PubMed Health⌕ Search

Biomedical subjects

H D Fink

Publications and source records attributed to H D Fink.

11 recordsLinked to original sources
PubMed1991

Demographic, clinical, and psychosocial predictors of the reliability of mothers' clinical judgments.

The purpose of this study was to investigate to what extent selected adverse demographic, clinical, and psychosocial data measured at the 2-week well child visit could predict poorer reliability of mothers' judgments during acute illness episodes over the next 32 months. The study was a randomized trial of the Acute Illness Observation Scales (AIOS); 369 mothers participated, 183 in the intervention group using the Acute Illness Observation Scales and 186 in the control group using a three-point global assessment scale. There were 704 acute illnesses judged simultaneously and independently by mothers and pediatricians. Standard Pearson r correlations were performed between the independent variables, taken singly and in all possible combinations, and the dependent variable, reliability of mothers' judgments as measured by weighted kappa (kappa W). Group assignment was entered as an independent variable. Analyses were performed separately for all first, second, and third acute illness visits to control for any "practice effect" (analysis 1). To control for consistency of observers, the first, second, and third visits of mothers with three visits were also analyzed (analysis 2). Depending on the visit number, adverse demographic, clinical, and psychosocial characteristics did correlate with poorer reliability independent of group assignment. The correlations ranged from small (analysis 1, first visit, multiple variable r2 = 4%) to large (analysis 2, second visit, multiple variable r2 = 29%). Controlling for both visit number and consistency of observers vs visit number alone (analysis 2 vs analysis 1) increased multivariate correlations to kappa W. The results support the untoward impact that adverse demographic, clinical, and psychosocial factors have on mothers' clinical judgment. These data may assist pediatricians in identifying parents who might benefit from more intensive teaching and support about acute illness episodes in their children.

Acute Disease↗
PubMed1990

Mothers' clinical judgment: a randomized trial of the Acute Illness Observation Scales.

The purpose of this study was to investigate whether the reliability, sensitivity, and specificity of mothers' judgments about acute illnesses in their children could be improved by using the Acute Illness Observation Scales (AIOS). At the 2-week well child care visit in a primary care center and a private practice, 369 mothers were divided at random into an intervention group (n = 183) and a control group (n = 186). A teaching film and booklet were used to educate mothers in the intervention group about the AIOS; control group mothers were taught a 3-point global scoring system for evaluating the chance of serious illness. In the 32 months of follow-up, 704 acute illnesses were evaluated in tandem and independently by mothers and pediatricians before the history and physical examination; 20 of these illnesses were serious. The judgments of the intervention group were more reliable than those of the control group (weighted kappa = 0.50 vs 0.26, respectively), as was the specificity of their judgments (85% vs 52%, respectively; p less than 0.0001). No difference was noted in the sensitivity of intervention group and control group mothers' judgments (80% vs 90%, respectively). Teaching parents to assess specific clinical information, as represented in the AIOS, has its greatest effect on the reliability and specificity, not the sensitivity, of their judgments. Such teaching could lead to fewer unnecessary office visits during acute illnesses.

Acute Disease↗
PubMed1989

The reliability and validity of the pediatric appropriateness evaluation protocol.

Researchers at Yale-New Haven Hospital (New Haven, Connecticut) tested the reliability and validity of the Pediatric Appropriateness Evaluation Protocol (PAEP) through a comparison of inter-rater agreement between experienced pediatricians and less experienced clinicians. The PAEP is a diagnosis-independent instrument with 26 criteria in three categories used to assess appropriate hospital use in pediatrics. Pediatrician raters, using clinical judgment alone, and clinicians (fellows in pediatrics and nurse practitioners), using both clinical judgment and the PAEP, reviewed a sample of 47 days and judged which inpatient days were medically appropriate. A day was judged appropriate if any of the 26 criteria were fulfilled for that day and inappropriate if none of the criteria was fulfilled. The PAEP was found to be a reliable and valid instrument with a 93% sensitivity and a 78% specificity for detecting medically inappropriate days.

Evaluation Studies as Topic↗
PubMed1989

Blood cultures in private pediatric practice: an eleven-year experience.

