Understanding the etiology of serious medical events involving children: implications for pediatricians and their risk managers.
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Causality↗
Biomedical subjects
G B Hickson
Publications and source records attributed to G B Hickson.
Pediatric practice and liability risk in a managed care environment.
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Case Management↗
Universal screening for group B streptococcus: recommendations and obstetricians' practice decisions.
OBJECTIVE: To determine how obstetricians' opinions regarding universal screening of pregnant women for group B streptococcus (GBS) and their responses to positive culture results vary from American Academy of Pediatrics recommendations, and to determine the physician characteristics that predict divergent opinions. METHODS: One hundred ninety-four practicing obstetricians in the middle Tennessee region were queried by a mail survey. They were asked if they agreed with universal screening for GBS and to indicate whether they would prescribe antibiotics for women in labor, represented by six scenarios that differed with respect to presence or absence of preterm labor, premature rupture of membranes (ROM), prolonged ROM, and a positive GBS cervical culture. They were also asked to describe their practice and personality characteristics. RESULTS: Completed surveys were returned by 135 of 194 obstetricians (70%). Although only 28% of the respondents agreed with routine prenatal screening for GBS, most (74%) said they would treat a patient on the basis of a positive culture alone. Other risk factors, when added to a positive culture, slightly increased the decision to treat (from 74 to 88%). Multiple logistic regression, used to assess the relative effect of clinical and physician characteristics on treatment decisions, revealed that chemoprophylaxis for GBS was predicted most strongly by a positive culture at 28 weeks' gestation followed by prolonged ROM and preterm labor. Practicing in an urban location and seeing fewer than 20 patients per day also influenced the decision to treat. CONCLUSION: Although most obstetricians in the middle Tennessee region do not believe in universal screening, most will prescribe intrapartum antibiotics on the basis of a positive screening culture. However, other clinical risk factors and physician characteristics significantly and independently affect the decision to treat as well.
Adult↗
Parents' responses to vaccine information pamphlets.
OBJECTIVE: To assess parents' knowledge and opinions about immunizations and immunization practices before and after introduction of vaccine information pamphlets. RESEARCH DESIGN: Telephone questionnaire administered to parents whose children received immunizations in the preceding week. SETTING: Six private pediatric practices in Nashville area and resident continuity clinic at Vanderbilt University Medical Center. PARTICIPANTS: Parents whose children were scheduled to receive immunizations were asked to participate. Interviews were completed with 177 parents whose children received immunizations before and 156 parents after pamphlets were introduced. These two groups of parents had similar demographic characteristics. RESULTS: Parents who received vaccine information pamphlets learned more about vaccines (2.38 facts/parent after vs 1.18/parent before vaccine information pamphlets, z = -6.28, P < .0001) and were more eager to obtain immunizations for their children (76% vs 38%, chi 2 = 47.24, P < .001). Receipt of pamphlets did not make parents significantly more likely to report side effects from vaccines (63% after vs 55% before, NS) but tended to make them less likely to turn to non health care providers for information (58% after vs 69% before, chi 2 = 3.73, P = .06). Parents who received pamphlets, however, said more often that they received too much information (20% vs 4%, chi 2 = 14.9, P < .001). CONCLUSIONS: Vaccine information pamphlets enhanced parents' knowledge and acceptance of immunizations. There is room for further improvement.
Child↗
An account of the usefulness of a pilot clinical ethics program at a community hospital.
This article describes the development and implementation of a six-month pilot clinical ethics program at Saint Thomas Hospital (Nashville, Tenn). To assess the impact of this program, baseline data were gathered from a self-selected sample of critical and special care unit nurses and physicians about the "most troublesome" ethical dilemmas in their practices. Nurses and physicians reported facing similar dilemmas in practice. Nurses believed that chaplains and peers were most "beneficial" in resolving their "most troublesome" cases; physicians did not deem one particular individual or service to be of any greater benefit than any other in dilemma resolution. Nurses and physicians indicated that in many cases patients and families did not appear involved in the process. In a posttest survey following the pilot program, nurses rated the beneficial role of chaplains somewhat lower and agreed that the clinical ethics service was beneficial. As with the pretest sample, the posttest nurses evaluated the role of the attending physician as "detrimental" to resolving their ethical conflicts. In the posttest, physicians ranked the role of the clinical ethicist as comparable to that of chaplains and social workers.
