities. Results on the whole are consistent with a framework used to study innovations in other contexts in which the decisions of whether to innovate and timing depend on anticipated streams of returns and cost. Innovation tends to be more likely to occur in markets in which the more generous payers predominate. But the marginal effects of payer mix are small compared to effects of location and hospital characteristics, such as size and teaching status. Hospital rate-setting sometimes retarded diffusion. Certificate of need programs did not.
Communication↗
Does increased physician supply affect quality of care?
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Health Resources↗
In-hospital mortality of surgical patients: is there an empiric basis for standard setting?
Several public and private groups have set minimum procedure-specific volume standards. Such standards reflect concerns about hospital quality and cost. In-hospital mortality rates are often taken as one measure of quality. To learn about variations in in-hospital mortality rates, we analyzed data on patients who underwent any of seven surgical procedures from a national cohort of 521 hospitals observed continuously between 1972 and 1981. On the average, mortality rates fell as the number of procedures performed annually at the hospital rose. Volumes at which mortality rates reached minimum levels were far higher than actual volumes achieved by the vast majority of hospitals. However, knowledge of hospital volumes left the major part of variation among hospitals' procedure-specific mortality rates unexplained. Many hospitals with low volumes of certain procedures had no associated deaths. Hospitals experienced appreciable year-to-year variation in mortality even though mortality rates fell with the number of years the procedure was performed at the hospital. Correlations among mortality rates for the procedures were low, suggesting that variation in rates is procedure rather than hospital specific. State rate-setting programs had no effect on mortality rates associated with the procedures analyzed. For several reasons, we conclude that an adequate statistical basis for setting minimum volume standards does not presently exist.
Coronary Artery Bypass↗
Changing patterns of hospitalization for children requiring surgery.
Increasing health care costs have directed public attention to changing rates of hospital care. We examined changes in hospitalization and surgical rates for children during the decade from 1972 to 1981. Total hospitalizations for children younger than 15 years of age increased by only 4% during the decade. For teenagers and young adults (ages 15 to 24 years), hospitalizations declined by 19%. Admissions for surgery declined more for the younger group than for the older one. For children younger than 15 years of age, inpatient tonsillectomies and adenoidectomies (T and A) decreased 43%, representing 58% of the total decline in surgical procedures for this age group. Teaching hospitals continued to provide a sizable proportion of all childhood surgeries and increased their share of both high- and low-technology procedures during the decade. Payment sources varied among procedures. Self-pay varied from a low of 1.6% for T and A to 13.5% for spina bifida. Private insurance or Blue Cross payment varied from 59% for congenital heart disease surgery to 84% for T and A. These data on payments suggest that some children may lack access to some surgical care. Furthermore, insofar as the bulk of payment is from nonfederal sources, changes in hospitalization for surgical procedures will likely come mainly from changing incentives in the private sector.
Adolescent↗
The teaching hospital's growing surgical caseload.
A competitive marketplace potentially creates new pressures for teaching hospitals. To assess possible trends in teaching hospitals' caseload, we studied surgical utilization in 1972 and 1981 using two national data sets. The percentage of total patients hospitalized for surgery increased in teaching hospitals between 1972 and 1981. Nonteaching hospitals adopted several new procedures, such as hip arthroplasty. However, increased volume attributable to the spread of procedures to additional hospitals was small when compared with volume increases experienced by hospitals that performed these procedures in 1972. Teaching hospitals' caseloads grew for well-established surgical procedures such as cholecystectomy, delivery, and mastectomy and for newer, high-technology procedures such as hip arthroplasty and coronary artery surgery. Overall surgical case complexity was relatively high in teaching hospitals in 1972, and the disparity with nonteaching hospitals increased during the decade. Distribution of surgical patients by payment source varied appreciably among surgical procedures, but not among hospitals by teaching status. Teaching hospitals were successful in attracting patients from 1972 to 1981; however, several new pressures are emerging that should be watched.
Commission on Professional and Hospital Activities↗