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PURPOSE: Tooth decay is one of the more common diseases of childhood. Slightly >40% of US children are already affected by the time they reach kindergarten. Primary care physicians can play an important role in prevention and control of this disease because of their ready access to this population. Unlike dentists, they see a large percentage of children during their infant and toddler years. However, few studies have been conducted on oral screenings and referrals by primary care physicians or the effectiveness of their oral health preventive activities. The purpose of this study was to determine the accuracy of pediatric primary care providers' screening and referral for Early Childhood Caries. METHODS: We sought to compare independent, blinded oral screening results and referral recommendations made by primary care providers with those of a pediatric dentist, considered for purposes of the study to be the reference gold standard. The study was conducted at a private pediatric group practice in North Carolina. The practice was selected because it serves a large volume of Medicaid patients and includes a large number of pediatric primary care providers (11 pediatricians and 1 nurse practitioner). Study participants included Medicaid-eligible children younger than 36 months of age with erupted teeth. The pediatric primary care providers in this practice received 2 hours of training in infant oral health. The training consisted of a review of the study methods and clinical slides illustrating dental caries in various stages of progression. Specific instructions were given to the providers on how to recognize a cavitated carious lesion and how to determine when a dental referral is needed. Providers were instructed to refer any child with 1 or more cavitated carious lesions, soft tissue pathology, or evidence of trauma to the teeth or mouth. Before commencing the study, calibration and a comparative analysis were performed to establish reliability and validity of the examinations performed by the pediatric dentist. Both a pediatric dentist and a pediatric primary care provider conducted a dental screening on each child and recorded carious teeth and whether a dental referral was needed. Sensitivity and specificity were calculated to compare the pediatric primary care providers' screenings to the gold standard (pediatric dentist) in 3 categories: caries at the tooth level, caries at the patient level (1 or more affected teeth), and need for referral. RESULTS: The final study sample consisted of 258 preschool-aged children (122 males and 136 females) with a mean age of 21.2 months (standard deviation [SD]: 9.13). One hundred eighty-four (71.3%) of the participants were white, 58 (22.5%) were black, and 16 (6.2%) were Hispanic. Tooth-Level Analysis: The pediatric dentist reported an average of 0.30 (SD: 0.005) cavitated teeth per child, whereas the pediatric primary care providers reported a mean of 0.25 (SD: 0.004). This difference was not statistically significant (t test). The pediatric dentist identified 80 (2.4%) teeth with cavitated carious lesions, whereas the pediatric primary care providers identified 64 (1.9%), 25 of which were false-positives. Their screening results include 41 false-negative teeth. Thus, the primary care providers tended to under-count the number of teeth with carious lesions. They achieved a sensitivity of 0.49 (95% confidence interval [CI]: 0.47-0.51) and a specificity of 0.99 (95% CI: 0.99-1.0) when their screening results for individual teeth were compared with the gold standard. Patient-Level Analysis: At the patient level, the pediatric dentist identified 25 (9.7%) children with 1 or more teeth affected by cavitated lesions. The pediatric primary care providers collectively identified 30 (11.6%) children who had cavitated lesions. They achieved a sensitivity of 0.76 (95% CI: 0.71-0.81) and a specificity of 0.95 (95% CI: 0.93-0.98) in identifying those children with cavitated carious lesions. There were 6 false-negatives and 11 false-positives when the pediatric primary care providers' findings were compared with the gold standard. At the patient-level, the positive predictive value of the dental screening was 0.63 and the negative predictive value was 0.97. Dental Referral: The pediatric dentist referred a total of 27 (10.5%) children to a dentist. Two of these children were referred for trauma and the other 25 were referred for cavities. The pediatric primary care providers referred a total of 23 (8.9%) children to a dentist. Two referrals were made because the provider was concerned about stains on the teeth, whereas the remaining 21 were referred for cavities. The pediatric primary care providers achieved a sensitivity of 0.63 (95% CI: 0.57-0.69) and a specificity of 0.98 (95% CI: 0.96-0.99) when their recommendations for referral were compared with the gold standard. The number of children receiving a referral from a pediatric primary care provider for cavities (N = 21) was less than the number of children they identified as having cavities (N = 30). The providers as a whole tended to under-refer, and only 70% of children with evidence of dental disease received a referral. CONCLUSIONS: After 2 hours of training in infant oral health, the pediatric primary care providers in this study achieved an adequate level of accuracy in identifying children with cavitated carious lesions. Additional training and research would be needed to optimize pediatric primary care providers' identification of carious teeth if that were the goal of screening. However, the purpose of screening by nondental personnel generally is to accurately identify those in need of referral, which does not require a tooth-by-tooth identification of cavities. Additional research is also needed to determine how to improve dental referrals by pediatric primary care providers. Results of our study suggest that dental screenings can easily be incorporated into a busy pediatrics practice and that pediatric primary care providers can significantly contribute to the overall oral health of young children by the identification of those children who need to be seen by a dentist.
