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Objective. To assess the adequacy of the Primary Care Assessment Tool-Child Edition (PCAT-CE) for evaluating the attainment of the key characteristics of primary care services for children and youth. Design. Community-based telephone survey. Setting. Specific political subdivision in Washington, DC. Participants. Four hundred fifty parents/guardians of offspring 18 years of age or less. Measures. Reliability, validity and principal component analysis of 5 scales representing key aspects of the 4 cardinal domains of primary care included in the PCAT-CE. In addition, 2 subdomains (first contact use and extent of affiliation with a primary care source) were included as indices to describe overall patterns of use and affiliation with the particular source of care. Results. Most scales had adequate internal consistency, test-retest reliability, and construct validity. The principal components factor analysis yielded 5 separate factors. These corresponded to the subdomains of first contact accessibility; coordination of care; characteristics of the professional-patient relationship over-time; and comprehensiveness (both services available and indicated services received). Conclusions. Psychometric assessment supported the integrity and general adequacy of the PCAT-CE for assessing the characteristics and quality of primary care for children and youth. Testing of revised versions in a variety of different settings is underway. A major component of this testing is to explore the possibility of reducing the number of items while retaining sufficient detail about each component of primary care to make judgements about people's experiences with that care.

This study examined the impact of low birth weight on children's health and assessed the influence of the social environment on various aspects of health in low birth weight and normal birth weight children. Data on 8661 children aged 2 through 11 from the 1981 Child Health Supplement of the National Health Interview Survey provided strong evidence for two major conclusions: (1) Low birth weight children in high-risk social environments are at increased for poor health outcomes compared with comparable normal birth weight children. This vulnerability was found across all age groups, suggesting that the effects of low birth weight are long-lasting. The poor health outcomes for low birth weight children in high-risk social environments were found for all seven aspects of child health status studied: excessive bed days, restricted-activity days, and school-loss days; school failure, low school-ranking, behavior problems, and maternal perception of child health status as fair/ poor. (2) The mechanism of risk was complex and differed by birth weight group. Whereas certain combinations of individual risk factors protected normal birth weight children from several adverse outcomes, none for low birth weight children were identified. However, low birth weight children in low-or moderate-risk social environments were not at greater risk for poor outcomes compared with comparable normal birth weight children. This study underscores the importance of a healthy social environment for children who are already at high risk for poor health outcomes by virtue of being low birth weight.

Reduction in medical care utilization is one criteria for assessing the impact of mental health treatment for children with psychosocial problems. This reduction has been termed the "offset" effect. Almost all published research concerning offset after mental health treatment concerns adults, and the few studies in pediatric populations are limited by methodologic problems. A study of health care utilization after mental health treatment for children was conducted. Mental health treatment for psychosocial problems was significantly associated with decreased use of medical care only for older children, after potentially confounding variables were controlled for. Furthermore, this decreased use was found only for nonmental health specialty care visits. No reduction in primary care visits occurred. Other factors such as previous patterns of use and the presence of other morbidity were stronger predictors of subsequent primary health care use than was mental health treatment. Mental health treatment does not have a major impact on the high utilization of most children with psychosocial problems in pediatric settings. Because the reasons for this may be particular morbidity patterns in these children, future studies should include some measure of case mix as a potentially important variable in assessment of mental health treatment effects.

Objective. To review the extent to which the literature supports the position that a medical home is important and to review the extent to which insurance is related to having a medical home. Methods. A review of literature concerning the benefits of a medical home on effectiveness, costs, and equity (reducing disparities) was conducted. Results. International and within-nation studies indicate that a relationship with a medical home is associated with better health, on both the individual and population levels, with lower overall costs of care and with reductions in disparities in health between socially disadvantaged subpopulations and more socially advantaged populations. Although important in facilitating use overall, insurance does not guarantee a medical home. Conclusions. A medical home, with its 4 key features, provides better effectiveness as well as more efficient and more equitable care to individuals and populations. A concerted attempt to provide a means of universal financial access as well as a medical home should be of high priority for the United States.

