Why Are General Pediatricians Failing?

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(No Transcript)
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Why Are General Pediatricians Failing?

• National Study of 1536 children in the US
• 12 metropolitan areas (including Indy)
• 142 quality indicators
• Children received 46.5 of indicated care
• 40.7 of preventive care
• 37.8 of screening
• 34.5 of adolescent preventive care

Mangione-Smith, et al, NEJM 2007 3571515-23
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Variable Guideline Adherence 4 practices, 210
children aged 1 yr
Newborn Screening 56-80
Hearing Risk Assessed 0-5
Anemia Screening 76-98
TB Screening 2-63
Lead Screening 23-94
Assess Tobacco Smoke Exposure 6-38
Car Seat Counseling 4-76
Smoke Detector Counseling 0-27
Hot Water Heater Counseling 8-37
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Too Many Guidelines!
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Pediatricians Are Overwhelmed With Preventive
Care Guidelines

• Multiple guidelines from authoritative sources
• AAP
• CDC
• USPSTF
• HRSA
• ACMG
• Medicaid
• HMO
• Average preventive care visit 18.3 minutes
• Pediatricians No time for developmental
  assessments and psychosocial issues

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AAP Periodicity Schedule
1.00
2.00
0.50
5.50
12.00
21.00 minutes
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USPSTF

• Evaluation of 230 charts in family practice
• 25 services due at each patient visit (Medder)
• Physician time required for services family
  practice
• 7.4 hours per day (Yarnall)
• Extrapolating to only pediatric services
• 16 hour per day!!

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Bright FuturesGuidelines for Health Supervision
of Infants, Children, and Adolescents
338 Pages
450 Pages
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Bright FuturesSet

• Guidelines for Health Supervision of Infants,
  Children, and Adolescents
• Mental Health Volumes 1 and 2
• Physical Activity
• Bright Futures, Nutrition, and Oral Health Pocket
  Guides

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Computer Decision Support Systems (CDSS) Can Help

• Critical review of 100 clinical trials of CDSS
  compared to usual care controls
• Practitioner performance 62/97 (64) improved
  care
• Preventive care 16/21 (76) improved care
• Disease mgmt 23/40 (62) improved care

Garg, et al. JAMA, 2005 2931223-38
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• So if decision support systems improve rates of
  services.
• What services should systems support?

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Lead Levels in Childhood
(everyone) Testicular cancer screening
Herpes Simplex, Genital screening
Idiopathic Scoliosis in Adolescents
(Scoliosis) Screening
Infant/Newborn Gonococcal Ophthalmia Neonatorum
prophylaxis Newborn screening (select
tests) Child Visual Impairment in Children Ages
0-5 Screening Blood pressure Fluoride
prescription Adolescent Cervical cancer
screening Chlamydial Infection screening
Gonorrhea screening - (if risk) Human
Immunodeficiency Virus (HIV) Infection screening
- (if high risk) Sexually Transmitted Infections
- (if sexually active) Depression in
Adolescents
Hyperbilirubinemia in Infants Routine
Screening Hip, Developmental Dysplasia
Screening Developmental screening Counseling
to prevent skin cancer Cholesterol screening
Depression in Children Motor Vehicle Occupant
Restraints Dental Caries in Preschool Children
risk assessment Exercise (Physical Activity)
Counseling Healthy Diet (Nutrition) Counseling
Family Violence Iron Deficiency Anemia (Anemia)
Screening Lead Levels in Childhood (high risk)
Overweight in Children and Adolescents
Screening Alcohol Misuse (Drinking,
Risky/Hazardous) Illicit Drug Use Smoking
(Tobacco Use) counseling Suicide Risk Screening
No Data
Dont Do
US Preventive Services Task Force Services
evaluated for children
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AAP Statements

• Policy Statement
• Organizational principles to guide and define the
  child health care system and/or improve the
  health of all children.
• Clinical Reports
• Guidance for the clinician in rendering pediatric
  care.
• Clinical Practice Guidelines
• Evidence-based decision-making tools for managing
  common pediatric conditions.

414
99
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371
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Downss Decision Rule

• if decision support systems get services provided
• and there are more recommended services than can
  be done in a visit
• then the system must prioritize which services it
  recommends

Prevalence
x Severity
x Effectiveness
x Evidence
Priority
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Thank You