More on problem-based learning and self-directed learning.
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Humans↗
Biomedical subjects
R E Stein
Publications and source records attributed to R E Stein.
Impact of problem-based learning on residents' self-directed learning.
OBJECTIVE: To examine the effect of a problem-based learning (PBL) curriculum on self-directed learning behaviors among a group of pediatric residents. METHODS: A controlled comparison study was conducted with 80 pediatric residents at a large urban academic medical center. Residents were observed over 3 distinct but consecutive periods. First, all residents participated in a 3-month-long daily lecture series (pre-exposure phase). Then, for another 3 months, 39 residents (PBL group) were exposed to twice-weekly PBL sessions while 41 residents continued with the daily lectures (lecture-based group) and served as controls. Problem-based learning was withdrawn after 3 months and all residents returned to the lecture series (follow-up phase). Residents' self-directed learning behaviors were assessed through self-administered questionnaires during the pre-exposure, exposure, and follow-up phases. RESULTS: There were no significant preexposure differences in self-directed learning behaviors between the groups. During the exposure phase, the PBL group had significantly higher self-directed learning: 5 or more hours of independent study (26% vs 7%) [corrected] (P=.001); 5 or more hours of medical discussions (28% vs 4%) (P=.008); 2 or more computer literature searches (51% vs 30%) (P=.005); and total hours of self-study per week (6 vs 4 hours) (P<.05). At the 3-month follow-up, the PBL group had returned to baseline levels of self-directed learning and there were no significant differences between the groups. CONCLUSION: Residents exposed to PBL engaged in significantly higher levels of self-directed learning than their counterparts.
Adult↗
To help or not to help... That is the question.
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Adolescent↗
Shortening the questionnaire for identifying children with chronic conditions: what is the consequence?
OBJECTIVE: To determine whether a reduced item set can identify children who have chronic conditions with a level of at least 90% accuracy compared with the complete Questionnaire for Identifying Children With Chronic Conditions (QuICCC). BACKGROUND: The QuICCC was developed to operationalize a conceptually based, noncategorical definition of chronic conditions developed by Stein et al. It contains 39 item sequences administered to a parent that assess 3 types of consequences: functional limitations; reliance on compensatory mechanisms or assistance; and service use or need above usual for age. The QuICCC has been validated and widely adopted as a means of identifying children without using a diagnosis checklist, but there is considerable interest in shortening it. DESIGN/METHODS: Through secondary analyses of 3 data sets (Ns = 1265, 1388, and 4831), we identified a short list of items that identified >90% of children who were identified by the 39-item QuICCC. We administered these 16 items to 2 new samples of parents. In Study 1 we administered the 16 items in the shortened version first, followed by the other 23 items, and compared the results on the short and reordered long versions. In Study 2, the 39- and 16-item versions were each administered, one in person and the other by phone, in random order to the same respondent within a 2-week period. These data were analyzed to compare the short and longer versions at the 2 time points and within the single, longer 39-item format (simultaneous data). RESULTS: In Study 1 (N = 630) only 4 children were missed by the 16-item version who were identified by the longer version (sensitivity 98.6%; specificity 100%; positive predictive value 100%; negative predictive value 98.8% kappa 0.987). In Study 2 (N = 552), no children were missed by the 16-item subset of the 39 items when looking at the simultaneous data. When the two forms were administered 2 weeks apart, the 16-item version had a sensitivity of 87%, specificity of 90%, positive predictive value of 93%, negative predictive value of 82%, and kappa of 0.78 compared with the longer QuICCC. These results correspond exactly to the data obtained in a 2-week test-retest study for the QuICCC itself. The new form (the QuICCC-R) takes <2 minutes to administer on average (range 1-4 minutes) compared with 7 to 8 minutes for the full QuICCC. CONCLUSIONS: The results met our criteria for agreement, and we conclude that the QuICCC-R is a satisfactory alternative for screening populations. However, the full QuICCC has other applications beyond screening that may not apply to the QuICCC-R, the shorter version.
Adult↗
Asthma symptoms, morbidity, and antiinflammatory use in inner-city children.
