Why Are General Pediatricians Failing?

• National Study of 1536 children in the US*• 12 metropolitan areas (including Indy)• 142 quality indicators• Children received 46.5% of indicated care

– 40.7% of preventive care– 37.8% of screening– 34.5% of adolescent preventive care

* Mangione-Smith, et al, NEJM 2007; 357:1515-23

Variable Guideline Adherence 4 practices, 210 children aged 1 yr

Newborn Screening 56-80%

Hearing Risk Assessed 0-5%

Anemia Screening 76-98%

TB Screening 2-63%

Lead Screening 23-94%

Assess Tobacco Smoke Exposure

6-38%

Car Seat Counseling 4-76%

Smoke Detector Counseling 0-27%

Hot Water Heater Counseling 8-37%

Too Many Guidelines!

Pediatricians Are Overwhelmed With Preventive Care Guidelines

• Multiple guidelines from authoritative sources– AAP– CDC– USPSTF– HRSA– ACMG– Medicaid– HMO

• Average preventive care visit: 18.3 minutes • Pediatricians: No time for developmental

assessments and psychosocial issues

AAP Periodicity Schedule

0.50

2.00

5.50 12.00

21.00 minutes

1.00

USPSTF

• Evaluation of 230 charts in family practice– 25 services due at each patient visit (Medder)

• Physician time required for services – family practice– 7.4 hours per day (Yarnall)

• Extrapolating to only pediatric services– 16 hour per day!!

Bright Futures:Guidelines for Health Supervision of Infants, Children, and

Adolescents

338 Pages450 Pages

Bright Futures:Set

• Guidelines for Health Supervision of Infants, Children, and Adolescents

• Mental Health Volumes 1 and 2• Physical Activity• Bright Futures, Nutrition, and Oral Health Pocket Guides

Computer Decision Support Systems (CDSS) Can Help

• Critical review of 100 clinical trials of CDSS compared to usual care controls*

• Practitioner performance: 62/97 (64%) improved care

• Preventive care: 16/21 (76%) improved care• Disease mgmt: 23/40 (62%) improved care

* Garg, et al. JAMA, 2005; 293:1223-38

• So if decision support systems improve rates of services….

• What services should systems support?

Infant/NewbornGonococcal Ophthalmia Neonatorum prophylaxis

Newborn screening (select tests)Child

Visual Impairment in Children Ages 0-5: Screening

Blood pressure

Fluoride prescription

AdolescentCervical cancer screening

Chlamydial Infection screening Gonorrhea screening - (if risk)

Human Immunodeficiency Virus (HIV) Infection screening - (if high risk)Sexually Transmitted Infections - (if sexually active)

Depression in Adolescents

Hyperbilirubinemia in Infants: Routine Screening Hip, Developmental Dysplasia: Screening

Developmental screening

Counseling to prevent skin cancerCholesterol screening

Depression in ChildrenMotor Vehicle Occupant RestraintsDental Caries in Preschool Children risk assessment

Exercise (Physical Activity): Counseling Healthy Diet (Nutrition): Counseling Family ViolenceIron Deficiency Anemia (Anemia): Screening

Lead Levels in Childhood (high risk) Overweight in Children and Adolescents: Screening

Alcohol Misuse (Drinking, Risky/Hazardous)

Illicit Drug UseSmoking (Tobacco Use) counselingSuicide Risk: Screening

Lead Levels in Childhood (everyone)

Testicular cancer screening

Herpes Simplex, Genital screening

Idiopathic Scoliosis in Adolescents (Scoliosis): Screening

No Data Don’t Do

US Preventive Services Task ForceServices evaluated for children

AAP Statements

• Policy Statement– Organizational principles to guide and define the child

health care system and/or improve the health of all children.

• Clinical Reports– Guidance for the clinician in rendering pediatric care.

• Clinical Practice Guidelines– Evidence-based decision-making tools for managing

common pediatric conditions.

414

99

14

37:1

Downs’s Decision Rule

if decision support systems get services provided

and there are more recommended services than can be done in a visit

then the system must prioritize which services it recommends

Prevalence x Severity x Effectiveness

x Evidence

= Priority

Thank You