Finding information on the use of drugs fro infants and children is becoming easier with the publication of excellent resources for pediatric and neonatal drug information. Useful pediatric texts and journals are listed. Texts are graded A and B. Category A books would be useful to include in a basic pharmacy library; Category B books are more comprehensive but expensive, or texts that are not as highly recommended as those in Category A. Some of the resources listed include: (1) Pediatrics--Nelson Textbook of Pediatrics, Rudolph's Pediatrics, Current Pediatric Diagnosis and Treatment, Manual of Pediatric Therapeutics; (2) Dosage Guides--The Pediatric Drug Handbook, Harriet Lane Handbook, Problems in Pediatric Drug THerapy; (3) Intensive Care--Textbook of Pediatric Intensive Care; (4) Infectious Disease--Report of the Committee on Infectious Diseases, Pocketbook of Pediatric Antimicrobial Therapy; (5) Poisoning--Handbook of Poisoning, Medical Toxicology; (6) Parenteral Nutrition--Manual of Pediatric Parenteral Nutrition; (7) Pregnancy and Lactation--Drugs in Pregnancy and Lactation; (8) Compounding--Handbook on Extemporaneous Formulation; (9) IV Administration--Guidelines for Administration of Intravenous Medications to Pediatric Patients; (1) Neonatology--Schaffers Diseases of the Newborn, Neonatology, Basic Management, On-Call Problems, Diseases, Drugs, Drug Therapy in Infants; (11) Pediatric Journals--Pediatrics, Journal of Pediatrics, American Journal of Diseases of Children, Pediatric Infectious Disease Journal, Pediatric Alert, Clinics in Perinatology, Pediatric Clinics of North America, Pediatric Clinical Oncology Journal, and Pediatric Surgery.
OBJECTIVE: To teach residents to recognize and treat critically ill or injured infants, children, and adolescents in a 1-month, intensivist-designed, second-year resident pediatric intensive care rotation curriculum while maintaining optimal patient care and resident educational satisfaction. DESIGN: Descriptive evaluation of an intensivist-designed, second-year resident pediatric intensive care rotation curriculum from September 1994 to May 1996. SETTING: Multispecialty 16-bed pediatric intensive care unit (ICU) staffed by five pediatric critical care physicians in a university-affiliated children's hospital supporting a pediatric residency program. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Our second-year resident pediatric ICU rotation curriculum consisted of direct patient care, participation in clinical rounds under the supervision of a pediatric critical care attending physician, and a 1-month formal curriculum. A standardized test evaluated resident pediatric critical care knowledge before and after the pediatric ICU rotation. Number and type of resident procedures were documented. Four-point Likert scale questionnaires were used to evaluate resident educational satisfaction and resident performance. Opportunity cost, the graduate medical education return on educational investment, the critical care attending physician's return on resident investment, and the optimal teaching time for number of rotation residents were calculated. Unit demographics were documented. Data analysis included multivariate analysis, t-test, and chi-squared techniques. Significance was defined as p < .05, rotated factor loading > 0.5, and Eigenvalues > or = 1. Kmeans identified clusters. From September 1994 to May 1996, 71 residents, 34 (48%) from pediatric or medicine-pediatric programs and 37 (52%) from emergency medicine residency programs, participated in our second-year pediatric ICU resident educational process. All residents showed improvement between pretest and posttest knowledge scores (p < .05). Seventy percent of the variance in critical care attending physician evaluations of the residents during their pediatric ICU rotation was based on bedside clinical skills (31%), communication skills (20%), and basic knowledge base (19%). Critical care attending physician evaluations of residents placed residents into three clusters: "hands-on," "well-rounded," or "book-heavy" residents. Prerotation test scores, postrotation test scores, and numbers of procedures performed did not correlate with how critical care attending physicians evaluated overall performances of individual residents. Three factors explained 61% of the variances in resident satisfaction with the pediatric ICU rotation: clinical experience (27%), formal didactics (18%), and text availability (16%). Resident educational satisfaction did not appear to depend on access to procedures. Critical care attending physicians spent a minimum of 12.6 hrs/wk involved in resident education. The opportunity cost for using critical care attending physicians to provide 12.6 resident teaching hours per week was calculated