BACKGROUND: Asthma is a major cause of morbidity that disproportionately affects inner-city children. For children with persistent asthma, defined as having asthma symptoms 3 or more days per week or 3 or more nights per month, national guidelines recommend the use of daily antiinflammatory agents. Despite these recommendations, antiinflammatory agents remain underused, particularly in inner-city children with high asthma morbidity. OBJECTIVES: The objectives of our study were to determine: 1) whether persistent asthma symptoms in inner-city children are related to acute care utilization and to the frequency of acute exacerbations; 2) whether children with persistent asthma are receiving recommended daily antiinflammatory agents; and 3) whether antiinflammatory medication use relates to sociodemographic factors, caretaker self-efficacy, the frequency of primary care visits, and/or measures of quality asthma care. DESIGN AND METHODS: A 64-item telephone survey was administered between July 1996 and June 1997 to 219 parental caretakers of 2- to 12-year-old children who had been hospitalized with asthma at an inner-city medical center between January 1995 and February 1996. Persistent asthma symptoms were assessed by inquiring about the frequency of daily and nocturnal asthma symptoms over the last 4 weeks. Children's asthma severity was classified by applying the 1997 National Asthma Education and Prevention Program (NAEPP) Asthma Guidelines' severity classification scheme based on the frequency of asthma symptoms. Asthma morbidity was defined as the frequency of acute asthma exacerbations, emergency department visits and hospitalizations. Daily antiinflammatory medication use was compared by sociodemographic factors, caretaker self-efficacy, frequency of primary care visits, and measures of quality asthma home management. RESULTS: In this sample, quantifying persistent asthma symptoms and applying the NAEPP symptom criteria identified 17% of the children with mild intermittent asthma, 27% with mild persistent asthma and 56% with moderate to severe persistent asthma. There were no differences in the age of the children in the 3 groups (mean age: 6 years). Asthma morbidity, as measured by the number of asthma exacerbations in the last 6 months, was significantly higher in the children with moderate to severe persistent asthma compared with children with mild intermittent asthma (9.8 vs 3.5) or mild persistent asthma (9.8 vs 4.5). In addition, there were significantly more emergency department visits in the moderate to severe group than in the mild persistent (3.05 vs 1.69) or mild intermittent group (3.05 vs 1.76). Lastly, as asthma symptom frequency increased, there were trends toward more hospitalizations and more days hospitalized. Overall, 35% of the 219 families reported giving daily antiinflammatory medications to their child (mostly cromolyn sodium). Of the 181 children (83%) who met NAEPP symptom criteria for persistent asthma, only 39% were receiving daily antiinflammatory treatment. Of the children with symptoms of moderate to severe asthma, only 15% were receiving inhaled steroids in contrast to the guidelines' recommendations. Use of antiinflammatory agents was not related to caretaker sociodemographic factors or self-efficacy scores. Measures of quality asthma home management, which included use of mattress covers, written plans, and peak flow meters, correlated positively with use of antiinflammatory agents. Children whose families reported using daily antiinflammatory medications had more primary care visits in the last 6 months than those children not receiving antiinflammatory medications. CONCLUSION: Questioning parents about the frequency of their child's asthma symptoms is an important, inexpensive, and readily accessible bedside and office tool that may aid in the detection of persistent symptoms and help direct therapy. Our study suggests that classifying asthma severity by quantifying persistent asthma symptoms, as defined in the NAEPP Guidelines, is a clinically useful tool that relates to asthma morbidity. In our sample of previously hospitalized children with asthma, 83% met 1997 NAEPP symptom criteria for persistent asthma, and yet only 35% were receiving daily antiinflammatory agents. Use of antiinflammatory agents correlated positively with other indicators of quality asthma home management. Additional work is necessary to increase appropriate use of antiinflammatory agents in this population, and in particular, to increase inhaled steroid use for children with moderate or severe symptoms.
Administration, Inhalation↗
Recurrent episodes of asthma in a 10 year old.
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Asthma↗
How well does the questionnaire for identifying children with chronic conditions identify individual children who have chronic conditions?