Attitude of Health Personnel↗
Are you and your waiting room's televised "expert" saying the same thing?
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Child↗
Factors that prompted families to file medical malpractice claims following perinatal injuries.
OBJECTIVE: To identify self-reported reasons that prompt families to file malpractice claims following perinatal injuries. DESIGN: Families were interviewed by telephone using a questionnaire that contained structured and open-ended questions. PARTICIPANTS: Mothers of infants who had experienced permanent injuries or deaths and had closed malpractice claims in Florida between 1986 and August 1989 were interviewed. Questionnaires were completed by 127 (35%) of a total of 368 such families. OUTCOME MEASURES: Reasons prompting families to file and families' descriptions of medical events, advice from acquaintances, and the quality of physician-family communication. RESULTS: Families volunteered numerous reasons for filing: advised by knowledgeable acquaintances (33% of respondents), recognized cover-up (24%), needed money (24%), recognized that their child would have no future (23%), needed information (20%), and decided to seek revenge or protect others from harm (19%). Over one third of all families indicated that they were told by medical personnel prior to filing that the care provided had caused their children's injuries. Families expressed dissatisfaction with physician-patient communication. Families believed that physicians would not listen (13% of sample), would not talk openly (32%), attempted to mislead them (48%), or did not warn about long-term neurodevelopmental problems (70%). CONCLUSION: Families give many reasons for filing a claim. Obtaining money may not be the only goal for some families who file suit.
Family↗
Improving resources for foster care.
The number of foster children and their psychological and medical morbidity are growing. To gain insight into how to recruit and retain foster homes, characteristics of 64 foster families were determined by interview. Foster parents had low-to-moderate incomes, were approaching middle age, had underutilized home space, and wanted more children. Most enjoyed foster care and planned to continue. Twenty-three percent of the 64 had half of all foster children in the study in their homes at interview and had cared for seven times as many children in the past, including 66% of all the teens and 83% of all the handicapped children who had been in the 64 homes. These "high providers" functioned like group homes for mentally handicapped individuals. Adapting the group-home concept to foster homes could improve care, especially for children with special needs.
Adult↗
Compensation under the National Childhood Vaccine Injury Act.
The purpose of this article is to look at the effect of the federal compensation scheme under the National Childhood Vaccine Injury Act on the people and institutions involved in the administration of vaccinations. More vaccine-injured children will probably receive compensation than would have been true under state law, but each child will probably receive less money for damages. Manufacturers will pay excise taxes to fund the compensation scheme and receive, in return, substantial immunity from liability under state law. Although these provisions create incentives that work in opposite directions, producers likely will still have reason to improve the safety and efficacy of vaccines. The situation for those who administer vaccinations is less clear. Freeing them from the threat of litigation would leave them with little incentive to use immunizations appropriately because they do not contribute to the compensation scheme. Although Congress intended to make those who give vaccines immune from state claims, it may have failed to do so, leaving providers with their liability largely unchanged. The most pervasive uncertainty is that the Act is designed to self-destruct and may soon return vaccine-injured children, manufacturers, and providers to the state of the law before Congress acted.
Child↗
Should promethazine in liquid form be available without prescription?
Promethazine, available by prescription only since its introduction in 1946, has been widely used for pediatric patients because of its antihistaminic, antiemetic, and sedative properties. Recently, it's makers have sought Federal Drug Administration approval to introduce two liquid over the counter allergy/cold/cough products containing promethazine as an active ingredient. Although millions of doses have been administered, promethazine use has not been free of risk. Promethazine has been reported to cause significant sedation, agitation, hallucinations, seizures, dystonic reactions, and possibly apparent life-threatening events or sudden infant death syndrome. The impact of these relatively uncommon adverse reactions on children would be minimal if parents would use over the counter promethazine only for appropriate indications and only in children greater than 2 years of age. However, according to results of research evaluating the use of various over the counter medications by families for their children, promethazine will be used inappropriately. Both its over the counter status, implying a certain margin of safety, and its formulation as a syrup, providing ease of administration, should increase its use in all age groups including that by children less than 2 years of age who may be most vulnerable to the adverse reactions associated with the drug's use.