as $111,384/yr. Pediatric ICU patient demographics, morbidity, and mortality did not change during the introduction of the resident educational program in the pediatric ICU. CONCLUSIONS: During a required pediatric ICU resident rotation, balancing the resident's educational and decision-making autonomy needs and the critical care attending physician's desire to provide consistent bedside care of the critically ill child is an ongoing interactive process that requires substantial personnel, time, and financial commitments. It is possible to maintain patient care in the pediatric ICU and provide residents with a satisfying pediatric ICU experience. Trends in financial reimbursement may limit our present time commitment to the resident pediatric ICU curriculum.
OBJECTIVES: This report presents estimates on the availability of pediatric services, expertise, and supplies for treating pediatric emergencies in U.S. hospitals. METHODS: The Emergency Pediatric Services and Equipment Supplement (EPSES) was a self-administered questionnaire added to the 2002-03 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS samples non-Federal, short-stay and general hospitals in the United States. The EPSES content was based on the 2001 guidelines for pediatric services, medical expertise, small-sized supplies, and equipment for emergency departments (EDs) developed by the American Academy of Pediatrics (AAP) and the American College of Emergency Physicians (ACEP). Combined response rate for both years was 86 percent. Estimates were weighted to produce average annual estimates of pediatric services, expertise, and equipment availability in EDs. RESULTS: One-half of hospitals (52.9 percent) admitted pediatric patients, but did not have a specialized inpatient pediatric ward. One-third (38.3 percent) admitted pediatric patients and had a separate pediatric ward; the remainder did not admit pediatric patients. Among those that did not admit pediatric cases, 30.4 percent were in counties that had a children's hospital. One-quarter of EDs had access 24 hours and 7 days a week to a board-certified pediatric emergency medicine attending physician. Only 5.5 percent had all recommended pediatric supplies, but one-half had greater than 85 percent of recommended supplies. Most hospitals without pediatric trauma service (90.7 percent) or pediatric intensive care units (97.5 percent) transferred critical pediatric patients to hospitals with these services. EDs in hospitals with specialized inpatient facilities for children were more likely to meet the AAP and ACEP guidelines for pediatric ED services, expertise, and supplies.
OBJECTIVE: Digital health sciences libraries (DHSLs) bring order to the chaos of the Internet by making authoritative medical information easily and conveniently available to patrons. The goal of this project was to perform a baseline usage analysis of the pediatric-related information in a general DHSL and to determine whether reorganization of the pediatric-related information into its own pediatric DHSL could increase the usage of the pediatric-related information. METHODS: From March through August 1997, a baseline analysis of a general DHSL (Virtual Hospital) was conducted using computer server log file analysis programs. The quantity of pediatric-related information in the general DHSL and its baseline usage were determined. In September 1997, the pediatric-related information was reorganized into its own pediatric DHSL (Virtual Children's Hospital), and server log file analyses were conducted of the pediatric DHSL from September 1997 to August 1998. Statistical analysis was performed by time series autoregression. RESULTS: During the baseline, the general DHSL and the pediatric-related information received a monthly average of 2 320 782 and 141 444 qualified hits, respectively. After the intervention, the general DHSL and the pediatric DHSL received a monthly average of 2 765 454 and 256 998 qualified hits, respectively. This is an increase of 19. 2% for the general DHSL and 81.7% for the pediatric DHSL. These changes were statistically significant at the P >.0001 level. The most requested pediatric-related content in the pediatric DHSL did not change substantively from preintervention to postintervention. DISCUSSION: On the Internet, as in real life, children's services must have their own distinct identity and must be differentiated from adult services. Therefore, pediatric-related information will receive increased usage if it is part of a pediatric DHSL rather than part of a general DHSL. Others can use this process and the lessons learned to develop and enhance their own pediatric-related information on the Internet. Internet, pediatrics, digital health sciences libraries, digital library, medical library.