BACKGROUND: The Questionnaire for Identifying Children With Chronic Conditions (QuICCC) is an instrument based on a conceptual noncategorical definition that uses parental responses to identify children with chronic conditions for epidemiological purposes. OBJECTIVES: To determine whether the QuICCC is sufficiently valid, sensitive, and specific to be used to identify individual children as having a chronic condition or disability; whether parents are accurate enough that their answers to QuICCC items can be accepted as valid; and what kinds of errors in classification occur when the QuICCC is used to identify children with chronic conditions. METHODS: The sample consisted of 424 children who were patients of 9 physicians in separate practice settings throughout New England. Each physician was briefly trained in the conceptual definition on which the QuICCC is based and then was asked to identify 25 children in his or her practice who met the definition and 25 children who did not meet the definition. The QuICCC was administered to the parents of these children by blinded interviewers via telephone. The QuICCC classification was compared with physician categorization. Discrepant cases were then followed up by asking physicians and parents to answer the original questions a second time. RESULTS: Complete data were available on 379 (89.4%) of 424 children. There was agreement on 89% (kappa = 0.78). The sensitivity was 94%; specificity, 83%; positive predictive value, 86%; and negative predictive value, 92%. Of the 42 discordant cases, 30 parent reports on the QuICCC qualified the child as having a chronic condition when the physician classified the child as being without such a condition. Fewer (n = 12) discrepancies occurred because physicians identified children with chronic conditions that the QuICCC failed to identify. When the questions were readministered at follow-up, physicians corrected errors in rating in 9 cases; mothers changed their answers in 5 instances. In 13 instances the issues were known to both parties and appeared to arise in the "gray zone" or boundary area, where there was disagreement over whether a particular child qualified using the theoretical definition. For 11 children identified as having a chronic condition only by the parent's responses to the QuICCC, physician report appeared to be inaccurate primarily due to the physician's lack of information. In 3 cases where the physician reported the child to have a chronic condition, but the parent did not, the physician appeared to be correct. Follow-up data were incomplete on 1 child. CONCLUSIONS: These data support the validity of parent-generated information for the evaluation of health status. Although these findings should be replicated, this study suggests that the QuICCC may be applicable also as a screening tool for individual child identification, provided that several sources of error are considered.
Child↗
Can one size fit all?
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Activities of Daily Living↗
A single source of health care: does it affect health experiences for inner-city children?
This study was designed to determine whether having a single source of health care affects the health experiences of inner-city children. Seventy-five women were interviewed about the health experiences of their preschool-aged children (range 10-58 months) and were asked about utilization, emergency room use, preventive care, delays in care, and availability of a provider for the child's various medical needs. While most (94.7 percent) of the mothers identified a regular source of care for their child's preventive care, 74.7 percent named the same source for their child's sick care. There were no differences in most measures between mothers with a single source of care and those with multiple sources. However, those with a single source of care reported feeling their providers were more available (p < 0.05). Thus, naming a single source of health care may not be a useful indicator of better health experiences for inner-city children.
Adolescent↗
Do pediatricians recognize mothers with depressive symptoms?
OBJECTIVE: To determine whether pediatric health care providers recognize maternal depressive symptoms and to explore whether maternal, provider, and visit characteristics affect pediatric providers' ability to recognize inner-city mothers with depressive symptoms. DESIGN: A cross-sectional study was conducted at a hospital-based, inner-city, general pediatric clinic. Two groups of participants completed questionnaires, each unaware of the other's responses: 1) mothers who brought their children ages 6 months to 3 years for health care maintenance or a minor acute illness and 2) pediatric health care providers (attending pediatricians, pediatric trainees, and nurse practitioners). The mothers' questionnaire consisted of sociodemographic items and a self-administered assessment of depressive symptoms using the Psychiatric Symptom Index (PSI). Pediatric providers assessed child, maternal, and family functioning and documented maternal depressive symptoms. Criteria for positive identification of a mother by the pediatric health care provider were met if the provider reported one or more maternal symptoms (from a 10-item list of depressive symptoms), a rating of 4 or less on a scale of functioning, a yes response to the question of whether the mother was acting depressed, or a response that the mother was somewhat to very likely to receive a diagnosis of depression. RESULTS: Of 338 mothers who completed the questionnaire, 214 (63%) were assessed by 1 of 60 pediatric providers. Seventy-seven percent of surveys were completed by the child's designated pediatric provider. The mean visit length was 23 minutes. Mothers primarily were single, were black or Hispanic, and had a mean age of 26 years (15-45 years). Almost 25% of mothers were living alone with their children. Eighty-six (40%) mothers scored >/=20 on the PSI, representing high symptom levels. Of these, 25 were identified by pediatric providers (sensitivity = 29%). A total of 104 of 128 mothers with a PSI score <20 were identified as such by providers (specificity = 81%). Pediatric providers were more likely to identify mothers who were <30 years old, living alone, and on public assistance. Also, mothers who were assessed by the child's own primary provider or by an attending pediatrician were more likely to be identified accurately than were mothers whose children were seen by a pediatric trainee or a nurse practitioner. CONCLUSIONS: Pediatric health care providers did not recognize most mothers with high levels of self-reported depressive symptoms. Pediatricians may benefit from asking directly about maternal functioning or by using a structured screening tool to identify mothers who are at risk for developing depressive symptoms. In addition, training pediatric providers to identify mothers with depressive symptoms may be beneficial.
