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Biomedical subjects

R C Wasserman

Publications and source records attributed to R C Wasserman.

At least 19 recordsLinked to original sources
PubMed2001

Impact of the change to inactivated poliovirus vaccine on the immunization status of young children in the United States: a study from pediatric research in office settings and the National Medical Association.

OBJECTIVE: To determine whether the change from an all oral poliovirus vaccine (OPV) schedule to an inactivated poliovirus vaccine (IPV)-containing schedule has adversely affected the immunization status of young children in the United States. METHODS: Immunization data were abstracted from the medical records of children 8 to 35 months old seen consecutively for any reason in the offices of practicing pediatricians who are members of the Pediatric Research in Office Settings network of the American Academy of Pediatrics or the National Medical Association. Data on up to 120 eligible children were collected in each practice between March 1998 and January 2000. Patients were classified as fully immunized at 8 months old if they had received 3 diphtheria-tetanus-pertussis, 2 Haemophilus influenzae type b, 2 hepatitis B, and 2 poliovirus vaccines. Study children who were >/=12 months of age at the time that data were collected were categorized as being fully immunized at 12 months if they had received the same vaccines before their first birthday. To assess the effect of type of poliovirus vaccines on these outcomes, study patients were classified as being in an IPV or OPV group based on the initial type of vaccine received. Logistic regression was used to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) for IPV as a predictor of being fully immunized at 8 and 12 months of age, after adjusting for race/ethnicity of the patient, maternal education level, year of birth, and method of payment for vaccines. In addition, the effect of clustering of children within practices was accounted for by the use of generalized estimation equation techniques. RESULTS: Data were analyzed on 13 520 children from 177 practices in 42 states; 79.4% of patients were fully immunized at 8 months of age, and 88.7% of those eligible were fully immunized at 12 months of age. A total of 6910 patients (51.1%) were classified as OPV recipients, wheras 5282 (39.1%) received IPV. In addition, 1328 children (9.8%) were documented as having received poliovirus vaccine, but the particular type could not be determined. Compared with OPV recipients and after controlling for the confounding variables and the effect of clustering within practices, children in the IPV group were as likely as were OPV recipients to be fully immunized at 8 months of age (OR: 1.04; 95% CI: 0.88,1.23). At 12 months of age, the OR for IPV as a predictor of being fully immunized was 1.08 (95% CI: 0.90,1.30). When compared with OPV recipients, adjusted ORs for children in the undetermined poliovirus vaccine type group being fully immunized at 8 and 12 months of age were 0.84 (95% CI: 0.68,1.04) and 0.84 (95% CI: 0.67,1.07), respectively. CONCLUSIONS: The results of this national study indicate that the implementation of an IPV-containing poliovirus vaccine schedule has not had an adverse effect on the immunization status of young children who were vaccinated in the offices of practicing pediatricians.

Child, Preschool↗
PubMed2001

Earlier onset of puberty in girls: relation to increased body mass index and race.

OBJECTIVE: A recent study conducted by the Pediatric Research in Office Settings network provided evidence that girls in the United States, especially black girls, are starting puberty at a younger age than earlier studies had found, but the reasons for this are not known. Because nutritional status is known to affect timing of puberty and there is a clear trend for increasing obesity in US children during the past 25 years, it was hypothesized that the earlier onset of puberty could be attributable to the increasing prevalence of obesity in young girls. Therefore, the objective of this study was to reexamine the Pediatric Research in Office Settings puberty data by comparing the age-normalized body mass index (BMI-ZS; a crude estimate of fatness) of girls who had breast or pubic hair development versus those who were still prepubertal, looking at the effects of age and race. RESULTS: For white girls, the BMI-ZS were markedly higher in pubertal versus prepubertal 6- to 9-year-olds; for black girls, a smaller difference was seen, which was significant only for 9-year-olds. Higher BMI-ZS also were found in girls who had pubic hair but no breast development versus girls who had neither pubic hair nor breast development. A multivariate analysis confirms that obesity (as measured by BMI) is significantly associated with early puberty in white girls and is associated with early puberty in black girls as well, but to a lesser extent. CONCLUSIONS: The results are consistent with obesity's being an important contributing factor to the earlier onset of puberty in girls. Factors other than obesity, however, perhaps genetic and/or environmental ones, are needed to explain the higher prevalence of early puberty in black versus white girls.

Adolescent↗
PubMed2000

Increasing identification of psychosocial problems: 1979-1996.