OBJECTIVE: To analyze the results of surveillance for new smear positive pediatric tuberculosis (TB) cases at the age of 0 to 14 years in China, to understand the trend of prevalence and finding of the new smear positive pediatric cases with TB, to illuminate the significance of surveillance for pediatric TB in TB epidemiology and to explore how to prevent and control pediatric TB with the modern TB control strategy (directly observed treatment, short-course, DOTS). METHODS: According to the register of new smear positive pediatric TB cases at the age of 0 to 14 years in the National Annual Surveillance Reporting from 1992 - 2004, the proportion of new smear positive pediatric TB cases among all the new smear positive TB cases in China, the notification rate of new smear positive pediatric TB, the case detection rate of new smear positive TB in the eastern, central and west parts of China, in Beijing, Tianjin and Shanghai municipalities and 13 provinces where the modern TB control strategies have been implemented in 1992 and 15 provinces where the strategies have not been implemented except Beijing, Tianjin and Shanghai municipalities, were analyzed. RESULTS: From 1992 to 2004, 31,358 new smear positive pediatric cases with TB at the age of 0 to 14 years were registered, among whom 14,727 were males (47%) and 16,631 were females (53%). The proportion of new smear positive pediatric TB cases among all the new smear positive TB cases was 1.26%, while the proportion among males was 0.89% and among females was 2.03%. The proportion among females was higher than that among males (P < 0.01). The notification rate of new smear positive pediatric cases with TB was between 0.42/100,000 and 1.08/100,000. Among the new smear positive pediatric TB cases, 44.9% were from western parts of China, followed by central and eastern parts of China and only 0.9% were from Beijing, Tianjin and Shanghai municipalities. Excluding Beijing, Tianjin and Shanghai municipalities, 13 provinces where DOTS was implemented since 1992 were compared with the other 15 provinces. The notification rate of new smear positive TB was respectively 75% and 25%. Western region of China was listed on the top in the proportion of new smear positive pediatric TB cases among all the new smear positive TB cases in every year. CONCLUSION: Among the registered new smear positive pediatric cases with TB, the number of females was higher than that among females and the proportion among males was also higher than that among males. The number of new smear positive pediatric TB cases in western parts of China was higher than that in central and eastern parts of China and the number in DOTS area was higher than that in non-DOTS area, which meant that the case detection of pediatric TB was associated with TB epidemic and DOTS strategy. Thus, in the implementation of DOTS, strengthening the prevention and control of pediatric TB, tracing the infection source of pediatric TB has certain impact on the TB epidemiological status.
OBJECTIVE: The objective of this study was to describe geographic proximity, quantify variation in supply, and estimate pediatric population increments that are needed to support providers across pediatric subspecialties. METHODS: Data from the American Board of Pediatrics and the Claritas Pop-Facts Database were used to calculate subspecialty-specific straight-line distances between each zip code and the nearest board-certified subspecialist. These data sources also were used to estimate the percentage of hospital referral regions with providers and calculate physician-to-population ratios for each of 16 pediatric medical subspecialties. Coefficients of variation for the ratios were used to assess intraspecialty variation in supply across markets. Estimates of the pediatric population that is needed to support an initial or additional physician in a market were generated using subspecialty-specific ordered logit analyses. RESULTS: The population-weighted average distance to a subspecialist ranged from 15 miles for neonatology to 78 miles for pediatric sports medicine. For most pediatric subspecialties, more than two thirds of children live within 40 miles of a certified physician. For 7 of 16 of pediatric subspecialties, fewer than one half of hospital referral regions have a provider. Coefficients of variation vary across subspecialties and are lowest for neonatology at 76% and greatest for pediatric sports medicine at 287%. Pediatric population thresholds likewise vary with a tendency toward lower thresholds for procedural specialties, such as cardiology and critical care medicine. CONCLUSIONS: The practice locations of pediatric subspecialists parallel the geographic distribution of children in the United States, yet many hospital referral regions lack pediatric subspecialists and coefficients of variation vary widely across subspecialties. These findings suggest that either the supply of pediatric subspecialists is inadequate, pediatric subspecialists are distributed inequitably, or the market for pediatric subspecialists is larger than the hospital referral regions. Furthermore, population thresholds for many cognitive pediatric subspecialties are high; the extent to which high thresholds reflect low disease prevalence versus other factors, such as inadequate reimbursement, is not established.