Adolescent↗
Exposure to violence among urban school-aged children: is it only on television?
OBJECTIVE: To measure exposure to different types of violence among school-aged children in a primary care setting. DESIGN: Child interviews using an instrument measuring 4 types of exposure (direct victimization, witnessing, hearing reports, media). Violent acts measured include being beaten up, chased/threatened, robbed/mugged, stabbed/shot, killed. SETTING: Pediatric primary care clinic of large urban hospital. PATIENTS: Convenience sample of 175 children 9-12 years old and their mothers. A total of 53% of the children were boys, 55% were Hispanic, and 40% received public assistance. RESULTS: All children had been exposed to media violence. A total of 97% (170/175) had been exposed to more direct forms of violence; 77% had witnessed violence involving strangers; 49% had witnessed violence involving familiar persons; 49% had been direct victims; and 31% had witnessed someone being shot, stabbed, or killed. Exposure to violence was significantly associated with being male. CONCLUSION: Most school-aged children who visited a pediatric primary care clinic of a large urban hospital had directly experienced violence as witnesses and/or victims.
Child↗
Operationalizing a conceptually based noncategorical definition: a first look at US children with chronic conditions.
OBJECTIVE: To apply a conceptually based noncategorical definition in the analysis of a nationally representative sample of US children to determine the prevalence and sociodemographic characteristics of US children with chronic conditions. DESIGN: Data on 30032 children, aged 0 through 17 years, from the 1994 National Health Interview Survey Disability Supplement were analyzed using a noncategorical conceptual definition of chronic conditions and a method that parallels that outlined in the development of the Questionnaire for Identifying Children with Chronic Conditions. We determined the percentages of children with chronic conditions overall and in 3 conceptual domains: (1) functional limitations, (2) dependence on compensatory mechanisms, and (3) service use or need beyond routine care for age. RESULTS: Content that corresponded to 35 of 39 items on the Questionnaire for Identifying Children with Chronic Conditions assessing consequences was available in the National Health Interview Survey Disability Supplement data set. An estimated 10.3 million children (14.8%) had chronic conditions; 7.0% of the children met enrollment criteria in a single conceptual domain, 5.2% in 2 domains, and 2.6% in all 3 domains. Significant sociodemographic correlates of having a chronic condition were being school-aged or older, male, white, living with a responsible adult with less than a college education, and having a family income below the poverty index (all P<.01). CONCLUSIONS: We established the feasibility of operationalizing a noncategorical conceptual definition by using a large-scale data set and provided an estimate of the prevalence of chronic conditions among US children. We confirmed that several sociodemographic correlates of chronic conditions in samples identified through diagnostic checklists were related to the presence of chronic conditions among these children.
Adolescent↗
Sociodemographic and condition-related characteristics associated with conduct problems in school-aged children with chronic health conditions.
OBJECTIVE: To examine whether sociodemographic and condition-related characteristics are associated with conduct problems in children with chronic health conditions. DESIGN: Cross-sectional survey. PARTICIPANTS: Mothers of children 5 to 8 years old with diverse chronic health conditions who received care at 2 large urban medical centers. MEASURES: Mothers responded to a face-to-face structured interview that included the Eyberg Child Behavior Inventory, the Psychiatric Symptom Index, and questions about sociodemographic and health condition-related characteristics. RESULTS: Of the 356 children assessed, 138 (38.8%) had conduct problems as defined by criteria of the Eyberg Child Behavior Inventory. In logistic regression analyses, conduct problems were associated with younger child age, mother having a husband or partner unrelated to her child, poorer perceived prognosis, child having a learning disability, and maternal self-report of high emotional distress on the Psychiatric Symptom Index. Conduct problems were not related to child sex, maternal ethnicity or education, family receiving welfare, or a wide range of condition-related factors, including age at diagnosis, visibility to others, need to watch for sudden changes, presence of mobility or sensory-communication problems, using medication or equipment, annual hospitalizations, or physician visits. CONCLUSIONS: Conduct problems in children with chronic health conditions appear to be associated more closely with their sociodemographic and family characteristics than with condition-related risk factors. Additional research remains to be done on the ways that maternal adjustment, diagnosis-specific condition characteristics, and other risk factors influence children's behavior.