We describe an 11-year experience with bacteremia in a two-physician suburban private pediatric practice. Patients studied were ages 3 to 24 months with a body temperature of greater than or equal to 39.4 degrees C and nonfocal illness. During these 11 years, 23 such babies had bacteremia, 21 with Streptococcus pneumoniae. Three risk factors for bacteremia were identified: absolute neutrophil counts greater than or equal to 10,500/microliters; cool season (November to April), and Yale observation score greater than 10. The positive predictive values for bacteremia were 33, 41 and 57%, respectively, when (1) absolute neutrophil count was greater than or equal to 10,500, (2) absolute neutrophil count was greater than or equal to 10,500 and it was the cool season, and (3) all 3 risk factors existed. Of 158 babies at low risk for bacteremia by these criteria, none was treated and none developed serious complications of bacteremia. Eight of the 23 bacteremic infants received no expectant antibiotic therapy and 15 received presumptive amoxicillin treatment in dosages ranging from 20 to 174 mg/kg/day. Twelve bacteremic infants either were not treated or received dosages of 100 mg/kg/day or less; complications developed in 5 of the 12 (persistent bacteremia, 2; facial cellulitis, 3). The remaining 11 bacteremic babies received approximately 150 mg/kg/day (range, 136 to 174) and none had complications (P = 0.03 by Fisher's exact test). The costs of identifying and treating infants suspected of having possible occult bacteremia were examined.

Anti-Bacterial Agents↗
PubMed1987

Observation, history, and physical examination in diagnosis of serious illnesses in febrile children less than or equal to 24 months.

To determine if observational assessment performed in a systematic manner adds to the efficacy of the traditional history and physical examination in detecting serious illnesses in febrile children, and to determine the sensitivity of the combined evaluation, we studied consecutive patients less than or equal to 24 months of age seen for evaluation of fever at the Primary Care Center-Emergency Room (PCC-ER) of the Yale-New Haven Hospital (n = 143) and a suburban private practice (n = 207). An attending pediatrician performed the observation using the previously reported Acute Illness Observation Scales (AIOS). Subsequently, the history and physical examination were done by an attending pediatrician, and findings were scored as to whether they suggested the presence of a serious illness. Thirty-six patients, 28 in the PCC-ER and eight in the private practice, had a serious illness. The combined AIOS, history, and physical examination had a higher sensitivity and r correlation for serious illness than did the traditional history and physical examination. Three children with serious illnesses, all of whom had no abnormalities on history and physical examination, were identified only by use of AIOS. We conclude that assessment of appearance in a child with fever, when performed in a careful, integrated, stepwise fashion, improves the sensitivity of the history and physical examination in detecting serious illnesses in febrile children.

Evaluation Studies as Topic↗
PubMed1987

Do mothers overestimate the seriousness of their infants' acute illnesses?

The purpose of this study was to determine if mothers generally perceive their infants as more ill than do pediatricians, and if the presence of fever has an impact on the perceptions of either the mother or pediatrician. One hundred eighty-seven mothers and their infants, from a primary care clinic (n = 109) and private practice (n = 78), were enrolled at the 2-week well-child visit and were asked to contact a physician participating in the study whenever their infants became acutely ill. The mothers were asked to rate the severity of their infants' illness according to a 3-point scale, first at home and then simultaneously, but independently, with a physician in the office. In general, mothers rated their infants equally as ill at home as in the office (kappa = 0.59). However, both their home ratings (kappa = 0.15) and office ratings (kappa = 0.29) were in poor agreement with the ratings of the physicians. The mothers consistently rated their infants as more ill than did the pediatricians (p less than 0.0001). Both the mothers and physicians perceived infants with higher temperatures (greater than or equal to 38.9 degrees C) as significantly (p = 0.0004) more ill than infants with lower temperatures (less than 38.9 degrees C). We conclude that mothers generally perceive their infants as more ill than do pediatricians, and that it is important for pediatricians to address the perceptions of mothers in order to establish effective communication with them.

Acute Disease↗
PubMed1985

Predictive value of abnormal physical examination findings in ill-appearing and well-appearing febrile children.

In order to study the occurrence and positive predictive value of history and physical examination findings suggestive of serious illness in ill-appearing and well-appearing febrile children, 103 consecutive children aged less than or equal to 24 months with fever greater than or equal to 38.3 degrees C were evaluated from July 1, 1982 to Nov 24, 1982. Patients were initially classified by an attending physician (A) as to whether they appeared ill (Yale Observation Scale score greater than 10) or well (scale score less than or equal to 10). The history was then taken by two attending physicians (A and B) and a resident; the physical examination was performed by attending physician B and the same resident. As history and physical examination findings were elicited, they were scored as to whether they did or did not suggest a serious illness. Serious illness was defined as the presence of a positive laboratory test. Ill-appearing patients had a significantly greater (P less than .001, Fisher's exact test) occurrence of physical examination findings suggesting serious illness (14 of 22, 64%) than well-appearing children (12 of 81, 15%). The positive predictive values of abnormal physical examination findings for serious illness in ill-appearing (11 of 14, 79%) and well-appearing children (3 of 12, 25%) were significantly different (P = .02 by Fisher's exact test). The trends for abnormal history findings in ill-appearing and well-appearing children were similar to those for abnormal physical examination findings but did not achieve statistical significance. The results, indicating an important interaction between a febrile child's appearance and physical examination findings, are discussed in terms of probability reasoning in clinical decision making.

Bayes Theorem↗