STUDY OBJECTIVE: To describe emergency department quality assurance (QA)/improvement (QI) practices for pediatric patients. DESIGN: Mail survey of a cohort of emergency physicians. PARTICIPANTS: Pediatric Section members of the American College of Emergency Physicians and a computer-generated random sample of general ACEP members. RESULTS: Pediatric Section and general ACEP physicians were mailed a 13-question QA survey. Of the 500 surveys distributed, 207 (41.4%) were returned. Three emergency care settings for pediatric patients seen in the ED were identified: (1) children's hospital ED (14%), (2) general ED with a separate area designated for the evaluation of pediatric patients (12%), and (3) general ED where pediatric and adult patients are evaluated in the same area (74%). Separate QA indicators were used to monitor care of the pediatric patients seen in the ED by 61% of the respondents; 39% used "adult" indicators only. High pediatric census was associated with pediatric representation on the ED QA/QI Committee, the use of separate pediatric indicators to monitor care of pediatric patients in the ED, the separation of pediatric and adult patient care areas and satisfaction with the respondent's ED QA/QI plan. CONCLUSION: The bulk of pediatric emergency patients are cared for in a general ED. Most ACEP members surveyed reported the use of separate QA indicators to monitor the care of pediatric patients seen in the ED. This survey provides the first description of QA/QI practices for pediatric patients by EDs nationwide.
What is the training in pediatric surgery like, how is pediatric surgery defined in other countries and what are the possibilities of quality control for training in pediatric surgery? The results of an inquiry together with information about training in pediatric surgery in 24 countries are summarised to show the different possibilities of organising training in pediatric surgery inside and outside Europe. The number of trainees in pediatric surgery (ranging from 0 to 339 trainees per country), the density of pediatric surgeons (ranging from 424 to 35 714 live births/year per pediatric surgeon) and the number of Centres of Pediatric Surgery (ranging from 4167 to 65,000 live births or 450,000 to 5,300,000 inhabitants per Centre) varies a lot in the different countries. Countries with a higher density of pediatric surgeons often also have a higher number of trainees irrespective of the birth rate and the number of inhabitants within the country, indicating a good infrastructure for pediatric surgery. In 87.5 % of the countries pediatric surgery is recognised as a specialty. The mean duration of training is about 6 years and 3 months, excluding the countries where it is necessary to become a fully accredited general surgeon before doing pediatric surgery. The mean duration of stay in general surgery is 2 years and 10 months. In one third of the countries it is obligatory to spend some time (3 to 12 months) in pediatrics. An elective or a compulsory period of time (1 - 6 months) in other specialties such as orthopedic surgery, plastic and reconstructive surgery, thoracic surgery and urology exists in 41.7 % of the nations. The most common subspecialties within pediatric surgery practised during the training by the resident are abdominal surgery, thoracic surgery, oncological surgery, head and neck surgery and urology. Possible means of control to guarantee a high quality of training include a defined time of stay in each subspecialty, the number of operations done by the trainee or the number of cases treated by the resident in the respective subspecialty and the distinction of different levels of surgery done by the trainee during his residence. In many cases the type of control is not specified.