Child↗
How does home management of asthma exacerbations by parents of inner-city children differ from NHLBI guideline recommendations? National Heart, Lung, and Blood Institute.
OBJECTIVES: 1) To describe the asthma morbidity, primary care practices, and asthma home management of inner-city children with asthma; 2) to determine the responses of parental caretakers to asthma exacerbations in their child; and 3) to compare these responses to the recommendations of the National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines for home management of acute exacerbations of asthma. DESIGN AND METHODS: A 64-item telephone survey was administered between July 1996 and June 1997 to 220 parental caretakers of 2- to 12-year-old children who had been hospitalized with asthma at an inner-city medical center from January, 1995 to February, 1996. Sociodemographics, primary care practices, asthma morbidity, and asthma home management were assessed. Parents were asked what they would do if their child "began wheezing and breathing faster than usual." RESULTS: Morbidity measures indicated that there were an average of 2.5 +/- 4.5 emergency department visits for asthma in the last 6 months, 1.6 +/- 2.2 hospitalizations for asthma in the last 12 months, and 18.1 +/- 17.9 asthma-related school absences in the previous school year. Most, but not all, of the families had primary care providers and most had phone access to them. Half of the families (51%) reported having been given a written asthma action plan. Only 30% of families with children age 5 years and older had peak flow meters. In contrast, almost all families (97%) had equipment for inhalation of beta-agonists. Only 39% of the 181 children with persistent symptoms were receiving daily antiinflammatory agents as recommended in the guidelines of the NHLBI. In response to the scenario of an acute exacerbation of asthma, no one mentioned that they would refer to a written plan, only 1 caretaker would measure peak flow and 36% would give beta-agonists. Two percent would give oral steroids initially, and 1 additional person would do so if wheezing continued 40 minutes later. Only 4% responded that they would contact their clinician. Reports of actual practice differed from the scenario responses in that more people began beta-agonists and oral steroids in response to an exacerbation in the past 6 months than said they would in response to the scenario. CONCLUSION: In this population of previously hospitalized inner-city children with asthma, the NHLBI guidelines for the home management of asthma exacerbations are not being followed. Interventions are needed to affect both clinician and caretaker practices.
Adolescent↗
Children with chronic conditions in the 21st century.
The care of children who have chronic conditions should focus on improving the lives of the children and their families. This is accomplished most effectively through community-based, family-centered care. Critical issues for these children and families in entering the next century include the level of insurance, content of benefits package, level of evidence required for health insurance reimbursement, preparation of and incentives for health care professionals, roles being demanded of families. As the richest country in the world, we should be able to (1) provide universal coverage, (2) guarantee a comprehensive benefits package that applies a child-specific standard of medical necessity, (3) establish criteria for requiring insurers to reimburse for new effective therapies, (4) develop strategies for overcoming professional barriers, and (5) create mechanisms for compensating family caretakers for their care.
Child↗
Relationship of parental psychological distress to consequences of chronic health conditions in children.
OBJECTIVE: To assess whether parents' self-reported psychological distress was related to consequences of chronic health conditions in their children as reflected by three domains: functional limitations, reliance on compensatory mechanisms, and service use above routine care. METHODS: We used telephone survey data on children's health and parents' psychiatric symptoms from an inner-city community sample (n = 380) and a population-based national sample (n =398). RESULTS: In the national sample, parents of children with functional limitations were more distressed than parents whose children experienced other types of condition consequences or none. In the inner-city sample, presence of a health condition was associated with greater parental distress, but there were no significant effects by consequence type. CONCLUSION: Research needs to determine if parents of children with functional limitations represent a high-risk group and to identify the factors associated with their elevated distress.
Adolescent↗
Implications for estimates of disability in children: a comparison of definitional components.