OBJECTIVE: To examine the changes in identification of pediatric psychosocial problems from 1979 to 1996. RESEARCH DESIGN: Comparison of clinician-identified psychosocial problems and related risk factors among large primary care pediatric cohorts from 1979 (Monroe County Study) and 1996 (Child Behavior Study). Data were collected from clinician visit questionnaires developed originally for the 1979 study. SETTING: Private practice offices of 425 community-based pediatricians and family practitioners across both studies. PATIENTS: We enrolled all children from 4 to 15 years of age who presented for nonemergent services in primary care offices. The 1979 study included 9612 children seen by 30 clinicians and the 1996 study included 21 065 children seen by 395 clinicians. SELECTION PROCEDURE: Each clinician enrolled consecutive eligible patients for both studies. MEASUREMENTS AND RESULTS: From 1979 to 1996, clinician-identified psychosocial problems increased from 6.8% to 18. 7% of all pediatric visits among 4- to 15-year-olds. We found increases in all categories of psychosocial problems, except for mental retardation. Attentional problems showed the greatest absolute increase (1.4%-9.2%) and emotional problems showed the greatest relative increase (.2%-3.6%). The use of psychotropic medications, counseling, and referral also increased substantially. In particular, the percentage of children with Attention deficit/hyperactivity problems receiving medications increased from 32% to 78%. These increases in psychosocial problems were associated with increases in the proportions of single-parent families and Medicaid enrollment from 1979 to 1996. Changes in clinician characteristics did not appear to be the source of increases in clinician diagnoses of psychosocial problems. CONCLUSIONS: Substantial increases in the identification of psychosocial problems in primary care paralleled demographic changes in children presenting to primary care offices and in the larger population.

Adolescent↗
PubMed2000

Uninsured children with psychosocial problems: primary care management.

OBJECTIVE: Nearly 14% of children in the United States are uninsured. We compared the prevalence of psychosocial problems and mental health services received by insured and uninsured children in primary care practices. METHODS: The Child Behavior Study was a cohort study conducted by Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Network. Four hundred one primary care clinicians enrolled an average sample of 55 consecutive children (4-15 years old) per clinician. RESULTS: Of the 13 401 visits to clinicians with 3 or more uninsured patients, 12 518 were by insured children (93.4%) and 883 were by uninsured children (6. 6%). A higher percentage of adolescents, Hispanic children, those with unmarried parents, and those with less educated parents were uninsured. According to clinicians, uninsured children and insured children had similar rates of psychosocial problems (19%) and severe psychosocial problems (2%). For children with a clinician-identified psychosocial problem, we found no differences in clinician-reported counseling, medication use, or referral to mental health professionals. CONCLUSIONS: Among children served in primary care practices, uninsured children have similar prevalence of clinician-identified psychosocial and mental health problems compared with insured children. Within their practices, clinicians managed uninsured children much the same way as insured children. psychosocial problems, uninsured children, pediatrics, family medicine, primary care.

Adolescent↗
PubMed1999

Size and age-sex distribution of pediatric practice: a study from Pediatric Research in Office Settings.

OBJECTIVES: To estimate (1) the average number of patients per practitioner in Pediatric Research in Office Settings, the national practice-based research network of the American Academy of Pediatrics; (2) the total number of active patients cared for in the network; and (3) the age-sex distribution of patients seen in pediatric practice. SETTING: Eighty-nine practices in 31 states with 373 Pediatric Research in Office Settings practitioners (59% of Pediatric Research in Office Settings members). METHODS: Practices were asked to enumerate the number of patients visiting the practice during the 2-year period from January 1, 1991, through December 31, 1992. Patients making multiple visits were counted only once, resulting in a patient count rather than a visit count. Age-sex registers were completed using computer billing records or medical record sampling. RESULTS: Study participants cared for 529513 active patients (50.7% male). Each practitioner cared for an average of 1546 patients. The number of patients per practitioner was significantly higher in less-populated areas and in solo practices. Children aged 12 years and younger comprised 81% of the patients seen by Pediatric Research in Office Settings practitioners, and more than half of the children were aged 6 years or younger. Before age 5 years, boys accounted for a slightly, but significantly, higher number of patients, whereas after age 14 years, girls comprised a significantly larger proportion of patients. CONCLUSIONS: The average number of 1546 patients per practitioner derived from these private practice data is in line with health maintenance organization-based estimates. Pediatric practitioners predominantly serve younger children. These data provide the only current national estimates of the size and age-sex distribution of independent pediatric practices, and can help pediatricians and health service researchers plan for the future provision of health care to children.