Chemistry, Pharmaceutical↗
Information search and decision making in the selection of family health care.
Two studies on consumer information search and decision strategies involved in the selection of family health care providers are reported. The first study examined the selection process for both adults and children within the family. Factors associated with dissatisfaction with provider were identified. The second study explored differences among individuals in self-reported presence of a regular health care provider and use of recent innovations in health care such as walk-in clinics and HMOs.
Arkansas↗
Parental administration of chemical agents: a cause of apparent life-threatening events.
Nine infants with apparent life-threatening events that occurred as a result of poisoning by a caretaker are described. These episodes were characterized by apnea plus some combination of color change, choking or gagging, and abnormal muscle tone. Five of the infants responded to vigorous stimulation, and four required cardiopulmonary resuscitation. Most poisonings (seven infants) were detected by a urine drug screen. Medications detected included acetaminophen, amphetamine, benzodiazepines (two infants), cocaine, codeine, meperidine (two infants), Methadone, phenobarbital, and phenothiazines (three infants). Four infants received two or more drugs. Most perpetrators of the poisonings were mothers (seven) and five of the parents admitted administering the various agents. Reasons for the poisonings included an apparent attempt to harm an infant, the need to sedate a fussy infant, or a gross misunderstanding of the potential risk of various agents to infants. Because no history of drug administration was elicited at the time of hospital admission, six infants might have been discharged with a diagnosis of apnea of infancy had not an attempt been made to investigate the possibility of poisoning. These cases suggest that poisoning by a caretaker should be added to the differential diagnosis of any infant brought to medical attention because of an apparent life-threatening event and that urine drug screening should be considered in the evaluation.
Acetaminophen↗
First step in obtaining child health care: selecting a physician.
To investigate the process by which families identified and selected their children's current physicians, a close-ended questionnaire was administered to 750 families in a mail panel. Of 630 responses (84.0%), 244 had children in the home; 229 (93.9%) identified a regular and current physician for their youngest child. However, parents did not spend much time or energy selecting a physician and rarely explored medical expertise in their decisions. Families averaged 1.2 sources of information consulted per decision; few considered more than two physician choices and infrequently considered alternative types of doctors (pediatricians v family or general practitioners). Selection priorities ranked in order of importance concerned parents' perceptions of their doctors' communication skills, accessibility, and quality as determined by recommendations of friends or physicians. Parents appeared less concerned with issues of cost and convenience. Families selecting pediatricians differed from those selecting family and general practitioners in sources of information used and selection priorities. The survey also identified 84 families who had changed or seriously considered changing the physician who was caring for their youngest child. The most frequent dissatisfaction was the perception that an illness was not being managed adequately, followed by believing that the doctor or staff were rude or unconcerned. Families unhappy with pediatricians expressed different reasons from those unhappy with family or general practitioners. The study results provide insight about the first step in obtaining child health care services, a relatively unexplored area of patient decision making.
Adolescent↗
Physician reimbursement by salary or fee-for-service: effect on physician practice behavior in a randomized prospective study.
We used a resident continuity clinic to compare prospectively the impact of salary v fee-for-service reimbursement on physician practice behavior. This model allowed randomization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior. Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians (3.69 visits v 2.83 visits, P less than .01) and saw their patients more often (2.70 visits v 2.21 visits, P less than .05) during the 9-month study. Almost all of this difference was because fee-for-service physicians saw more well patients than salaried physicians (1.42 visits and .99 visits per enrolled patient, respectively, P less than .01). Evaluating visits by American Academy of Pediatrics' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended visits and scheduled visits in excess of those recommendations. Fee-for-service physicians also provided better continuity of care than salaried physicians by attending a larger percentage of all visits made by their patients (86.6% of visits v 78.3% of visits, P less than .05), and by encouraging fewer emergency visits per enrolled patient (0.12 visits v 0.22 visits, P less than .01). Physicians' interest in private practice, as determined by their career plans, correlated significantly with total number of patients enrolled (r = .48, P less than .05) and total clinic patients seen by each resident during the study (r = .40, P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Apparent intentional poisoning of an infant with acetaminophen.