Objective. In this study we examined how gatekeeping arrangements influence referrals to specialty care for children and adolescents in private and Medicaid insurance plans. Design/Participants. We conducted a prospective study of office visits (n = 27 104) made to 142 pediatricians in 94 practices distributed throughout 36 states in a national primary care practice-based research network. During 10 practice-days, physicians and patients completed questionnaires on referred patients, while office staff kept logs of all visits. Physicians used medical records to complete questionnaires for a subset of patients 3 months after their referral was made. Results. Gatekeeping arrangements were common among children and adolescents with private (57.8%) and Medicaid (43.3%) insurance. Patients in gatekeeping plans were more likely to be referred with private (3.16% vs 1.85% visits referred) and Medicaid (5.39% vs 3.73%) financing. Increased parental requests for specialty care among gatekeeping patients did not explain the increased referral rate. Physicians' reasons for making the referral were similar between the two groups. Physicians were less likely to schedule an appointment or communicate with the specialist for referred patients in gatekeeping plans. However, rates of physician awareness that a specialist visit occurred and specialist communication back to pediatricians did not differ between the two groups 3 months after the referrals were made. Conclusions. Gatekeeping arrangements are common among insured children and adolescents in the United States. Our study suggests that gatekeeping arrangements increase referrals from pediatricians' offices to specialty care and compromise some aspects of coordination.

Objectives. Some inner-city infants grow to be successful, self-sufficient adults. This study is designed to identify characteristics from early childhood that foster or impede favorable outcomes and are useful for formulation of public policy. Methods. Population: 2694 children (G-2s), born 1960 through 1965, to 2307 inner-city women (G-1s) enrolled in the Johns Hopkins Collaborative Perinatal Study. Data: 1) prospective observations (birth through 8 years) of neurologic and cognitive development, health, behavior, and family and neighborhood socioeconomic characteristics and 2) completed interviews with 1758 G-2s (age 27 to 33) and 1552 G-1s, bridging the period from age 9 to present status. An intergenerational, life course model of development identified significant characteristics and events associated with G-2 outcome (education, physical and mental health, healthy lifestyle, and financial independence of public support, emphasizing educational attainment of a high school diploma or a graduate equivalency degree). Multiple logistic regression equations identified independent, predictive variables during infancy, preschool and early school years, and adolescence. The probability of a good outcome was estimated in the presence of combinations of the six variables most strongly associated with that outcome. Results. Among G-2s, 79% had a successful outcome for education, 60% health, 70% lifestyle, and 76% for financial independence. Black G-2s had more favorable outcomes than white G-2s in education and lifestyle, whites for financial outcome; health did not differ by race. The six variables most predictive of adult education were: G-1 education at G-2 birth and G-2 attainment of honor roll, average or better reading skills at 8 years, avoidance of regular smoking, and pregnancy before age 18, and not repeating a grade in school. Conclusions. Substantial proportions of inner-city children become successful adults. Attention to improving public education, particularly language and reading skills, and the prevention of smoking and adolescent pregnancy are clearly indicated.

This study was undertaken to describe subspecialty characteristics and practices of the population of pediatricians given the ongoing controversy regarding a projected manpower oversupply of general pediatricians. A questionnaire was mailed to a national random sample of 1620 United States physicians listed in the American Medical Association's Pysician Masterfile as being in office-based pediatric practice. The final response rate was 63%. Seventy percent of respondents designated their practices as "general pediatrics" versus 17% as "general pediatrics with a specific subspecialty interest" and 13% as "subspecialty practice." The general pediatricians with a specific subspecialty interest were intermediate in the proportion that had some training in a pediatric fellowship program (general pediatricians with a specific subspecialty interest, 63% versus general pediatricians, 14%, P < .0001, and pediatricians with a subspecialty practice, 92%, P < .0001) and that were certified in a pediatric subspecialty by the American Board of Pediatrics (general pediatricians with a specific subspecialty interest 16% versus general pediatricians, 2%, P < .0001, and pediatricians with subspecialty practice, 62%, P < .0001). They were also intermediate in the proportion involved in various academic pursuits. Their practices, however, more closely resembled general pediatricians than pediatricians with a subspeciality practice in their location, setting, associates, and commitment to primary care. They were more likely than general pediatricians to utilize or provide specialized tests or procedures. A large percentage of pediatricians incorporate subspecilaty elements into their general pediatric practices. Models of current and projected pediatric manpower supply need to be reassessed in light of this form of practice.

