This report builds on a highly valued predecessor, the 1994 Institute of Medicine (IOM) report entitled Reducing Risks for Mental Disorders: Frontiers for Preventive Intervention Research. That report provided the basis for understanding prevention science, elucidating its then-existing research base, and contemplating where it should go in the future. This report documents that an increasing number of mental, emotional, and behavioral problems in young people are in fact preventable. The proverbial ounce of prevention will indeed be worth a pound of cure: effectively applying the evidence-based prevention interventions at hand could potentially save billions of dollars in associated costs by avoiding or tempering these disorders in many individuals. Furthermore, devoting significantly greater resources to research on even more effective prevention and promotion efforts, and then reliably implementing the findings of such research, could substantially diminish the human and economic toll.

Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities

Advances in medical, biomedical and health services research have reduced the level of uncertainty in clinical practice. Clinical practice guidelines (CPGs) complement this progress by establishing standards of care backed by strong scientific evidence. CPGs are statements that include recommendations intended to optimize patient care. These statements are informed by a systematic review of evidence and an assessment of the benefits and costs of alternative care options. Clinical Practice Guidelines We Can Trust examines the current state of clinical practice guidelines and how they can be improved to enhance healthcare quality and patient outcomes. Clinical practice guidelines now are ubiquitous in our healthcare system. The Guidelines International Network (GIN) database currently lists more than 3,700 guidelines from 39 countries. Developing guidelines presents a number of challenges including lack of transparent methodological practices, difficulty reconciling conflicting guidelines, and conflicts of interest. Clinical Practice Guidelines We Can Trust explores questions surrounding the quality of CPG development processes and the establishment of standards. It proposes eight standards for developing trustworthy clinical practice guidelines emphasizing transparency; management of conflict of interest; systematic review--guideline development intersection; establishing evidence foundations for and rating strength of guideline recommendations; articulation of recommendations; external review; and updating. Clinical Practice Guidelines We Can Trust shows how clinical practice guidelines can enhance clinician and patient decision-making by translating complex scientific research findings into recommendations for clinical practice that are relevant to the individual patient encounter, instead of implementing a one size fits all approach to patient care. This book contains information directly related to the work of the Agency for Healthcare Research and Quality (AHRQ), as well as various Congressional staff and policymakers. It is a vital resource for medical specialty societies, disease advocacy groups, health professionals, private and international organizations that develop or use clinical practice guidelines, consumers, clinicians, and payers.

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Clinical Practice Guidelines We Can Trust

Patients with chronic illness often receive care from multiple providers in multiple settings and require coordination of their complex care. This report assesses the quality of the coordination of care, describes barriers to coordinated care, and discusses some solutions to improve care coordination in the United States.

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Coordinating Care — A Perilous Journey through the Health Care System

Objective To examine the reliability and validity of the 42-item Brief Infant-Toddler Social and Emotional Assessment (BITSEA), a screener for social-emotional/behavioral problems and delays in competence. Method Parents in a representative healthy birth cohort of 1,237 infants aged 12 to 36 months completed the Infant-Toddler Social and Emotional Assessment (ITSEA)/BITSEA, the Child Behavior Checklist (CBCL)/1.5-5, the MacArthur Communication Developmental Inventory vocabulary checklist, and worry questions. In a subsample, independent evaluators rated infant-toddler behavior. Results Test-retest reliability was excellent and interrater agreement (mother/father and parent/child-care provider) was good. Supporting validity, BITSEA problems correlated with concurrent evaluator problem ratings and CBCL/1.5-5 scores and also predicted CBCL/1.5-5 and ITSEA problem scores one year later. BITSEA measures of competence correlated with concurrent observed competence and predicted later ITSEA competence measures. Supporting discriminant validity, only 23% of high BITSEA problem scorers had delayed vocabulary. Moreover, the combined BITSEA problem/ competence cutpoints identified 85% of subclinical/clinical CBCL/1.5-5 scores, while maintaining acceptable specificity (75%). Conclusions Findings support the BITSEA as a screener for social-emotional/behavioral problems and delays in social-emotional competence.

The Brief Infant-Toddler Social and Emotional Assessment: Screening for Social-Emotional Problems and Delays in Competence

Inevitably, reading is one of the requirements to be undergone. To improve the performance and quality, someone needs to have something new every day. It will suggest you to have more inspirations, then. However, the needs of inspirations will make you searching for some sources. Even from the other people experience, internet, and many books. Books and internet are the recommended media to help you improving your quality and performance.

