Harvey P. Katz

Morbidity in childhood - A longitudinal view

We examined all the morbidity experienced in a six-year period by a total of 2591 children who were continuously enrolled in a prepaid medical plan. The children had received 19,291 diagnoses, each of which was assigned to one of 14 types of morbidity, and the frequency of each type was determined. Although the typical child had at least one problem in 5 of the 14 types of morbidity in the six-year period, over 20 per cent of children had at least 8 different types of problems during that time. Children with a greater variety of acute problems and more frequent acute problems were also more likely to have nonacute problems during the six-year period. Conversely, children with nonacute problems had more acute problems than other children. Our findings indicate that morbidity, like use of health services, occurred in clusters in this population of children. Therefore, an understanding of the cause and projected outcome of morbidity among children will be incomplete if the focus is only on specific diseases or specific types of illnesses.

Pediatric psychology in primary health care: Brief targeted therapy for recurrent abdominal pain *

Children with recurrent abdominal pain (RAP) are frequent users of medical care services, often seeking care for a variety of illnesses and symptoms. In a clinical replication series, we treated 16 children with RAP who were referred to a primary care-based pediatric psychology service. They received a multi-component targeted therapy, which included self-monitoring, limited parent attention, relaxation training, increased dietary fiber, and required school attendance. After treatment, improvement or resolution of pain symptoms was reported for 13 (81%) children, and school absences were significantly decreased. Medical care utilization significantly decreased after treatment, whereas a comparison group of untreated children with RAP showed no change in medical care visits over time. Brief targeted therapy delivered in a primary health care setting appeared to be effective in reducing a range of problems associated with RAP. A primary care service is an ideal setting for integrating behavioral medicine services into the health care system.

Patient safety and telephone medicine : some lessons from closed claim case review.

SummaryObjectivesThe telephone can facilitate medical care but also result in adverse outcomes leading to telephone-related malpractice suits. Analyzing claims might identify errors amenable to prevention. The objective of the study was to describe medical errors involving the telephone in patient–clinician encounters that significantly impacted medical care and medico-legal outcomes.DesignThe design of the study was a descriptive, retrospective case review of telephone-related closed malpractice claims that included depositions, expert witness testimony, medical records, allegations, injuries, and outcomes.Patients/ParticipantsForty defendants from 32 cases coded specifically as telephone related by a major provider of malpractice insurance. Leading specialists sued: Internists, pediatricians, and obstetricians.Measurements and Main ResultsCases were reviewed by a physician experienced in telephone medicine and independently checked by a risk management nurse specialist and discussed by 2 additional risk management analysts before arriving at full agreement. Twenty-four (60%) cases were settled or awarded to the plaintiff. The most common allegation was failed diagnosis (68%), most common injury was death (44%), and most common setting was general medicine ambulatory practice. Leading errors were documentation (88%) and faulty triage (84%). The average indemnity was

Quality assessment of a telephone care system utilizing non-physician personnel.

518,932, with a total indemnity of

Academia-industry collaboration in continuing medical education: description of two approaches.

12,454,375.ConclusionsTelephone-related claims were costly; injuries were catastrophic. Poor documentation and faulty triage were major factors influencing care and legal outcome. Telephone errors may represent the tip of the iceberg in patient safety in ambulatory practice; however, these preliminary results need to be confirmed in a larger sample of cases.

A 10-year experience in pediatric after-hours telecommunications

An approach to providing medical care by telephone is described and its content and quality assessed by means of an outcome study. Pediatric health assistants have been trained to evaluate, triage and offer home management advice in lieu of an office visit for medical problems presented by parents via telephone. During a four-week study period, data were collected on all calls (N = 2520) using a telephone encounter form. Fifty-nine per cent of all calls involved requests for care of illness, 30 per cent of which were independently handled by the health assistant. Quality of care was evaluated for those cases who received advice in home management by means of a seven day follow-up interview with parents (N = 247). Access, parent satisfaction, residual symptoms, and the need for further care were ascertained. Greater than 90 per cent of parents expressed satisfaction and 92 per cent of problems had resolved. Results indicate that this telephone care system can effectively sort out and advise parents in home management for the many minor problems which occur in a pediatric practice, thereby increasing time for direct contact with patients.

How important is money as a reward for teaching

Introduction: Although concerns have been raised about industry support of continuing medical education (CME), there are few published reports of academia‐industry collaboration in the field. We describe and evaluate Pri‐Med, a CME experience for primary care clinicians developed jointly by the Harvard Medical School (HMS) and M/C Communications. Methods: Since 1995, 19 Pri‐Med conferences have been held in four cities, drawing more than 100,000 primary care clinicians. The educational core of each Pri‐Med conference is a 3‐day Harvard course, “Current Clinical Issues in Primary Care.” Course content is determined by a faculty committee independent of any commercial influence. Revenues from multiple industry sources flow through M/C Communications to the medical school as an educational grant to support primary care education, Pri‐Med also offers separate pharmaceutical company–funded symposia. Results: Comparing the two educational approaches during four conferences, 221 HMS talks and 103 symposia were presented. The HMS course covered a wide range with 133 topics; the symposia focused on 30 topics, most of which were linked to recently approved new therapeutic products manufactured by the funders. Both the course and the symposia were highly rated by attendees. Discussion: When CME presentations for primary care physicians receive direct support from industry, the range of offered topics is narrower than when programs are developed independently of such support. There appear to be no differences in the perceived quality of presentations delivered with and without such support. Our experience suggests that a firewall between program planners and providers of financial support will result in a broader array of educational subjects relevant to the field of primary care.

PHENYLKETONURIA OCCURRING IN AN AMERICAN NEGRO.

A rapidly growing area within the field of telephone medicine is the use of centralized telephone triage systems to help in the after-hours coverage of pediatric practices. This paper describes a 10-year experience with a pediatric telecommunications program within the 302,000-member Health Centers Division of Harvard Pilgrim Health Care. Telephone volume averages 3,000 calls per month, and over 175,000 telephone calls have been received since the program began. This article highlights the linkage to the primary care physician, the enhancement of service by the automated medical record system, and the application of the telecommunications program to resident teaching. The literature review focuses on the rationale for structured telecommunications programs, including improved quality of care, reduction of medicolegal risk, and the potential for reimbursement of services.

The normal Achilles tendon reflex time in children as measured with the photomotograph.

Purpose To examine the effect of increases in payment for teaching on retention of primary care faculty, and to compare those faculty members’ needs and rewards for teaching with objective data on retention. Method In 2006–2007, the authors compared retention rates of primary care clerkship preceptors at Harvard Medical School (1997–2006) when their stipends were raised from

A Schema for Improving Efficiency in an Ambulatory Care Setting Description of a Communication System

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