Long-term outcomes of physician peer teaching

Research conducted in 10 cities assessed long-term pediatric asthma outcomes from a peer teaching intervention for physicians to improve their asthma-related clinical and counseling skills. Hypotheses were better outcomes for patients, symptom reduction, less health care use, and enhanced view of the physician. Peers trained 53 intervention group pediatricians (seeing 418 patients); 48 pediatricians (seeing 452 patients) were controls. Patients provided baseline and 2-year follow-up data, collected by telephone interview and from medical records. Intent-to-treat analyses used Poisson regression and general estimation equations. Treatment physicians' patients gave them higher performance ratings ( P = .02). Patients had fewer sleep disruptions from asthma symptoms ( P = .03). Those with baseline health care use had fewer ED visits ( P = .005), hospitalizations (P = .03), and urgent office visits (P = .001), and they made fewer phone calls to the doctor's office (P = .02). Treatment physicians spent no more patient visit time than control physicians. Peer training increased patient's positive views of clinician's performance and reduced children's symptoms and health care use up to two years post program.     

Increasing patient knowledge, satisfaction, and involvement: randomized trial of a communication intervention

A brief educational intervention to promote effective communication between physicians, children, and parents during pediatric office visits was designed and tested. A randomized clinical trial involving 141 children (5- to 15-year-olds) tested the effectiveness of the intervention to improve the process and outcome of medical care. The intervention was contained in three brief videotapes (one each for parents, physicians, and patients) and in accompanying written materials. Materials were designed to build skills and motivation for increased child competence and participation during pediatric medical visits. Control subjects saw health education videotapes and received materials comparable in length with those of experimental subjects. Postintervention medical visit process was analyzed using videotapes of visits. Visit outcomes, assessed with standardized instruments and interviews, included children's rapport with physicians, children's anxiety, children's preference for an active health role, children's recall of information, parents' satisfaction with the medical visit, and physician satisfaction. Results indicated that physicians in the intervention group, compared with their counterparts in the control group, more often included children in discussions of medical recommendations (50% vs 29%, t = 2.39, P less than .05); that children in the intervention group, compared with control children, recalled more medication recommendations (77% vs 47%, P less than .01) and reported greater satisfaction and preference for an active health role; and that the intervention and control groups did not differ in parent satisfaction, physician satisfaction, or child anxiety. The results suggest that a brief educational intervention administered during waiting room time can positively impact physician-child rapport and children's preference for an active role in health and their acquisition of medical information.     

Specialty referrals made during telephone conversations with parents: a study from the pediatric research in office settings network.

OBJECTIVES: To characterize variation in pediatricians' telephone referral practices, to identify differences in the types of referrals made during telephone versus office visit encounters, and to examine the impact of referring by telephone on coordination and outcomes of the referral as assessed by physicians. METHODS: We conducted a prospective study of a consecutive sample of referrals (N = 1856) made from the offices of 142 pediatricians in a national practice-based research network. During 20 consecutive practice-days, physicians completed questionnaires about patients referred during regular business hours. They used office records 3 months later to complete questionnaires about referral outcomes. RESULTS: Pediatricians made 1 telephone referral every 5 practice-days, which constituted 27.5% of all referrals they made during office hours. Pediatricians who saw more patients per day, saw more patients in gatekeeping health plans, and referred more during office visits made more telephone referrals than their counterparts. Compared with specialty referrals made during office visits, those occurring during telephone encounters were more frequently at the request of parents or because of insurance administrative guidelines. Office visit referrals were more often made for diagnostic evaluation or a surgical procedure. Referrals made during telephone conversations were less well coordinated: office staff or referring physicians scheduled fewer specialty appointments and were less likely to send information to specialists. Three months after referrals were made, specialist feedback and referring physician satisfaction with specialty care were comparable between the two groups. CONCLUSIONS: Specialty referrals made during telephone conversations with patients are a regular occurrence in pediatric practice. Changes in the health system that lead to greater demands on primary care physician productivity or more patients in gatekeeping health plans will likely increase the number of referrals made during telephone conversations with parents. Pediatricians are less likely to coordinate telephone referrals than office visit referrals. Pediatricians are frequently unaware whether or not referrals are completed.     