Adolescent↗
PubMed1999

Identification of attentional and hyperactivity problems in primary care: a report from pediatric research in office settings and the ambulatory sentinel practice network.

OBJECTIVES: To 1) determine the frequency of identification of attentional and hyperactivity problems (AHPs) by clinicians, and 2) examine whether minority children or children from less well-educated, lower-income, or lower-functioning families would be more likely to be identified as having AHPs. DESIGN: Prospective cohort study of 22 059 consecutive children 4 to 15 years of age being seen for acute, chronic, and health supervision visits. SETTING: Practices of 401 pediatric and family practice clinicians in 44 states, Puerto Rico, and 4 Canadian provinces. METHODS: Parent questionnaires included demographic information and the Pediatric Symptom Checklist. Clinician questionnaires categorized psychosocial problems and addressed how assessment of problems was made. Analyses compared children with newly identified AHPs with those with other newly identified psychosocial problems. RESULTS: Clinicians identified behavior problems in 18.7% of children, with 9.2% of the entire sample identified as having AHPs. Among those with newly assessed AHPs, clinicians identified minority children and those from low-income or poorly functioning families as having AHPs at the same rate as other children. However, even after controlling for symptoms, males were more likely than females (odds ratio, 2.81) to be identified as having AHPs. Older clinicians were significantly more likely to identify children as having AHPs (odds ratio, 2.09). In assessing AHPs, clinicians used standardized tools such as behavioral questionnaires for only 36.9% of children, and Diagnostic and Statistical Manual criteria for 38.3% of children. CONCLUSIONS: AHPs are highly prevalent in primary care practice. Clinicians do not appear predisposed to label children from disadvantaged backgrounds as having AHPs. Primary care assessment of AHPs lacks standardization.

Adolescent↗
PubMed1998

Pediatric research in office settings (PROS): a national practice-based research network to improve children's health care.

OBJECTIVES: To describe the establishment of a national pediatric primary care research network to improve children's health care-Pediatric Research in Office Settings (PROS), and to evaluate the network's progress toward achieving its objectives. SETTING: Pediatric practices in all 50 states and Puerto Rico. PARTICIPANTS: Approximately 1400 pediatric practitioners from more than 470 practices. RESULTS: Beginning in 1986, a core of volunteer pediatrician coordinators from participating American Academy of Pediatrics chapters were identified to oversee local PROS efforts, represent practitioners, and inform the development of proposed research studies. PROS subsequently recruited practitioners from around the country, building a research infrastructure and a system of collaboration between the practitioners, research staff at the AAP, and investigative teams at academic institutions. This PROS collaboration has developed and conducted 10 primary care research studies that have added to the knowledge base of pediatric primary care. CONCLUSIONS: PROS has accomplished two of its initial objectives-development of a structure and process for pediatric practice-based research and provision of research experience to practitioners. Successful and consistent achievement of a third objective-meaningful dissemination of study results to relevant audiences-will depend on meeting several challenges.

Child↗
PubMed1997

Insurance status and recognition of psychosocial problems. A report from the Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Networks.

OBJECTIVE: To examine the effect of insurance status on clinician recognition of psychosocial problems for pediatric primary care visits. DESIGN: A cohort study of 10,250 visits by children 4 to 15 years old for nonemergent care. SETTING: Two large primary care research networks reported data from 172 primary care clinicians in office-based practice. PATIENTS: Ten thousand two hundred and fifty unique children presenting consecutively to participating physicians for nonemergent services with a parent or caregiver. MAIN OUTCOME MEASURE: Children were classified as positive for psychosocial problems if their score on the parent-reported Pediatric Symptom Checklist exceeded the standard cutoff of 28. Clinician recognition was obtained by report as a dichotomous variable. Insurance status was categorized by payor and plan structure. RESULTS: Clinicians did not recognize psychosocial problems for a substantial number of children with scores suggestive of marked psychosocial dysfunction on the Pediatric Symptom Checklist. Insurance type was not associated with rates of recognition. However, provider familiarity with patients, provider discipline, and patient demographics were associated with increased recognition of psychosocial problems. CONCLUSIONS: Differences in treatment among various insurance groups documented in prior studies are not likely to be related to varying recognition rates, but rather to availability and choices of treatment by insurers, families, and clinicians. Continuity of care was the strongest predictor of clinician recognition.

Cohort Studies↗
PubMed1997

Research in private pediatric practice and the challenge of network research.

