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OBJECTIVES. Our goals were to assess (I) compliance with nurse disposition recommendations, (2) frequency of death or potential underreferral associated with hospitalization within 24 hours after a call, and (3) factors associated with potential underreferral, for children receiving care within an integrated health care delivery organization who were triaged by a pediatric after-hours call center. METHODS. The study population included all pediatric patients enrolled in Kaiser Permanente Colorado whose families called the Children's Hospital after-hours call center in Denver, Colorado, during the period between October 1, 1999, and March 31, 2003. Postcall disposition recommendations were categorized as urgent (visit within 4 hours), next day (visit in >4 hours but within 24 hours), later visit (visit in >24 hours), or home care (care at home without a visit). Compliance with the nurses' triage disposition recommendations was calculated as the proportion of cases for which utilization data matched the disposition recommendations. RESULTS. Of the 32 968 eligible calls during the study period, 21% received urgent, 27% next day, 4% later visit, and 48% home care disposition recommendations. Rates of compliance with both urgent and home care disposition recommendations were 74%, and the rate of compliance with next day recommendations was 44%. No deaths occurred within 12 years and being triaged after 11 PM were associated with higher rates of potential underreferral. CONCLUSIONS. Approximately three fourths of families complied with recommendations for their child to be evaluated urgently or to be treated at home, with much lower rates of compliance with intermediate dispositions. The rate of potential underreferral with hospitalization was low, and age and time of call triage were associated with this outcome. Key Words telephone medicine, telephone triage, call center, health care delivery Abbreviations KPCO--Kaiser Permanente Colorado CI--confidence interval, IN THE PAST decade, the delivery of health care after office hours has undergone profound changes. Many primary care providers have stopped taking after-hours calls themselves, instead signing out to [...]

The role of stories in clinical practices with reference to its use in research, health policy, and difference between unique and representative stories is presented. In clinical practice, stories help clinicians appreciate the voice of the individual patient and tailor recommendations to his or her needs and preferences.

Background. There currently are few published data evaluating the effect of State Children's Health Insurance Programs on health care outcome measures in children. Colorado's Child Health Plan Plus (CHP+) is a non-Medicaid State Children's Health Insurance Program that began enrollment in April 1998. The objectives of this study were to compare reported (1) access to care, (2) utilization of health care, and (3) quality of care during the year before and the first year after enrollment into CHP+. Methods. We interviewed 480 randomly selected families by telephone 2 months after their first enrollment into CHP+ (September 1999 to January 2000) and, again, 1 year later. We used generalized linear models to examine the effect of enrollment on health care access, utilization, and quality while controlling for type of previous insurance, length of time uninsured before enrollment, race/ethnicity, and age. Results. Regarding access to care, the percentage of families who reported a usual site of preventive care did not change significantly, but families reported more often being able to see providers as soon as desired for routine care (incidence ratio [IR]: 2.03; 95% confidence interval [CI]: 1.37-3.02]), for care when sick or injured (IR: 2.77; 95% Ch 1.85-4.16), for specialty care (IR: 1.96; 95% Ch 1.16-3.32), and for all health care (IR: 2.35; 95% CI: 1.81-3.07). Unmet medical needs decreased after versus before enrollment for prescription medications (IR: 0.38; 95% CI: 0.26-0.55), mental health care (IR: 0.63; 95% CI: 0.40-0.97), prescription glasses (IR: 0.44; 95% CI: 0.29-0.65), and dental care (IR: 0.59; 95% CI: 0.47-0.76). Regarding utilization, the proportion who saw a provider for routine care in the past year increased (IR: 1.39; 95% Ch 1.06-1.83), but reported visits for sick, specialty, and emergency department care and hospitalizations did not increase. Regarding quality of care, the proportion who rated their health care as "best" increased (RI: 1.31; 95% Ch 1.04-1.66) after versus before enrollment. Conclusions. Families who were newly enrolled into CHP+ perceived dramatic increases in access to all types of care and decreases in unmet medical needs, no increase in utilization of emergency department or hospitalization services, and improved overall quality of care in the year after enrollment into CHP+. SCHIP, access to health care, health insurance, quality of health care., ABBREVIATIONS. SCHIP, State Children's Health Insurance Program; CHP+, Child Health Plan Plus; FPL, federal poverty level. In response to the growing problem of uninsured children, the Balanced Budget Act of [...]

Objectives. We assessed the distribution of immunization records among 3 health care delivery sectors and the impact of a regional immunization registry on 'up to date' rates. Methods. Immunization registry records in 2 regions were categorized as having originated in private practices, community health centers, or public health clinics. 'Up to date' rates were calculated after we sequentially added immunization records from the 3 sectors. Results. The percentage of children with immunizations documented in multiple sectors increased with age from 7 to 24 months, and children who were seen in multiple sectors were more likely to be up to date. There were relative increases in 'up to date' rates of 50% for children aged 24 months. Conclusions. The regional immunization registry is a powerful public health tool for increasing documented 'up to date' rates and providing insights into patterns of immunization delivery.

