Faculty Bibliography

Managed-care plans for low-income Americans are widely promoted to improve the quality and control the cost of medical care by reducing unnecessary specialty and emergency room (ER) care through the use of primary care physicians as case managers/gatekeepers. The purpose of this study was to evaluate one element of managed care, gatekeeping prior approval, for children who use the pediatric ER of one urban public hospital. Over a 6-month period, 518 children and adolescents insured under managed-care plans that required authorization from the primary care physician to receive treatment presented to the ER. Of the 385 records reviewed for this study, the majority (87%) received their primary care at community health centers or the hospital's own outpatient clinics. Most ER visits (72%) were made when primary care sites were closed. According to nursing triage assessment, 57% presented with urgent or emergent conditions, and 26% had a history of chronic illness. Nine percent required hospitalization. Although an elaborate system for gatekeeping was established, only 13 (3%) patients' requests for ER care were denied. Of these, 3 were seen in the ER without authorization, 6 received the recommended follow-up, and 4 were not seen in follow-up. Twenty-nine participating primary care physicians (74%) and 19 ER staff (63%) responded to a survey of their experience with and attitudes toward prior approval. For a variety of reasons, the majority of primary care physicians and ER staff found the gatekeeping policies for after-hours visits burdensome and inappropriate.(ABSTRACT TRUNCATED AT 250 WORDS)

OBJECTIVE: To determine the prevalence of cocaine exposure among preschool children with clinically unsuspected signs and/or symptoms. DESIGN: Prevalence study. SETTING: Pediatric emergency department in an inner-city hospital. PARTICIPANTS: 250 children aged 2 weeks to 5 years who underwent urine assays for cocaine prior to discharge from the emergency department. INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: Six (2.4%) of the 250 urine assays (95% confidence interval, 0.5% to 4.3%) were positive for benzoylecgonine, the major urinary cocaine metabolite. Four of the positive urine assays were from children younger than 1 year and all children with positive urine assays were younger than 24 months. None of these children presented with a complaint or was identified as having clinical problems currently associated with childhood exposure to cocaine. Possible exposure routes include breastfeeding, intentional administration, accidental ingestion of cocaine or cocaine-contaminated household dust via normal hand-to-mouth activity, and passive inhalation of 'crack' vapors. CONCLUSION: Among the inner-city children served by this hospital, significant numbers of infants and young children are being exposed to cocaine, and this exposure occurs in a clinically unsuspected population

HIV disease has emerged as a major chronic illness of childhood. Children with HIV infection and children with other chronic health impairments have much in common, including the need for comprehensive, multidisciplinary, coordinated care that includes special attention to the psychosocial effects on the child and family. However, because the mother and often the father and siblings share this lethal viral infection, the impact of HIV disease upon the family surpasses that of virtually all other chronic conditions. This is compounded by the association of the disease with drug use, its preponderance among the most disenfranchised populations in the United States, and the persistent public fear and discrimination surrounding AIDS. We have made substantial progress already in the medical management of this infection, and while we await the development of more effective therapies, we already have the tools and knowledge in hand to help these families

Unlike a number of childhood problems, it is not clear that there are racial or socioeconomic disparities in the prevalence of childhood asthma. We analyzed data from the Child Health Supplement to the 1981 National health Interview Survey, a population-based survey with information concerning 15,416 children, to address the following questions: are there racial or socioeconomic differences in rates of childhood asthma; if yes, what is the contribution of social and environmental characteristics to the observed differences? In this sample, black children were more likely to have asthma than were white children (4.4% vs. 2.5%). Racial disparities in prevalence emerged early and at all childhood ages were due to higher black rates of onset between the ages of 1 and 3 years. Poverty status, maternal cigarette smoking, large family size, smaller size of home, low birth weight, and maternal age younger than 20 years at the child's birth were all associated with increased rates of childhood asthma. When available social and environmental characteristics were controlled for using multivariate analyses, the increased risk for asthma among black and poor children was reduced to statistical insignificance. We conclude that black and poor children in the United States do have higher rates of asthma, that social and environmental factors exert substantial influences on rates of asthma, and that much of the racial and economic disparity in prevalence can be accounted for by a variety of social and environmental characteristics

According to a substantial literature, passive smoking by children is associated with an increased incidence of lower respiratory illness and diminished pulmonary function. The relationship between passive smoking and childhood asthma, however, is not clear. Data from the Child Health Supplement to the 1981 National Health Interview Survey were analyzed with information about 4331 children aged 0 to 5 years to study the relationship between maternal smoking and (1) the prevalence of childhood asthma, (1) the likelihood of taking asthma medication, (3) the age of onset of children's asthma, and (4) the number of hospitalizations among children with and without asthma. An odds ratio for asthma of 2.1 was shown by multivariate logistic regressions among children whose mothers smoke 0.5 packs of cigarettes or more per day compared with children of nonsmokers (P = .001). In similar analyses maternal smoking of 0.5 packs per day was identified as an independent risk for children's use of asthma medications (odds ratio 4.6, P = .0006) and for asthma developing in the first year of life (odds ratio 2.6, P = .0006). Maternal smoking is also associated with increased numbers of hospitalizations by its association with an increased risk of asthma as well as by contributing to hospitalizations independently of a child having asthma. Among children with asthma, however, maternal smoking is not associated with increased numbers of hospitalizations. It was concluded that maternal smoking is associated with higher rates of asthma, an increased likelihood of using asthma medications, and an earlier onset of the disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Children with a chronic health condition have long been considered at excess risk for psychosocial morbidity. Despite an increasing prevalence of chronic childhood conditions and heightened concerns for the quality of life of the chronically ill, population-based studies of behavior problems among children with chronic physical conditions are rare. Findings on the epidemiology of behavior problems in a nationally representative sample of 11,699 children and adolescents aged 4 to 17 years in the United States are reported. Data included a 32-item parent-reported behavior problem index, measures of chronic childhood conditions, measures of school placement and performance, and sociodemographic variables. Analyses confirmed that chronic physical conditions were a significant risk factor for behavior problems, independent of sociodemographic variables. Among children these differences were observed across all subscales; among adolescents the largest differences were found for the Depression/Anxiety and Peer Conflict/Social Withdrawal subscales. Rates of extreme behavior problem scores (those in the top 10th percentile) were 1.55 times higher among children with a chronic health condition compared with children without a chronic condition (95% confidence interval 1.29 to 1.86). These independent odds were lowered to 1.44 when covariates for confounding were introduced via a multivariate logistic regression. Other independent risks included the absence of either biologic parent (odds ratio 2.05), male gender (1.53), low vs high family income (1.30), low vs high maternal education (1.51), and young vs old maternal age at childbirth (2.57). Chronic health conditions were also a major risk factor for placement in special education classes and having to repeat grades. Despite evidence for effective interventions, health services for children with chronic conditions--particularly mental health services--remain fragmented, signaling the need for increased attention to behavioral problems and their treatment among all health professionals caring for children