OBJECTIVE: To describe the trends in the pediatric surgeon workforce during the last 25 years and to provide objective data useful for planning graduate medical education requirements. SUMMARY BACKGROUND DATA: In 1975, the Study on U.S. Surgical Services (SOSSUS) was published, including a model to survey staffing. A pediatric surgeon workforce study was initiated in conjunction with SOSSUS as a population, supply, and need-based study. The study has been updated every 5 years using the same study model, with the goals of determining the number and distribution of pediatric surgeons in the United States, the number needed and where, and the number of training programs and trainee output required to fill estimated staffing needs. This is the only such longitudinal workforce analysis of a surgical specialty. METHODS: Questionnaires were sent to 100 pediatric surgeons representing the 62 standard metropolitan statistical areas (SMSAs) in the United States with a population of 200,000 or more to verify the names and locations of all active pediatric surgeons and to gain information about the 5-year need for new pediatric surgeons by region. A program was developed to predict the number of pediatric surgeons relative to the total population and the 0-to-17-year-old population in the subsequent 30 years using updated data on the present number and ages of pediatric surgeons, age-specific death and retirement rates, projections of U.S. population by age group, and varying numbers of trainees graduated per year. As each 5-year update was done, previous projections were compared with actual numbers of pediatric surgeons found. The trends during the last 25 years were analyzed and compared and additional information regarding the demographics of practice, trends in reimbursement, and volume and scope of surgery was obtained. RESULTS: The birth rate has been stable since 1994. The 0-to-17-year-old population has been increasing at 0.65% per year; a 0.64% annual rate is projected to 2040. At present, 661 pediatric surgeons are distributed in every SMSA of 200,000 or more population, with an average age of 45 and an average age of retirement 65. The actual number of pediatric surgeons in each 5-year survey has consistently validated previous projections. Trainee output has increased markedly in the past 10 years. The rate of growth of the pediatric surgeon workforce at present is 50% greater than the forecasted rate of increase in the pediatric age group, and during the past 25 years the rate of growth of the pediatric surgeon workforce has been double that of the pediatric population growth. Nationally, significant changes in reimbursement, volume of surgery, and demographics of practice have occurred.
Academic general pediatrics and ambulatory care are closely linked to the development of the Ambulatory Pediatric Association, an organization with nearly 2000 members active in teaching, patient care, and research. Primary care, behavioral-developmental pediatrics, prevention, health promotion, community pediatrics, socioeconomic issues, cultural and ethnic diversity, advocacy, research in education, social issues, and environmental health lie within the purview of general pediatrics. In part, because of their teaching and patient care obligations, but also due to a lack of fellowship research training, many general pediatrics faculty have had difficulty in accomplishing significant research. By supporting fellowship training in general pediatrics, The Robert Wood Johnson Foundation General Pediatrics Academic Development Program and the current fellowship program supported by the Bureau of Health Manpower are important efforts to remedy this deficiency. The sciences basic to general pediatrics research include epidemiology, biostatistics, and the behavioral sciences. In addition, general pediatrics research often borrows from other sciences and collaborates with investigators in other disciplines. Partnerships between general pediatrics divisions and practicing pediatricians for teaching and research, e.g. the Community Education in Community Settings program, provides a realistic educational program for future pediatricians. The Pediatric Research in Office Setting network is another important vehicle for translation of research into the practice of general pediatrics. The steady growth of the Ambulatory Pediatric Association over the past four decades is testimony to the creativity, adaptability, and verve that has characterized the discipline of general pediatrics.
The Future of Pediatric Education II (FOPE II) Project was a 3-year, grant-funded initiative, which continued the work begun by the 1978 Task Force on the Future of Pediatric Education. Its primary goal was to proactively provide direction for pediatric education for the 21st century. To achieve this goal, 5 topic-specific workgroups were formed: 1) the Pediatric Generalists of the Future Workgroup, 2) the Pediatric Specialists of the Future Workgroup, 3) the Pediatric Workforce Workgroup, 4) the Financing of Pediatric Education Workgroup, and 5) the Education of the Pediatrician Workgroup. The FOPE II Final Report was recently published as a supplement to Pediatrics (The Future of Pediatric Education II: organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century. Pediatrics. 2000;105(suppl):161-212). It is also available on the project web site at: This report reflects the deliberations and recommendations of the Pediatric Generalists of the Future Workgroup of the Task Force on FOPE II. The report looks at 5 factors that have led to changes in child health needs and pediatric practice over the last 2 decades. The report then presents a vision for the role and scope of the pediatrician of the future and the core attributes, skills, and competencies pediatricians caring for infants, children, adolescents, and young adults will need in the 21st century. Pediatrics 2000;106(suppl):1199-1223; pediatrics, medical education, children, adolescents, health care delivery.