The impact of record format on provider performance and recording of the process of care and their concordance were examined in this study. The process of care was defined by existing sets of explicit criteria developed for quality assessment. The study was conducted in an urban teaching hospital pediatric primary care clinic. Housestaff were encouraged, but not required, to use the clinic's structured, age-specific forms for recording well-child care. Performance and recording were compared during required well-child visits using the structured form and those using the basic clinic form. Study data from 1031 visits to 68 housestaff during a 14-month period were collected using medical record abstracting of all visits and direct observation of 243 of them. Twenty-three of the providers were assigned randomly to an unobserved control group to assess the effect of observation on recording. Use of the structured form was associated with significantly higher levels of both recorded and observed performance. When performance could be merely checked off to document performance, overdocumentation was found. Record-based estimates of performance were more accurate during visits when the structured form was used. Record format can improve provider performance and recording of the process of care.

McBurney et al1 report on an unusual approach to measuring continuity in a “continuity clinic,” in which residents follow assigned patients, primarily for well-child care. Their method assesses the proportion of all visits made by patients who are members of the residents’ panels. In primary care practice, in contrast, continuity would be the extent to which patients see their doctor for both well- and sick-child care, which is a very different measure. Primary …

To the Editor. The paper by Fowles and Anderson is a welcome addition to the literature on a subject of considerable practical importance in this managed care era. As the developers of one of the systems assessed (ambulatory care groups [ACGs]), we wish to clarify some points about that system. The authors characterize this system as …

Objective. To identify a characteristic pattern of health and illness for adolescents with asthma, we compared the health status of teenagers with asthma to those without asthma using a recently developed generic health status instrument, the Child Health and Illness Profile, Adolescent Edition (CHIP-AE). Methods. This was a cross-sectional survey using a school sample of 3109 teenagers. Participants completed the CHIP-AE during school in northern Baltimore City, rural western Maryland, and rural Arkansas. The health and functioning scores of teens without asthma (“well” group) were compared with those with asthma with and without recent wheezing. Results. Of the 12% who reported that a physician had ever told them they had asthma, 50% had problems with wheezing in the past 28 days. Compared with well teenagers, those with asthma and recent wheezing had lower perceived well-being, more physical and emotional symptoms, greater limitations in activity, more comorbidities, and more negative behaviors that threaten social development. These findings held true in multivariable regression models that controlled for sociodemographics and sites of data collection. Teenagers with asthma without recent wheezing reported a greater number of comorbidities than well teens and showed similar trends in health status as those with recently symptomatic asthma. Conclusions. Multiple aspects of adolescent health status are affected by asthma, particularly if it is recently symptomatic. These results argue for incorporating a generic health status instrument, such as the CHIP-AE, in studies that document the health needs or outcomes of medical care for populations of teenagers with asthma. asthma, quality of life, adolescence. * Abbreviations: CHIP-AE = : Child Health and Illness Profile, Adolescent Edition • CI = : confidence interval

In this longitudinal study in two prepaid group practices, many more children stayed at the same level of use of services over a six- to ten-year period than would be expected if use of services had distributed randomly. Overall, about 13% remained consistently in the highest third of the distribution of use, and another 13% remained consistently in the middle or lowest third. If use of services had distributed randomly, 4% and 7%, respectively, would have been in these groups. Conversely, many fewer children (25%) showed fluctuating patterns of use over time than would be expected by chance alone (37%). Although the reasons for this phenomenon are unknown (and may be multiple), the findings have implications both for clinical care and for development of policy regarding the organization and financing of health services for children.