Although most children receive their primary care in private physicians' offices, surprisingly little of the child health knowledge base has been generated from office settings. Research in practice settings is increasing, however, especially through networks of office-based pediatricians who are now collaborating with academic researchers to produce high-quality research on primary pediatric care. This paper provides a current overview of practice-based research in pediatrics, highlights contributions by regional and national pediatric research networks, and suggests directions for practice-based research in the future.

Humans↗
PubMed1997

Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings network.

OBJECTIVE: To determine the current prevalence and mean ages of onset of pubertal characteristics in young girls seen in pediatric practices in the United States. METHODS: A cross-sectional study was conducted by 225 clinicians in pediatric practices belonging to Pediatric Research in Office Settings, a practice-based research network. After standardized training in the assessment of pubertal maturation, practitioners rated the level of sexual maturation on girls 3 through 12 years who were undergoing complete physical examinations. RESULTS: Data were analyzed for 17,077 girls, of whom 9.6% were African-American and 90.4% white. At age 3, 3% of African-American girls and 1% of white girls showed breast and/or pubic hair development, with proportions increasing to 27.2% and 6.7%, respectively, at 7 years of age. At age 8, 48.3% of African-American girls and 14.7% of white girls had begun development. At every age for each characteristic, African-American girls were more advanced than white girls. The mean ages of onset of breast development for African-American and white girls were 8.87 years (SD, 1.93) and 9.96 years (SD, 1.82), respectively; and for pubic hair development, 8.78 years (SD, 2.00) and 10.51 years (SD, 1.67), respectively. Menses occurred at 12.16 years (SD, 1.21) in African-American girls and 12.88 years (SD, 1.20) of age in white girls. CONCLUSIONS: These data suggest that girls seen in a sample of pediatric practices from across the United States are developing pubertal characteristics at younger ages than currently used norms. Practitioners may need to revise their criteria for referral of girls with precocious puberty, with attention to racial differences.

Age Distribution↗
PubMed1996

Methodological issues in determining rates of childhood immunization in office practice. A study from pediatric research in office settings (PROS).

OBJECTIVE: To compare 3 methods for measuring pediatric office immunization rates. DESIGN: Retrospective and prospective cross-sectional surveys. PATIENTS: Children 2 and 3 years old from 15 pediatric practices in 11 states. METHODS: Immunization rates were determined for each practice using 3 methods. The Consecutive method used data from the practice's medical records of patients seen consecutively in the office; the Chart method used data from randomly selected practice medical records; and the Active method (reference standard) used a combination of medical record data with a telephone interview to collect additional immunization data and current patient status, using data only on current patients. Analyses were based on a mean of 57, 62, and 51 (Consecutive, Chart, and Active method, respectively) patients per practice. Patients were considered fully immunized if they had received 4 doses of DTP/DT vaccine, 3 doses of OPV/IPV, and 1 dose of MMR vaccine by their second birthday Comparisons were made using the paired t test. RESULTS: The mean immunization rate by method was Consecutive, 81.5% (range, 51%-97%); Chart, 71.6% (range, 42%-94%); and Active, 79.6% (range, 53%-96%). Within a given practice, the differences between methods varied considerably (0 to 28 percentage points). The mean difference from the reference standard Active method was 8 percentage points (P < .001) for the Chart method and -1.9 percentage points (P = .36) for the Consecutive method. The largest difference was between the Consecutive and Chart methods (mean difference, 9.9 percentage points; P = .003). Practitioners uniformly found the Consecutive method easiest to implement. CONCLUSIONS: Practice-specific immunization rates are one of the few objective measures of the quality of preventive pediatric care. Pediatric practices monitoring their immunization rates should consider using the Consecutive method, a simple, acceptable, and valid measure of practice immunization rate.

Child↗
PubMed1992

Recurrent otitis media and parenting stress in mothers of two-year-old children.

This study examined the impact of recurrent otitis media on mothers' perceptions of themselves and of their 2-year-old children. Fifty-two mothers of children with and without histories of recurrent otitis media completed measures that rated the level of stress in the mother-child relationship at two points in time. The mothers of children who experienced six or more episodes of otitis media in the first 2 years of life rated their children as significantly more demanding at age two and at follow-up 6 months later than did the mothers of children who experienced no more than one episode of the illness. At the first point in time, these mothers also rated themselves as significantly more depressed and less competent than did control mothers, a pattern that was maintained at the follow-up. Findings of the study suggest that recurrent otitis media early in life may contribute to adverse perceptions of child and self that may persist for some time after the child has been relatively disease free and further suggest that parental perceptions may mediate relationships between early recurrent otitis media and later developmental outcomes.