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Acetaminophen↗
Concerns of mothers seeking care in private pediatric offices: opportunities for expanding services.
A surplus of general pediatricians has been predicted for 1990. This surplus could provide both opportunity and need for practitioners to identify areas of maternal concern that might guide expansion of marketable physician services. For this purpose, maternal concerns were assessed by interviewing 207 mothers seeking care in private pediatric offices. Only 30% of mothers were most worried about their child's physical health. The remaining 70% were most concerned about problems falling into six categories of parenting, behavior, and development (psychosocial concerns): personality/social development, discipline, mental development, mother-child interaction time, adjustment to divorce and other life changes, and adolescent transition. Although the majority of these concerns conceivably could be handled in private offices, only 28% of these mothers had discussed their greater psychosocial concern with their pediatrician. A search for explanations of this failure to communicate indicated mothers often were not aware that their pediatrician could help, or they questioned his ability or interest in assisting them. Characteristics that correlated significantly with communication were higher family socioeconomic levels, and greater physician self-perceived ability and interest in these psychosocial problems. Parenting, behavior, and development concerns represent an opportunity for expanding services if some of these obstacles can be overcome.
Attitude of Health Personnel↗
Obstetricians' prior malpractice experience and patients' satisfaction with care.
OBJECTIVE: To examine the relationship between prior physician malpractice experience and patients' satisfaction with care. DESIGN: Women were interviewed using a questionnaire that contained structured and open-ended questions. PARTICIPANTS: Mothers of all stillborn infants, infant deaths, and a random sampling of viable infants drawn from 1987 Florida Vital Statistics were sorted into four groups based on the malpractice claims experience of their obstetricians between 1983 and 1986. Interviews were completed with 963 of 1536 women, most by telephone, 53 by in-person interview. MAIN OUTCOME MEASURES: Mothers' responses to closed-ended and open-ended questions about their perceptions of the care they received during their pregnancy, labor, and delivery. RESULTS: Even though none of the women actually filed a claim, a consistent pattern of differences emerged when comparing women's perceptions of care received. Patients seeing physicians with the most frequent numbers of claims but without high payments were significantly more likely to complain that they felt rushed, never received explanations for tests, and were ignored. In response to the open-ended question, "What part of your care were you least satisfied with?" women seeing physicians in the High Frequency malpractice risk group offered twice as many complaints as those seeing physicians who had never been sued. Problems with physician-patient communication were the most commonly offered complaints. CONCLUSION: Physicians who have been sued frequently are more often the objects of complaints about the interpersonal care they provide even by their patients who do not sue.
Female↗
The relationship between malpractice claims history and subsequent obstetric care.
OBJECTIVE: To determine the relationship between prior malpractice claims experience and the quality of clinical obstetric care. DESIGN: Historical cohort study of obstetricians, classified by their prior malpractice claims experience, with blinded review of medical records from their practices 5 to 10 years later. SETTING: Florida obstetricians who lost, settled, or defended malpractice claims between 1977 and 1983 and who were still practicing obstetrics in 1987. MAIN OUTCOME MEASURES: Objective and subjective assessment of quality of clinical care of patients attended by obstetricians with different histories of malpractice claims. RESULTS: No differences were found in any of the objective or subjective measures of the quality of clinical care provided to patients of obstetricians who were classified into one of four groups according to their prior claims history. CONCLUSIONS: No relationship was found between prior malpractice claims experience and the technical quality of practice by Florida obstetricians. Strategies that attempt to identify physicians at risk for future clinical errors by using data on prior malpractice claims (such as the National Practitioner Data Bank) may be misjudging the likelihood that substandard clinical care will be provided by physicians with prior claims.
Cohort Studies↗