Clinical effects of a Long-term Educational Program for Children with Asthma – Aironet®. A 1-yr randomized controlled trial

Educational self-management programs for children with asthma have now become a routine feature in the management of the disease, as international guidelines underline. We designed this trial to find out whether Aironet^®, an educational program developed for children with asthma, influenced asthma severity and improved parents' knowledge of the disease. In a multicenter, prospective, randomized controlled trial we enrolled 123 children, 72 boys, mean age 8.78 yr (±2.33 s.d.), with intermittent or mild persistent asthma. Participants were randomly assigned to an education group, who received Aironet^® at baseline and 2 months later (60 children), or to a control group who did not (63 children). Follow-up lasted 12 months and included out-patient clinic visits and spirometry at 2, 4 and 12 months. At baseline and at 12 months follow-up, parents were questioned about their knowledge of asthma, and their children's asthmatic attacks, use of systemic corticosteroids, family physician or hospital emergency room visits, hospitalizations and asthma-related school absences. Questionnaire replies at 12-month follow-up reported significantly fewer asthma attacks in patients who received the program than in those who did not (1.65 ± 1.21 vs. 2.34 ± 1.73; p < 0.05). For the subgroup of children who had ≥3 asthma attacks at baseline, parents' knowledge improved significantly more in the educational group than in the control group. The out-patient educational program Aironet^® reduces the number of asthma attacks in children with intermittent or mild persistent asthma and improves knowledge of the disease.     

Which physicians are providing health care to America's children? Trends and changes during the past 20 years

BACKGROUND: Although pediatricians and family physicians are trained in the care of children, previous studies have revealed significant differences in the medical care and specialty referral patterns each provides. During the 1990s, several developments in the population and the health care system (eg, aging of the population and increases in Medicaid managed care) may have resulted in changes to the proportion of children seeking care from one or the other specialty. OBJECTIVE: To determine any changes in the proportion of office visits for children from birth through the age of 17 years provided by pediatricians or family physicians from 1980 to 2000. DESIGN: Analysis of the National Ambulatory Medical Care Survey data sets from 1980 to 2000. During our years of interest, the total number of visits sampled ranged from 2524 to 9151. Visits were analyzed for physician type and patient age. RESULTS: There have been marked changes in the proportion of office visits to general pediatricians vs family physicians during the 1990s. Overall, the percentage of all nonsurgical physician office visits for children from birth through the age of 17 years made to general pediatricians increased significantly, from 56.2% in 1990 to 64.2% in 2000 (P<.001). During the same period, the percentage of all nonsurgical physician office visits for children from birth through the age of 17 years made to family physicians declined significantly, from 33.7% in 1990 to 23.9% in 2000 (P<.001). Visits to pediatric specialists, as a proportion of all visits, increased significantly, from 1.6% in 1980 to 4.5% in 2000 (P<.001). CONCLUSIONS: Pediatricians are providing more primary care visits for children in the United States, and this trend has accelerated during the past 5 years. These findings have implications for the cost of care, the physician workforce, and the training of future physicians. It is unknown if these changes have had a positive or negative impact on the health of our nation's children.     

Improving follow-up for children with asthma after an acute Emergency Department visit

OBJECTIVE: To improve follow-up with primary care providers after acute Emergency Department (ED) asthma visits for children from low-income urban families. STUDY DESIGN: A prospective, randomized, controlled trial evaluated combined telephone asthma coaching and monetary incentive. The primary outcome was asthma-planning visits with primary care providers within 15 days of index ED visits. The subjects were urban parents whose children were treated for asthma in the ED and had Medicaid or no insurance. RESULTS: We enrolled 527 parents (264 control and 263 intervention). There was a significant difference ( P < .0001) between the intervention (35.7%) and control (18.9%) groups in the proportion of children who had asthma-planning visits and decreased mean nights/days with asthma symptoms by 4.36 intervention and 3.31 control at 2 weeks. The proportions of children with asthma-planning visits and acute asthma care visits during the 16-day to 6-month period were similar for both groups. CONCLUSIONS: Telephone coaching and a monetary incentive significantly increased the proportion of low-income urban parents who brought their children for asthma-planning visits, and decreased asthma symptoms shortly after asthma ED visits. The intervention did not increase subsequent asthma-planning visits or decrease ED visits or hospitalizations.     