Objective. The Colorado Child Health Plan Plus is a non-Medicaid state Child Health Insurance Plan. The objective of this study was to compare early enrolling (EE) children with uninsured children in low-income families (ULI) with respect to 1) sociodemographic factors and previous insurance, 2) health status, and 3) previous health care access and utilization. Methods. Cross-sectional telephone surveys were conducted during 1999 of 1) randomly selected EE children (n = 711) and 2) ULI children identified by randomdial survey (n = 105). Results. Enrolling children were less likely to be Hispanic (32.7% vs 55.2%); 5.5% of EE versus 27.6% of ULI children had never been insured. Prevalence of chronic conditions was similar (16.2% of EE vs 13.5% of ULI children), but learning/behavioral difficulties (9.7% of EE vs 18.6% of ULI) and fair/poor health (5.4% of EE vs 17.2% of ULI) were higher for uninsured children. In the previous year, 88.2% of EE versus 66.1% of ULI children had a usual source of care. The mean number of preventive visits was similar (1.4 vs 1.2), but the EE group reported a higher mean number of sick visits (2.0 vs 1.1), emergency visits (0.48 vs 0.15), and hospitalizations (0.09 vs 0.02). Conclusions. In the first 2 years of the program, Child Health Plan Plus is not yet reaching the "hard-to-reach" but, rather, disproportionately high numbers of non-Hispanic children who already have a usual source of care and recent insurance. EE children did not have higher rates of chronic conditions but did demonstrate higher utilization before enrollment, possibly reflecting patterns of enrollment into the program. Pediatrics 2003;111: 735-740; health insurance, state child health insurance plan, health care access., ABBREVIATIONS. CHIP, Children's Health Insurance Program; CHP+, Child Health Plan Plus; EE, early enrolling; ULI, uninsured low-income; BRFSS, Behavioral Risk Factor Surveillance System. The state Children's Health Insurance Program (CHIP) [...]

Objectives. Unintentional injuries are a major cause of childhood mortality and morbidity in the United States. However, there is little epidemiologic information about pediatric injuries seen in primary care settings. The objective of this study was to characterize types and external causes of childhood injuries seen by primary care physicians and to compare the demographic and visit characteristics of children with injury-related visits (IRVs) and non-IRVs. Methods. A stratified random sample survey of office-based practicing physicians in the National Ambulatory Medical Care Survey (1997 and 1998) was conducted. Injury-related primary care office visits were measured for patients who were Results. Visits for childhood injuries composed >10 million primary care office visits per year (a rate of 13.8 visits per 100 person-years). The most common diagnoses assigned to these injuries were open wounds, sprains and strains, contusions, and superficial injuries such as abrasions and splinters. Leading external causes of these injuries were sports and overexertion, accidental falls, natural factors such as bites and stings, and cutting instruments. The single most common cause of pediatric injuries was sports/overexertion. Children who had IRVs were more likely to be older (odds ratio [OR]: 1.10/year of age; 95% confidence interval [CI]: 1.08-1.12), to be male (OR: 1.5; 95% CI: 1.2-1.9), and to reside in the West (OR: 1.9; 95% CI: 1.4-2.6) or in a rural area (OR: 1.4; 95% CI: 1.1-1.9). They were less likely to be Asian (OR: 0.2; 95% CI: 0.1-0.5) or Hispanic (OR: 0.5; 95% CI: 0.3-0.8). At the visit, children with IRVs were more likely to see a physician who was not their primary care physician (OR: 1.8; 95% CI: 1.4-2.3) and to see a family physician rather than a pediatrician (OR: 2.3; 95% CI: 1.8-2.9). Conclusions. IRVs account for a significant portion of primary care for children in the United States. Identifying potentially preventable external causes of injury and characteristics of children who are more likely to be injured is important both for injury prevention programs and for the education of physicians who care for children. Pediatrics 2002;109:559-565; pediatric injury, primary care, sports injuries, NAMCS. ABBREVIATIONS. ED, emergency department; IRV, injury-related visit; NAMCS, National Ambulatory Medical Care Survey; PCP, primary care physician; NCHS, National Center for Health Statistics; PRF, patient record form; PSU, primary sampling unit; RSE, relative standard error; SE, standard error; CI, confidence interval; OR, odds ratio., Since the 1940s, unintentional injuries have caused more deaths per capita in children aged 1 to 19 years than all infectious diseases and now account for 44% of all childhood [...]

INTRODUCTION Several cost and reimbursement considerations affect physicians' provision of childhood vaccinations, including patients' ability to pay for vaccinations, vaccine cost, and revenue generated by vaccinations, including insurance reimbursement (1-7) […]