OBJECTIVE: To test how prevalence estimates and characteristics of children vary by the way that disability is defined. Specifically, to determine 1) the proportions of children identified as disabled by one particular operationalization of disability based on parental reports of three types of consequences (i.e., functional limitations [FL]), dependence on compensatory mechanisms (CD), and service use or need beyond routine [SU/N]), and 2) whether children identified as disabled by these three types of consequences differ by type of disorder or condition, age, socioeconomic status, or race. METHOD: We analyzed a national dataset representing a random sample of 712 households with 1388 children. The Questionnaire for Identifying Children with Chronic Conditions (QuICCC) was used to identify children with disabling conditions. We divided the QuICCC items into three discrete sets, reflecting three definitional components of disability, and compared the proportions and characteristics of children fitting these components separately and in combination. RESULTS: Using the QuICCC definition of disability, SU/N identified the largest proportion of children (72%), followed by CD (55%) and FLs (49%). Forty-four percent of children were identified by only one component, 36% by two components in any combination, and 20% by all three components. The type of disorder or condition generally did not vary by the three definitional components, although the FL component may be more effective at identifying children with sensory impairments. Children identified by two or more components were more likely to have multiple conditions and had more pervasive disorders than those identified by only one component. The youngest children (0 to 3 years old) may be less likely to be identified as disabled than children of other ages, especially by FLs. FLs also were more likely to identify children from the poorest and least educated families. CONCLUSIONS: Although the specific findings reported here pertain to a single definitional approach (the QuICCC), the data highlight that who will be classified as disabled (and who will not) may be dependent on how disability is defined. The implications of using different definitions and definitional components on both the prevalence and the characteristics of children with disabilities need to be considered before data can be applied responsibly and appropriately.
Adolescent↗
Upstairs downstairs: vertical integration of a pediatric service.
BACKGROUND: The combined effects of recent changes in health care financing and training priorities have compelled academic medical centers to develop innovative structures to maintain service commitments yet conform to health care marketplace demands. In 1992, a municipal hospital in the Bronx, New York, affiliated with a major academic medical center reorganized its pediatric service into a vertically integrated system of four interdependent practice teams that provided comprehensive care in the ambulatory as well as inpatient settings. One of the goals of the new system was to conserve inpatient resources. OBJECTIVE: To describe the development of a new vertically integrated pediatric service at an inner-city municipal hospital and to test whether its adoption was associated with the use of fewer inpatient resources. DESIGN: A descriptive analysis of the rationale, goals, implementation strategies, and structure of the vertically integrated pediatric service combined with a before-and-after comparison of in-hospital resource consumption. METHODS: A before-and-after comparison was conducted for two periods: the period before vertical integration, from January 1989 to December 1991, and the period after the adoption of vertical integration, from July 1992 to December 1994. Four measures of inpatient resource use were compared after adjustment for case mix index: mean certified length of stay per case, mean number of radiologic tests per case, mean number of ancillary tests per case, and mean number of laboratory tests per case. Difference-in-differences-in-differences estimators were used to control for institution-wide trends throughout the time period and regional trends in inpatient pediatric practice occurring across institutions. Results. In 1992, the Department of Pediatrics at the Albert Einstein College of Medicine reorganized the pediatric service at Jacobi Medical Center, one of its principal municipal hospital affiliates, into a vertically integrated pediatric service that combines ambulatory and inpatient activities into four interdependent practice teams composed of attending pediatricians, allied health professionals, house officers, and social workers. The new vertically integrated service was designed to improve continuity of care for patients, provide a model of practice for professional trainees, conserve scarce resources, and create a clinical research infrastructure. The vertically integrated pediatric service augmented the role of attending pediatricians, extended the use of allied health professionals from the ambulatory to the inpatient sites, established interdisciplinary practice teams that unified the care of pediatric patients and their families, and used less inpatient resources. Controlling for trends within the study institution and trends in the practice of pediatrics across institutions throughout the time period, the vertical integration was associated with a decline in 0.6 days per case, the use of 0.62 fewer radiologic tests per case, 0.21 fewer ancillary tests per case, and 2.68 fewer laboratory tests per case. CONCLUSIONS: We conclude that vertical integration of a pediatric service at an inner-city municipal hospital is achievable; conveys advantages of improved continuity of care, enhanced opportunities for primary care training, and increased participation of senior clinicians; and has the potential to conserve significant amounts of inpatient resources.
Academic Medical Centers↗