Medication management of stimulants in pediatric practice settings: a national perspective

Using a nationally representative sample of office-based physicians, the management practices of pediatricians, psychiatrists, and family practice physicians were investigated. The major aims were to determine (1) what types of services these physicians were providing to children who received stimulants, (2) what factors predicted receipt of stimulants, and (3) whether these practices were concordant or discordant with professional consensus on diagnosis and treatment of attention-deficit hyperactivity disorders (ADHD). Prescribing and management practice data from the 1995 National Ambulatory Medical Care Survey (NAMCS) were analyzed for children ages 0 to 17 years who were seen for psychiatric problems and received stimulant medication. Results indicated that 2 million visits by children were made in 1995 to psychiatrists, pediatricians, or family practitioners in which psychotropic medications were prescribed. In pediatric visits where stimulant medication was prescribed, mental health counseling was provided 47.3% of the time and psychotherapy 21.6%. Follow-up arrangements were made in 79.1% of the visits. Psychiatrists were significantly more likely to provide psychotherapy and to specify follow-up visits than were pediatricians, but less likely to provide other health counseling. Controlling for demographic and physician effects, the factors with the most significant effect on the probability of receiving stimulants were geographic region (living in the South), race (being white), receiving mental health counseling, not receiving psychotherapy, and having health insurance. Less than 50% of pediatric visits for psychiatric reasons involving stimulant medications included any form of psychosocial intervention. In 21% of these visits, no recommendations were made for follow-up care. These practices diverge from National Institutes of Health (NIH) consensus panel recommendations and association-issued practice parameters.     

Children with febrile seizures do not consume excess health care resources

BACKGROUND: Febrile seizures are benign but so terrifying for parents that they may subsequently view their affected children as "vulnerable". Children viewed as vulnerable may be brought to medical attention more frequently. We examined subsequent hospitalizations and physician visits during a 6- to 7 1/2-year period for a group of children who had participated in a case-control study of initial febrile seizures. METHODS: Individual data from a regional cohort of 75 children with a first febrile seizure and 150 febrile and 150 afebrile controls were linked to 2 comprehensive provincial health services databases-a hospital admissions/ separations database and a physician services database. RESULTS: Linkage was achieved for 98% of the study cohort, with heath care utilization data for 6 to 7 1/2 years available for 96%. Children with febrile seizures had nearly identical rates of subsequent hospitalization compared with age-matched controls (chi2 test, P = .88). An excess of day-surgery visits for primarily otolaryngologic procedures was seen for the febrile seizure patients 0 to 12 months after their initial febrile seizure (chi2 test, P < .001). During the next 6 to 7 1/2 years, the febrile seizure patients had nearly identical rates of physician visits (chi2 test, P = .15); however, they had more visits to otolaryngologists in the first 3 to 9 months after the febrile seizure (chi2 test, P < .001), but fewer visits to pediatricians during the next 1 to 4 years (chi2 test, P < .001). CONCLUSIONS: Children with febrile seizures have nearly identical rates of hospital and physician services utilization compared with controls. This supports the hypothesis that febrile seizures are benign, and that parents recover from their initial anxiety and do not consider their children vulnerable to additional illness in the years that follow.     

Office “Phone First” Systems Reduce Emergency Department/Urgent Care Utilization by Medicaid-Enrolled Children