Questionnaires were used to survey 1,435 parents and 446 physicians in order to determine and compare attitudes and beliefs about enuresis. Although both groups thought that bed-wetting is a maturational problem, the parent group thought emotional causes were important and were less likely to accept small bladder size as an etiology. Parents thought that children should be dry at a much younger age than did the physicians (2.75 vs 5.13 years, respectively). Only 63% of parents thought that medical intervention is a good way to deal with a child's bed-wetting, yet 87% of the physicians suggested medical evaluation. A comparison of the various methods used to stop bed-wetting indicated that parents use waking the child, reassurance and talking with the child, restricting fluids, and punishment significantly more often than physicians. Although many physicians prescribe medication, only 6.6% of the parents thought that medicines are a "very good way" to treat enuresis. When developing a treatment plan for a child with enuresis, the physician should recognize the wide differences between parental and physician attitudes toward this common problem of childhood.

Available evidence regarding the relationship between socioeconomic status and health in childhood has been summarized. Only studies that used income, education, or occupation as measures of socioeconomic status and provided data obtained subsequent to legislation facilitating access to care have been cited. Data are presented on the prevalence and severity of illness (mortality, acute conditions as a group, chronic conditions as a group, and hospitalization), sequelae of prematurity, and specific common health problems and their sequelae. These specific health problems are lead poisoning, vision problems, otitis media and hearing loss, cytomegalic inclusion disease, asthma, psychosocial and psychosomatic problems, and iron deficiency anemia. All of the above (with the possible exception of asthma) are more prevalent among poor children than among nonpoor children. Even more striking is the evidence for consistently greater severity of problems or likelihood of sequelae among poor children. Although causality cannot be inferred from these data, the findings suggest a need for more basic research on the social correlates of disease, on the effect of social progress on disease prevalence and severity, and on the effect of medical care in overcoming the disadvantage associated with low socioeconomic status.

Information in 51 tape-recorded physicianpatient encounters was compared with information written in the patients' medical records. Diagnoses, chief complaints, scheduled appointments, non-drug therapy, and diagnostic studies were uniformly well-recorded. Medication names were well-recorded but dosages were not. Characteristics of care such as levels of function, probable cause of illness, reason for follow-up, and compliance were recorded poorly. Patients were more likely to know about and understand their diagnosis, and names, dosage, and intended function of their medications when this information was written in the record than when it was not. These findings indicate a relationship between the quality of medical records and the effectiveness of care.

A mother's expectations about the development of her infant have been found to be a strong determinant of child development, but little is known about the factors that may affect maternal assessment of development. In this study, the relationship of the mother's opinion of the development of her infant with several sociodemographic, antenatal, intrapartum, and infant health variables was examined for a large sample of 1-year-old infants for whom gross motor observations were also obtained at the time of the interview. Among those observed to be developing at an appropriate rate, 4.0% were perceived by their mothers as developing more slowly than the mothers considered normal; among infants developing more slowly, 28.6% were considered to be developing slowly by their mothers. In both groups, the major determinants of maternal opinion of slow development concerned the infant's health: low birth weight, congenital anomalies regardless of severity, hospitalization during the first year of life, and high ambulatory care use. These results indicate that maternal perception of infant development may not reflect the infant's level, but past or present illness, and raise questions about the influence of infant health on maternal-infant interactions and the effect of such interactions on subsequent development in the child.

The reports of Valdez et al1 and Leibowitz et al2 mark the culmination of a landmark effort. Initiated over a decade ago, the Rand Health Insurance Experiment—the most ambitious and expensive randomized controlled trial ever conducted in health services research—was designed to produce estimates of the costs of various forms of national health insurance. Projected estimates of the costs of Medicaid and Medicare had been far too low and health policy experts hoped to obtain information that would prove closer to the mark in the (then) seemingly likely passage of some form of national health insurance. Although national health insurance has not materialized, the impact of medical care costs on utilization of services and health status is still of great interest. The amount of "cost-sharing" (medical costs paid by patients) has increased dramatically in public insurance programs, and many health policymakers favor increases in private insurance programs. The central question now, however, is how much of the cost burden can be borne by patients without inducing reductions in utilization that are harmful to health. The two papers1,2 in the May issue of Pediatrics reported on the impact of cost-sharing on children's utilization and health. The basic findings were similar to those for adults. In general, the higher the costs paid by families, the fewer the children receiving medical care and the fewer the services per user. The only exception was hospitalization of children aged 5 to 13, which was largely unaffected by cost-sharing; higher costs did appear to reduce hospitalization of younger children, as well as ambulatory care for children of all ages.