Adaptation, Psychological↗
PubMed1992

Preschool vision screening in pediatric practice: a study from the Pediatric Research in Office Settings (PROS) Network. American Academy of Pediatrics.

In this cross-sectional study, the vision-screening process is described for 8417 children aged 3 to 5 seen for health supervision in a group of 102 pediatric practices in 23 states and Puerto Rico. Three hundred forty children who failed screening (63% of those who failed) were followed up 2 months after initial screening. The sample was 52% male, 86% white, 9% black, 3% Hispanic, and 1% Asian. Vision screening was attempted on 66% of children overall. Pediatricians' reasons for not screening were "not routine" (44%), "too young" (40%), and "screening done previously" (17%). Younger children were less likely to be screened than older children (39% of those aged 3), and Hispanics were less likely to be screened than other ethnic groups (P less than .001). Thirty-three percent of children received no screening for latent strabismus. Two months later, 50% of parents whose child had failed a vision test were unaware of this fact on questionnaire follow-up. Eighty-five percent of children referred to an eye specialist had made or kept an appointment. It is concluded that pediatricians need to increase vision screening among younger preschool children and communicate more effectively to parents the results of screening failure.

Amblyopia↗
PubMed1990

Infant temperament and school age behavior: 6-year longitudinal study in a pediatric practice.

We conducted a retrospective cohort study in a pediatric practice to assess the association between parents' ratings of temperamental difficulty (observations of specific infant behaviors) and perceptions of temperamental difficulty (impressions of one's infant as compared with other infants) in infancy and behavior problems at school age. Mothers of 129 infants, who had completed the Revised Infant Temperament Questionnaire at the 4-month visit, completed the Child Behavior Checklist when the child was 6 years of age. Teachers of 102 of these children completed the teacher Child Behavior Checklist. Temperamental difficulty was defined by assessments of rhythmicity, approach/withdrawal, intensity, mood, and adaptability. Initial analyses revealed that low socioeconomic status (r = -.29, P = .001), ratings of temperamental difficulty (r = .17, P = .06), and perceptions of temperamental difficulty (r = .22, P = .02) at 4 months of age were associated with increased maternal rating of behavior problems at 6 years of age (all 2-tailed tests). However, a multivariate regression analysis showed only low socioeconomic status (P less than .01) and increased perceptions of temperamental difficulty (P = .02) associated with maternal behavior problem scores. Teacher behavior problem scores were associated only with low socioeconomic status (r = -.27, P = .01). These results suggest that the link between difficult infant temperament and later behavior problems is complex and probably reflects both child factors and parent attitudes about what constitutes typical infant behavior.

Child↗
PubMed1989

Recurrent infantile vomiting due to intentional ipecac poisoning.

Recurrent vomiting is a common symptom in infancy that, when severe, may prompt an extensive diagnostic evaluation. We report a 1-year-old infant whose recurrent vomiting eluded diagnosis until ipecac syrup was detected in vomitus and urine. Separation of the infant from the mother resulted in complete resolution of the symptoms. In Munchausen syndrome by proxy, a disorder in which a mother fabricates or induces illness in her child, most reported fatalities are due to intentional poisoning. In atypical cases of recurrent vomiting, early screening of body fluids for unexpected drugs, particularly ipecac, may prevent potentially fatal delays in diagnosis.

Female↗
PubMed1989

Health care of physicians' children.

In anecdotal reports, problems have been cited in the health care of physicians' children, but no systematic study of this issue has been attempted. Pediatricians in a community of high physician density were interviewed to determine whether and how the health care of physicians' children differs from that of children of equivalent socioeconomic status. Of the community's 33 pediatricians, 94% responded to items in a 45-minute structured interview, for which test-retest reliability was demonstrated. Systematic differences in the care of physicians' children included delayed help seeking and increased self-referral to specialists by parents, and poor documentation of psychosocial history, less detailed instruction giving, and a reluctance to discuss problem behavior by pediatricians. Reasons cited by pediatricians for these problems included inappropriate assumptions concerning the medical knowledge of the physician's family, confusion between the roles of healer and help seeker, and embarrassment about discussing personal issues with colleagues. Pediatricians and physician parents need to become aware of and communicate about the potential for problems in the health care of physicians' children.

Adult↗