BackgroundEmergency department and urgent care (ED/UC) visits for common conditions can be more expensive with less continuity than office care provided by primary care physicians.MethodsWe used quality-improvement methods to enhance telephone triage for pediatric patients by adding additional “Phone First” services including: 1) enhanced office-hours telephone triage and advice with available same-day appointments, 2) follow-up calls to parents of children self-referred to an ED/UC, and 3) parent education to telephone the office for advice prior to seeking acute care. We hypothesized that enhanced office services would reduce ED/UC utilization and cost. We compared changes in ED/UC encounter rates between intervention and regional practices for 4 years (2014–2017) using general linear models, and evaluated balancing measures (after-hour phone calls, acute care phone calls, acute care visits, well child visits) for Medicaid-enrolled and commercially-insured children.ResultsThe study practices dramatically increased office-hours acute care phone triage and advice which correlated with 23.8% to 80.5% (P < 0.001) reductions in ED/UC rates for Medicaid-enrolled children. Office acute care visits decreased modestly. ED/UC visits did not decrease for children in the comparison region. In phone surveys, 94% of parents indicated satisfaction with the ED/UC follow-up call. The decrease in ED/UC visits resulted in an estimated annual cost of care savings for Medicaid-enrolled children in 2017 of $12.61 per member per month which projected to $169 million cost of care savings in Colorado and $6.8 billion in the United States.Conclusion“Phone First” services in pediatric practices during office-hours reduced ED/UC encounters and cost of care for Medicaid-enrolled children.     

Identification of resident and attending physicians: do parents know who is caring for their hospitalized child?

OBJECTIVE: Correct identification of a physician or resident is an essential first step in developing a good relationship between physicians, patients, and their families. However, many parents are unfamiliar with the individuals responsible for their children's care. This study was conducted to determine how often parents/guardians of hospitalized children could identify the residents and attending physicians caring for their children and what factors they considered important in physician identification. METHODS: This was a cross-sectional study with a convenience sample of the parents/guardians of hospitalized pediatric patients admitted to a university teaching hospital over a 2-month period; we used a self-administered, confidential questionnaire. RESULTS: Subjects were 144 parents/guardians of hospitalized children (100% of subjects asked to participate, 19.3% of all hospitalized children); parents had the following characteristics: mean age, 30 years; 51% Caucasian, 43% African American; 82% female. Physician identification was 76% for attending physicians and 73% for residents. The factors rated as most important to parents were physician introduction (50%-76%), prior relationship (27%-13%), wearing of a white coat (2%-8%), wearing of a name tag (4%-10%), and wearing of a stethoscope (0%-2%). Physician introduction was ranked higher for first hospitalizations. Subsequent hospitalizations increased identification of attending physicians but not residents. CONCLUSIONS: This study indicates that up to a quarter of parents could not identify the physician responsible for their children's care during a hospitalization. Improving physician identification may enhance other aspects of physician-family communication.     

Psychotherapeutic medication patterns for youths with attention-deficit/hyperactivity disorder

OBJECTIVES: (1) To describe temporal patterns of office visits for attention-deficit/hyperactivity disorder (ADHD) and stimulant treatment for 5- to 14-year-old US youths; (2) to compare youth visits for ADHD with and without melication according to patient demographics, physician specialty, reimbursement source, and comorbid diagnoses; and (3) to compare office visits for youths with ADHD in relation to common medication patterns (stimulants alone, stimulants with other psychotherapeutic medication, and nonstimulant psychotherapeutic medications alone). DESIGN: Survey based on a national probability sample of office-based physicians in the United States. SETTING: Physician offices. PARTICIPANTS: A systematically sampled group of office-based physicians. MAIN OUTCOME MEASURES: National estimates of office visits for ADHD and psychotherapeutic drug visits for ADHD for each year and for a combined 8-year period. RESULTS: Youth visits for ADHD as a percentage of total physician visits had a 90% increase, from 1.9% in 1989 to 3.6% in 1996. Stimulant therapy within ADHD youth visits rose from 62.6% in 1989 to 76.6% in 1996. While the majority of non-ADHD youth visits were conducted by primary care physicians, one third of ADHD youth visits were managed by psychiatry and neurology specialists. Health maintenance organization insurance was the reimbursement source for 17.9% of non-ADHD youth visits but only 11.7% of ADHD youth visits. Complex medication therapy was more likely to be prescribed by psychiatrists and less likely to be related to visits with health maintenance organization reimbursement. CONCLUSIONS: National survey estimates in the 1990s confirm the substantial increase in visits for youths diagnosed as having ADHD, with more than three quarters of these visits associated with psychotherapeutic medication treatment. Physician specialty and reimbursement source variables identify distinct patient populations with a gradient in psychotherapeutic medication patterns from single-drug standard (stimulant) therapy to complex multidrug treatment regimens for which evidence-based scientific information is lacking.     