Self-help is in vogue. Stimulated at least partly by the purported inadequacies of our health care system, it promises better results if only people would take responsibility for their own destinies. The Lewises and their colleagues (p. 499), in their customary fashion, have added an innovative twist to the idea. Why not start the process in childhood? In their article they describe a demonstration project in which children enrolled in an elementary school could initiate their own care from a school nurse. The nurse was trained to involve the children in the decisions required to cope with their problems. If

Pediatricians provide care to a minority of US children. To some extent this may be a result of organizational features of their practice. This review of the literature suggests that the practice of pediatrics has some attributes of primary care but in other respects it resembles a subspecialty. Pediatricians serve well as a longitudinal source of care for children who identify them as their regular source. As a group, however, pediatricians are not as accessible and available as they might be, probably do not uniformly provide the comprehensive care that they should, and could serve more adequately as coordinators of care. Concern about the extent to which the training of pediatricians addresses the achievement of the attributes of primary care and stresses the recognition and management of primary care problems should stimulate academicians and practitioners to develop a combined and concerted approach to these problems.

In the course of a routine screening program for indigent school-age children carried out in an ambulatory hospital clinic, 40% of the mothers spontaneously recorded a concern about a child's health. Physicians were much more likely to record their awareness of the complaint if it related to a body system or function, as compared with complaints made about behavior and mental problems.

All 96 physicians in pediatric practice in the Baltimore area were invited to join in a study assessing the quality of health management. The 15 practitioners who participated helped to set the criteria which were modifications of the standards set by the American Academy of Pediatrics. Medical records of 5-year-olds were audited for recording of preventive procedures, throat cultures for suspected pharyngitis, and urine cultures for suspected urinary tract infection. Some procedures were uniformly well performed; the performance of others varied widely. None of the practices had high rates of recording for all procedures. Existing records proved inadequate to assess the sequence of performance of activities and the relationships between problems, diagnostic procedures, responses, and follow-up. Data from questionnaires sent to all 96 physicians indicated that the performance of the 15 participants was probably higher than that which would be obtained if all the practitioners in the area had participated. This study has implications for the way in which peer review activities are organized and carried out.

The effectiveness of patient care was assessed by determining the adequacy of various steps in the care process and relating them to its outcome. Fifty-three children attending either of two university hospital clinics and having newly discovered low hemoglobins were randomly chosen. Review of medical records and home interviews showed that only 14 of the 53 low hemoglobin values were recognized, diagnosed, treated, and followed-up. In 39 children, the low hemoglobin value was unrecognized in 24, recognized but undiagnosed in six, diagnosed but untreated in one, and treated but not scheduled for follow-up in four; for four children the follow-up appointment was not kept. Mothers of 7 of the 22 children for whom treatment was prescribed denied receiving any therapy. Outcome in terms of eventual hemoglobin level was significantly related to the adequacy of the processes of care and especially to whether or not the patient received therapy. Major problems with record keeping also were apparent. The model used here is useful in evaluating the effectiveness of medical care because it relates specific activities of physicians, other health workers, and patients to outcome.

Enuresis is the most common chronic condition seen in general pediatric practice. Current medical literature contains more articles about entiresis than about infantile diarrhea or child abuse, and approximately the same number as are written about childhood malnutrition or infant nutrition. Enuresis is encountered in all societies. When I visited the Peoples' Republic of China, I encountered in every outpatient clinic at least one child, supine and sporting an acupuncture needle 7.6 cm(3 in) below the umbilicus. Physicians with whom I spoke said the rate of cure was "about 40% with most others improved," which is similar to the cure rate in the United States.

Drs. Mindlin and Lobach have raised interesting points in their letter. In our paper we described respondents' perceptions, corroborated by some independently obtained data about the ease of consulting the physician identified as the one from whom care is said to be usually sought. It was our aim to show how these perceptions of regular source of care vary with type of physician. The study dealt with children of all ages and socio-economic class in an entire metropolitan area.