Scott Shipman

Screening for Developmental Dysplasia of the Hip: A Systematic Literature Review for the US Preventive Services Task Force

BACKGROUND. Developmental dysplasia of the hip (DDH) represents a spectrum of anatomic abnormalities that can result in permanent disability. OBJECTIVE. We sought to gather and synthesize the published evidence regarding screening for DDH by primary care providers. METHODS. We performed a systematic review of the literature by using a best-evidence approach as used by the US Preventive Services Task Force. The review focused on screening relevant to primary care in infants from birth to 6 months of age and on interventions used in infants before 1 year of age. RESULTS. The literature on screening and interventions for DDH suffers from significant methodologic shortcomings. No published trials directly link screening to improved functional outcomes. Clinical examination and ultrasound identify somewhat different groups of newborns who are at risk for DDH. A significant proportion of hip abnormalities identified through clinical examination or ultrasound in the newborn period will spontaneously resolve. Very few studies examine the functional outcomes of patients who have undergone therapy for DDH. Because of the high rate and unpredictable nature of spontaneous resolution of DDH and the absence of rigorous comparative studies, the effectiveness of interventions is not known. All surgical and nonsurgical interventions have been associated with avascular necrosis of the femoral head, the most common and most severe harm associated with all treatments of DDH. CONCLUSIONS. Screening with clinical examination or ultrasound can identify newborns at increased risk for DDH, but because of the high rate of spontaneous resolution of neonatal hip instability and dysplasia and the lack of evidence of the effectiveness of intervention on functional outcomes, the net benefits of screening are not clear.

Characterizing a Practice-based Research Network: Oregon Rural Practice-based Research Network (ORPRN) Survey Tools

Objective: To present the survey methods and instruments used to characterize a geographically and professionally diverse rural practice-based research network (PBRN). Methods: A cross-sectional study of Oregon PBRN (ORPRN) member practices and clinicians using a 3-part survey including a survey of the practices, of clinician members, and an anonymous survey of clinician satisfaction. Results: A total of 31 of 32 (97%) participating ORPRN practices completed the practice survey, 96 of 129 (74%) clinicians within these practices completed the clinician member survey, and 81 of 129 (63%) clinicians completed an anonymous survey of clinician satisfaction. The survey provided a detailed description of the structure of member practices, patient and clinician demographics, services provided by the practices, and access to specialty and ancillary services. Conclusions: Survey tools that describe the network practices and individual clinician characteristics contribute to an understanding of the research capacity of an individual PBRN.

Family Physicians Closing Their Doors To Children: Considering the Implications

Together, general pediatricians and family physicians comprise the core workforce that delivers primary care to children in the United States. Although the supply of general pediatricians has grown dramatically relative to the population of children in the United States in recent decades, the geographic locations of pediatricians remains decidedly maldistributed relative to children in the United States. Family physicians, in contrast, are more equitably distributed relative to the population, and this workforce remains critical for ensuring access to primary care for children. Yet, as reported in this issue of the Journal, Bazemore and colleagues 1 demonstrate that, over the past decade, increasingly few family physicians provided any care to children in their practices; as of 2009, only 68% provided any care to this segment of the population, a 10% absolute decrease since 2000. This work complements previous research from Freed et al 2 that demonstrated that the role of the family physician in providing ambulatory services to children diminished significantly over the period from 1990 to 2000. Together, these studies demonstrate a persistent and potentially alarming trend. The brief report is descriptive only and displays trends only at a national level. It does not address regional or practice variations in the likelihood of a family physician delivering services to children, which is critical to understanding the impact of these trends on the care of children. For example, one partner in a sizable single specialty practice or a large multispecialty group who discontinues care of children, perhaps in the later years of practice by natural attrition, has different implications when compared with a rural doctor who is the only local provider of primary care services who decides not to care for children. The reasons for the declining role of family physicians in the care of children have not been studied adequately. It may be that the growing supply of pediatricians has created overt competition that has left family physicians wanting for children in their practices. This may be exacerbated by the vanishing rates of obstetric care in family medicine, arguably the most natural source of pediatric patients for the family physician. It may be that the growing demands of the baby boomer population, coupled with a dearth of general internists, has crowded out children from family physicians’ care. Perhaps the problem lies in low Medicaid reimbursement for chil