Children's and parents' visual perception of physicians.

The purpose of this study is to evaluate the child's and parents' visual perception of physicians. To do this, 50 children and their parents were asked which physician they preferred, when shown eight pairs of photographs. Four characteristics were tested twice, white coat versus no white coat, smile versus stern face, cartoon posters versus no posters, and standing versus stooping. We found that both children and parents preferred the smiling physician and the physician with cartoon posters on the wall. Surprisingly 54% of children preferred the physician in the white coat, whereas only 35% of parents preferred the white coat. Sixty-eight percent of children also preferred the standing physician compared with only 41% of parents. There was little correlation between the parent's and child's answers. The results did not differ significantly with age, gender, or number of hospitalizations. In conclusion our study did not confirm the popular belief that children are afraid of physicians in white coats, although children did strongly prefer physicians who smiled and those with cartoon posters on the wall.     

Counseling smoking parents of young children: comparison of pediatricians and family physicians

BACKGROUND: Secondhand smoke is a major cause of morbidity in young children, and exposure to smoking parents is the principal source. Physician visits for young children present an opportunity to effect behavioral change among smoking parents. OBJECTIVE: To survey pediatricians and family physicians in their knowledge and practice of smoking cessation counseling with parents. DESIGN: Cross-sectional mail survey. SETTING: Urban California. PARTICIPANTS: Pediatricians and family physicians in urban areas of California, younger than 65 years, practicing in an ambulatory setting, and randomly selected from the American Medical Association Physician Masterfile. MAIN OUTCOME MEASURES: Reported frequency of asking about tobacco use, using cessation counseling techniques with smokers, and perceived barriers to providing cessation services. RESULTS: Of the 1000 mailed surveys, 899 were eligible and 499 (56% response rate) were returned and completed. A higher proportion of pediatricians compared with family physicians were women (44% vs 29%; P<.01) and nonwhite (44% vs 32%; P =.01). Family physicians compared with pediatricians were more likely to report referring a parent to a smoking cessation program (41% vs 30%), giving pamphlets on smoking cessation (40% vs 28%), asking for a quit date (41% vs 18%), scheduling a follow-up visit to discuss quitting (27% vs 5%), and recommending nicotine replacement therapy (41% vs 13%) (for each comparison, P<.001). Pediatricians were more likely to report recording in the medical record smoking by a parent as a problem for the child (65% vs 48%; P<.001), but a higher proportion of pediatricians perceived that parents would ignore the advice (39% vs 24%; P<.001) and lacked interest in quitting smoking (45% vs 27%; P<.001). Pediatricians were more likely to agree that they lacked smoking cessation counseling skills (26% vs 7%; P<.001). Multivariate models showed that pediatricians were less likely to report performing 5 of 14 smoking cessation techniques in at least 50% of smoking parents. CONCLUSIONS: Pediatricians appear to lack training to implement smoking cessation counseling with smoking parents. Physicians in private practice are less likely to counsel smoking parents. Educational interventions for pediatricians are needed to decrease secondhand smoke exposure for young children.     

Effectiveness of an asthma management program for pediatric members of a large health maintenance organization

