Faculty Bibliography

Increasingly, hospital-based pediatric outpatient departments are recognized as settings that attempt to combine two critical, but not always compatible, mandates: (1) education of medical students and pediatric residents in outpatient pediatrics, and (2) service, often with inadequate resources, to a socially highrisk population with a disproportionately high prevalence of social, family, and psychological dysfunction. Coexistence of these two mandates has raised a number of concerns, because pediatric ambulatory care education and training have historically been based almost exclusively in a hospital setting. Trainees often get a false impression of the types of problems they will be dealing with in pediatric primary care and of how an efficient pediatric practice is managed. In addition, they often are supervised by full-time faculty who have little if any experience in community settings and who practice only part time or not at all. These problems have led to a widespread desire to train pediatric residents outside the hospital, in settings that more closely approximate the places in which they will practice in the future. Residency programs that address this issue also provide residents with the opportunity to be trained by seasoned practitioners whose primary professional responsibility is the outpatient care of children. To date, little has been written about the cost or the financing of such educational efforts. This article summarizes what is known about the costs. We also attempt to specify the costs that should be anticipated for the various components and steps involved in devising and implementing pediatric community-based educational programs and to describe potential sources of funding for such programs

As they try to make the most of their opportunities at school, children with chronic conditions need a pediatrician's advocacy. Use your knowledge of the illness, the law, and the resources in your community to play an active role.

OBJECTIVES: To describe the demographic characteristics, utilization of medical services, and health status of uninsured children compared with insured children in the United States and to assess the factors associated with lack of health insurance among children. An estimated 8 million children in the United States are uninsured. Medicaid expansions and tax credits have had little impact on the overall problem. An understanding of the characteristics of uninsured children is essential for the design of appropriate outreach and enrollment strategies, benefit packages, and health care provision arrangements for uninsured children. METHODS: Analysis of the 1988 Child Health Supplement of the National Health Interview Survey. RESULTS: Diverse groups of children in the United States lack health insurance. Residence in the South (odds ratio [OR], 2.3) and West (OR, 1.9. [corrected]) and being poor (OR, 2.2) or nearly poor (OR, 2.1) are independently associated with being uninsured. Substantial differences in both sources of care and utilization of medical services exist between uninsured and insured children. Uninsured children lack usual sources of routine care (OR, 3.1) and sick care (OR, 3.8) and also lack appropriate well-child care (OR, 1.5) compared with insured children. Neither being in fair or poor health nor emergency department use are significant independent predictors of being uninsured among children. Children who have a chronic disease, such as asthma, face difficulties of access to care and utilize substantially fewer outpatient and inpatient services. CONCLUSIONS: Universal health insurance, rather than efforts directed at specific groups, appears to be the only way to provide health insurance for all US children. Uninsured and insured children reveal marked discrepancies in access to and utilization of medical services, including preventive services, but have similar rates of chronic health conditions and limitations of activity. Uninsured children do not appear to form a population that will incur higher mean annual expenditures for medical care compared with insured children

The Environmental Protection Agency is required to set a standard for lead-contaminated house dust, but whether dust lead loading (micrograms/ft2) or concentration (micrograms/g) is more predictive of children's blood lead levels, which dust collection method should be used, and which surfaces should be sampled are unknown. Using a random sample of sequential births, we enrolled 205 urban children, 12 to 30 months of age, who had lived in the same house since at least 6 months of age. Samples of dust were obtained from predetermined surfaces in each child's residence using a wipe method and two vacuum methods, the Baltimore repair and maintenance method (BRM) and the dust vacuum method (DVM). Other potential sources of environmental exposure also were analyzed for lead, including soil, water, and paint. In general, dust lead loading is more predictive of children's blood lead levels than is dust lead concentration. Dust lead loading as measured with the BRM sampler explained more of the variation in children's blood lead levels than did wipe loading and DVM loading (13.7, 10.1, and 5.9%, respectively, adjusted for other significant predictors). The partial correlation between BRM lead loading and children's blood lead was significantly different than that for DVM lead loading, but it was not significantly different than that for wipe lead loading. Of the four surfaces measured, noncarpeted floors and interior window sills or wells were significantly associated with children's blood lead levels in multiple regression models. These data indicate that dust lead loading is more predictive of children's blood lead levels than is dust lead concentration and that, to determine if a housing unit is safe for children, noncarpeted floors and interior window sills or window wells should be measured using either the BRM or wipe sampling method