Sofia M. Franco

Primary Care Physician Access and Gatekeeping: A Key to Reducing Emergency Department Use

Use of the Emergency Department (ED) for nonurgent conditions results in increased cost and discontinuous health care. This prospective study evaluated a program (KenPAC) that required 24-hour access to a primary care physician (PCP) with ED gatekeeping responsibility. Following established criteria, medical records were reviewed for appropriateness of ED use by an urban indigent pediatric population. Emergency Department visits declined (10% to 7.6% (P=0.00005) and inappropriate visits dropped (41% to 8%) (P<0.00001) before KenPAC and after KenPAC, respectively. Parental experience, as judged by age and number of children, played a significant role in ED use. The institution of gatekeeping activity contributed to the reduced overall and inappropriate use of the ED.

A simplified table improves the recognition of paediatric hypertension

Aim:  Unrecognised and untreated hypertension can lead to significant morbidity and mortality over time. In a 2003 chart review, we found that our providers only recognised 15% of hypertensive blood pressure (BP). Our objective was to determine whether a simplified BP table improves the recognition of elevated BP in children.

The Impact of Early Literacy Guidance on Language Skills of 3-Vear-Olds

The objective of this prospective study was to determine the impact of early literacy anticipatory guidance (AG) with provision of books on language development in 3-year-olds in an early literacy program at a University-affiliated inner-city pediatric clinic. The Peabody Picture Vocabulary Test (PPVT-III) and the Expressive One Word Picture Vocabulary Test (EOWPVT-R) were administered to 33-39-month-old children exposed to an early literacy program, which included AG and provision of an age-appropriate book at each well-child visit starting at 2 months old. Children with developmental delays were excluded. Parental surveys on literacy and demographic data were obtained. Univariate and multivariate analyses were performed. Sixty-four children were evaluated; 88% African American, 89% Medicaid recipients. Fifty-eight percent of families reported familycentered literacy orientation. The PPVT-III scores directly correlated with the number of AG visits with book given x number of books purchased (r2 = 0.025, p = 0.0006). Higher scores in EOWPVT-R were predicted by race and the number of visits with books given x number of books purchased (r2 = 0.182, p = 0.0009). All families reported reading together, half reporting positive familycentered literacy. Given the same number of books purchased for each child, the outcome scores were higher the greater the number of clinic visits wherein AG included early literacy and provision of books.

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). Physicians 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.

Diagnosis and Treatment Frequency for Overweight Children and Adolescents at Well Child Visits

Obesity in children is a rapidly growing problem and may be underrecognized by pediatricians. We reviewed 473 consecutive well child visits to assess frequency of correctly identifying overweight children. Of children with a body mass index greater than the 95th percentile for gender and age, only 27 (29%) were diagnosed as overweight by the physician. Our results suggest that the frequency of diagnosing children as overweight at well child visits is critically low.

Bodyfat Analysis and Perception of Body Image

Obesity is a common nutritional problem among children. Using the Futrex 5000A method of bodyfat measurement, this prospective study determined the percentage bodyfat in a self-selected, indigent, predominantly black population and the accuracy of perceived body image. Bodyfat exceeded the optimal range in 39% and 67% of female and male children, respectively. Females tended to view themselves as fatter and males perceived themselves as thinner than their actual composition. Parents were more accurate in their perception of obesity in their daughters (88%) than in their sons (52%). Children did not recognize the importance of exercise in preventing obesity. Bodyfat measurement and counseling should be done at an early age to improve this remarkable lack of perception about obesity.

Reduction of Cerebral Palsy by Neonatal Intensive Care

Neonatal mortality has declined since the advent of intensive care. The incidence of cerebral palsy has likewise decreased in spite of increased survival of low birth weight infants.

Penicillin Minimum Inhibitory Concentration Drift in Identical Sequential Streptococcus pneumoniae Isolates from Colonized Healthy Infants

We monitored the timing of acquisition of nasopharyngeal colonization of Streptococcus pneumoniae in 125 healthy infants during their first 2 years of life. S. pneumoniae was isolated at least once from 59 (47%) of 125 infants aged between 2 and 18 months. Twenty-four infants (19%) were colonized with penicillin-resistant S. pneumoniae at some time during the study. During the course of this investigation, we identified sequential pneumococcal isolates of the same serotype from 5 infants, in which the penicillin minimum inhibitory concentration (MIC) increased over time. For 4 of the 5 infants, sequential isolates were identical, as determined by pulsed-field gel electrophoresis. Sequential S. pneumoniae nasopharyngeal isolates from some healthy infants demonstrated drift in penicillin MIC values over time, from penicillin-susceptible to penicillin-resistant.

Factors Associated With Improved Immunization Rates for Urban Minority Preschool Children

Urban, poor, preschool children are noted for having low immunization rates. To determine factors related to completion of immunization, vaccine records of 479 3-year-old children from an inner-city pediatric clinic were reviewed. Complete immunization was defined as four diphtheria-tetanus-pertussis doses, three oral polio vaccine doses, one measles-mumps-rubella dose, and one Haemophilus influenzae type b vaccine dose. Seventy percent of our patients were up-to-date by 2 years of age. The administration of all age-appropriate vaccines at a single visit for patients 15 months and older, the establishment of a continuous primary-care relationship, earlier age at first immunization, and lower birth weight were significantly associated with higher immunization levels in our study.

147 FOLLOW-UP OF OVERWEIGHT CHILDREN AND ADOLESCENTS DIAGNOSED AT WELL-CHILD VISITS.

Background The prevalence of overweight children in the United States is increasing. Barriers to obesity diagnosis and treatment are multifactorial. As with other chronic conditions, timely follow-up is an essential component of treatment. The purpose of this study was to determine the compliance with follow-up of children diagnosed as overweight. Hypothesis Appropriate diagnosis and counseling of overweight children will lead to better compliance with follow-up. Methods A chart review was conducted on 2- to 17-year-old children who presented for well-child visits between 7/31 and 8/16/03 at an inner-city university-affiliated clinic. Diagnosis of overweight, BMI, comorbid conditions, demographic data, and follow-up appointment were recorded. A year later, a second chart review was done on those identified as overweight and their BMI, diagnosis, management, and compliance with follow-up were recorded. Results We reviewed 278 charts: 88% were African American, 56% male, and 94% on Medicaid. Fifty-eight children (21%) were overweight, but only 40 were correctly identified, including 16 with comorbid conditions, while 18 overweight were not diagnosed. Of the 40 children correctly diagnosed, 93% received dietary counseling, 85% exercise advice, and 60% were told to decrease their sedentary activities. Referral to a nutritionist was made for 16 children but only two kept their appointments. Follow-up appointments were made for 31 of 40 (78%) overweight: 18 in 4 weeks, 13 in 6 to 12 weeks. Only 3 children returned at the appointed time, but none mentioned overweight as a reason for the visit among the complaints presented. The physician also failed to discuss the overweight diagnosis of the previous visit. Conclusion Majority of children diagnosed as overweight received appropriate counseling and follow-up appointment. The majority (93%) failed to return, and those who returned did so for reasons other than the weight issue. The physician likewise failed to address the problem. Barriers to compliance by both patient and physician need to be explored if we are to solve the problem of obesity.