OBJECTIVE: To assess the impact of an asthma management program on the dispensing of inhaled corticosteroids, hospitalizations, and emergency department (ED) visits on children, adolescents, and young adults. DESIGN: We used medical record and pharmacy data for the 18 months after initiation of a pilot asthma management program. Two intervention offices were matched with 2 control offices on pediatric volume, number of pediatricians or family practitioners, and specialist availability. SETTING: Primary care offices at Kaiser Permanente Colorado, in Denver and Boulder. PATIENTS: We identified 298 patients, 18 years or younger,who were listed in an asthma registry between February 1 and July 31, 1997, as having moderate or severe asthma. INTERVENTION: The Kaiser Permanente Colorado Asthma Care Management Program is an outpatient-based program that provides comprehensive evaluation, education, and follow-up to patients identified from an asthma registry or referred by providers. MAIN OUTCOME MEASURES: The proportion of patients who received more than 1 dispensing of inhaled corticosteroid during the observation period. Additional outcomes measured the proportion of patients with 1 or more hospitalizations or ED visits. RESULTS: A significantly greater proportion of patients from the intervention group received more than 1 dispensing of inhaled corticosteroid compared with controls (relative risk [RR], 1.41; 95% confidence interval [CI], 1.08-1.72). We found no significant difference in the proportion of patients who were hospitalized (RR, 1.37; 95% CI, 0.48-3.71) or visited the ED (RR, 0.86; 95% CI, 0.49-1.40). CONCLUSIONS: The presence of an asthma management program may improve dispensing of inhaled corticosteroids to young patients with moderate or severe asthma, as recommended by national guidelines. This type of program may not have an effect on hospitalizations or ED visits.     

The value of book distribution in a clinic-based literacy intervention program

The purpose of this study was to determine whether anticipatory guidance at well-child visits (WCV) that included early literacy development and the provision of books by the examining physician changed family literacy practices. It was conducted in an inner-city pediatric clinic that serves as the continuity practice site for pediatric and pediatric/internal medicine residents. There were 352 children (181 treatment: 171 control), aged 2 to 24 months, enrolled in this prospective, controlled study. The health care providers underwent training on literacy and on how to incorporate this information during WCV. Anticipatory guidance on safety, development, and early literacy was given to all parents. Additionally, the treatment group received an age-appropriate book at each WCV. There were 1,263 visits made (686 treatment, 577 control). Questionnaires were completed by parents on physician helpfulness and by physicians on parental receptiveness. Parental ratings on physician helpfulness were higher in the treatment group than in the control group (p<0.05). Physician's rating of parental receptiveness was also higher in the treatment group than in the control group (p<0.05). Two years after enrollment, mother-child pairs who received guidance and a book were two times more likely to report enjoyment in reading together than the controls who received guidance but no book. We conclude that anticipatory guidance that included early literacy development and distribution of books at WCV resulted in increased family literacy orientation, parental receptiveness, and perception of physician helpfulness.     

Health care for children and youth in the United States: annual report on patterns of coverage, utilization, quality, and expenditures by income.

OBJECTIVES: To examine differences by income in insurance coverage, health care utilization, expenditures, and quality of care for children in the United States. METHODS: Two national health care databases serve as the sources of data for this report: the 2000-2002 Medical Expenditure Panel Survey (MEPS) and the 2001 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). In the MEPS analyses, low income is defined as less than 200% of the federal poverty level and higher income is defined as 200% of the federal poverty level or more. For the HCUP analyses, median household income for the patient's zip code of residence is used to assign community-level income to individual hospitalizations. RESULTS: Coverage. Children from low-income families were more likely than children from middle-high-income families to be uninsured (13.0% vs 5.8%) or covered by public insurance (50.8% vs 7.3%), and less likely to be privately insured (36.2% vs 87.0%). Utilization. Children from low-income families were less likely to have had a medical office visit or a dental visit than children from middle-high-income families (63.7% vs 76.5% for office-based visits and 28.8% vs 51.4% for dental visits) and less likely to have medicines prescribed (45.1% vs 56.4%) or have utilized hospital outpatient services (5.2% vs 7.0%), but more likely to have made trips to the emergency department (14.6% vs 11.4%). Although low-income children comprise almost 40% of the child population, one quarter of total medical expenditures were for these children. Hospital Discharges. Significant differences by community-level income occurred in specific characteristics of hospitalizations, including admissions through the emergency department, expected payer, mean total charges per day, and reasons for hospital admission. Leading reasons for admission varied by income within and across age groups. Quality. Low-income children were more likely than middle-high-income children to have their parents report a big problem getting necessary care (2.4% vs 1.0%) and getting a referral to a specialist (11.5% vs 5.3%). Low-income children were at least twice as likely as middle-high-income children to have their parents report that health providers never/sometimes listened carefully to them (10.0% vs 5.1%), explained things clearly to the parents (9.6% vs 3.4%), and showed respect for what the parents had to say (9.2% vs 4.2%). Children from families with lower community-level incomes were more likely to experience ambulatory-sensitive hospitalizations. Racial/Ethnic Differences Between Income Groups. Use and expenditure patterns for most services were not significantly different between low- and middle-high-income black children and were lower than those for white children. CONCLUSIONS: While health insurance coverage is still an important factor in obtaining health care, the data suggest that efforts beyond coverage may be needed to improve access and quality for low-income children overall and for children who are racial and ethnic minorities, regardless of income.     

Mothers' clinical judgment: a randomized trial of the Acute Illness Observation Scales

The purpose of this study was to investigate whether the reliability, sensitivity, and specificity of mothers' judgments about acute illnesses in their children could be improved by using the Acute Illness Observation Scales (AIOS). At the 2-week well child care visit in a primary care center and a private practice, 369 mothers were divided at random into an intervention group (n = 183) and a control group (n = 186). A teaching film and booklet were used to educate mothers in the intervention group about the AIOS; control group mothers were taught a 3-point global scoring system for evaluating the chance of serious illness. In the 32 months of follow-up, 704 acute illnesses were evaluated in tandem and independently by mothers and pediatricians before the history and physical examination; 20 of these illnesses were serious. The judgments of the intervention group were more reliable than those of the control group (weighted kappa = 0.50 vs 0.26, respectively), as was the specificity of their judgments (85% vs 52%, respectively; p less than 0.0001). No difference was noted in the sensitivity of intervention group and control group mothers' judgments (80% vs 90%, respectively). Teaching parents to assess specific clinical information, as represented in the AIOS, has its greatest effect on the reliability and specificity, not the sensitivity, of their judgments. Such teaching could lead to fewer unnecessary office visits during acute illnesses.     

Six-year follow-up of an intervention to improve the management of preschool children with asthma

Aims:  In a randomized controlled study involving 60 preschool children with asthma, an intervention with extra information and support to parents in the form of group discussions was performed. An earlier follow-up after 18 months revealed an improved adherence and a reduction of exacerbation days. This is a 6-year follow-up.
Methods:  Fifty-four children performed clinical examinations, blood tests, measurements of exhaled nitric oxide, spirometry, bronchial provocation with dry air and skin prick tests. Data from the patients' records and questionnaires were obtained.
Results:  Twenty-nine per cent had no current signs of asthma, whereas 43% exhibited persistent and 28% intermittent asthma. The burden on the healthcare system was minimal. Intermittent inhaled corticosteroid (ICS) therapy was used by 81%. The intervention group (IG) had fewer contacts with nurses. Their parents had a better quality of life. Interviewing children separately contributed in identification of children needing treatment. More children in the IG had to restart ICS as they had signs of worse asthma control.
Conclusion:  Straightforward and timely support to parents of children with asthma can have long-term positive effects by strengthening the ability of parents to treat their children at home, although parents may also develop an underestimation of mild symptoms. It is important to directly ask children about their disease and to maintain regular follow-up visits.     

Web-based consultations for parents of children with atopic dermatitis: results of a randomized controlled trial

Aim: To analyse how web-based consultations for parents of children with atopic dermatitis affect self-management behaviour, health outcome, health resource use and family costs.
Methods: Ninety-eight children with atopic dermatitis were randomly assigned to intervention and control groups. The intervention group received remote dermatology consultations through a secure web-based communication system. The control group was encouraged to seek treatment through traditional means such as general practitioner visits and hospital care. Both groups received an extensive individual educational session prior to the intervention.
Results: Thirty-eight percent of the intervention group used web-based consultations 158 times ranging from 1 to 38 consultations per patient. We found no change in self-management behaviour, health outcome or costs. The intervention group tended to have fewer visits to practitioners offering complementary therapies than the control group, and we found a positive correlation between emergency visits at baseline and messages sent. Both groups, however, reduced the mean number of skin care treatments performed per week and had fewer total health care visits after the intervention.
Conclusion: We found no effect of supplementing traditional treatment for childhood dermatitis with web-based consultations. This study showed that web consultations is feasible, but more research is needed to determine its effect on self-management skills, health outcome and resource use.