Primary Care: America's Health in a New Era

communicated with the specialist compared with those for which neither activity occurred. Referring physicians’ satisfaction ratings were significantly increased by any type of specialist feedback and were highest for referrals involving specialist feedback by both telephone and letter. Elements of specialists’ letters that significantly increased physician ratings of letter quality included presence of patient history, suggestions for future care, follow-up arrangements, and plans for comanaging care; only the inclusion of plans for comanaging patient care was significantly related to the referring physicians’ overall satisfaction. Conclusions: Better coordination between referring physicians and specialists increases physician satisfaction with specialty care and enhances referral completion. Improvements in the referral process may be achieved through better communication and collaboration between primary care physicians and specialists. Arch Pediatr Adolesc Med. 2000;154:499-506

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Coordination of specialty referrals and physician satisfaction with referral care.

Objective: To describe how pediatricians refer patients to specialists, including frequency of referral decisions, reasons for referral, and types of referrals. Design: We conducted a prospective study of visits (N = 58 771) made to 142 pediatricians in a national primary care practice‐based research network. During 20 consecutive practice days, physicians and parents completed questionnaires for referred patients, and office staff kept logs of all visits. Physicians used medical records to complete questionnaires 3 months after referrals were made. Results: Pediatricians referred patients to specialists during 2.3% of office visits. Referrals made during telephone conversations with parents accounted for 27.5% of all referrals. The most common reason for referral was advice on diagnosis or treatment (74.3%). Referrals were made most commonly to surgical subspecialists (52.3%), followed by medical subspecialists (27.9%), nonphysicians (11.4%), and mental health practitioners (8.4%). Physicians requested a consultation or a referral with shared management in 75% of cases. Otitis media was the condition referred most often (9.2%). Fifty other conditions accounted for 84.3% of all referrals. Conclusions: About 1 in 40 pediatric visits result in referral. Getting advice from a specialist is the most common reason for referral. Pediatricians desire a collaborative relationship with specialists for most of their referred patients. Physician training to increase clinical competence may be most useful for the 50 most commonly referred conditions. Education concerning the referral process should focus on the respective roles of the referring physician and specialist, particularly as they pertain to successful approaches for comanaging referred patients. Arch Pediatr Adolesc Med. 1999;153:705-714

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The Pediatric Primary-Specialty Care Interface How Pediatricians Refer Children and Adolescents to Specialty Care

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.

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Gatekeeping and Referral of Children and Adolescents to Specialty Care

OBJECTIVE.Effective delivery of preventive services is an essential component of high-quality pediatric health care. However, both variation in and deviation from accepted guidelines have been reported. Learning collaboratives (LCs) have been shown to result in improvement in several aspects of pediatric care. The objective of this study was to determine whether pediatric practices that participated in a preventive services LC would improve their delivery of preventive services. METHODS.After conducting an initial audit of the medical records of twenty 2-yearolds and twenty 4-year-olds for documentation of preventive services on the basis of national standards, practice teams attended a quality improvement workshop. They were presented with evidence to support the value of preventive services and the results of their audits and taught quality improvement methods, eg, rapid cycles of change. Each team developed plans to improve 1 or more services. Brief audits with feedback and monthly conference calls were used to support practices to conduct rapid cycles of change, to discuss barriers and solutions, and to monitor progress. The results of final chart audits of twenty 2-year-olds and 4-year-olds were compared with the initial chart audits. A Preventive Service Score (PSS) was assigned to each practice on the basis of the number of services provided, and initial to final comparisons were made. RESULTS.Fourteen practices participated. PSSs improved for all practices after the LC. Mean PSS for 2-year-olds increased from 4.0 1.1 to 4.9 1.2 and for 4-year-olds increased from 3.8 1.8 to 5.6 1.9. The proportions of children who received 9 of the 10 individual preventive services also improved significantly. CONCLUSION.LCs are a potentially effective method of improving the quality of care that is delivered by pediatric practices.

Evaluation of a learning collaborative to improve the delivery of preventive services by pediatric practices.

Cimetidine, a potent H2receptor antagonist, recently introduced for the treatment of peptic ulcer and other related disorders, has gained widespread use. Most of the current knowledge of its use and effects is based on adult clinical trials. There is a lack of data on its effects in children and infants and virtually none on the human fetus. Animal studies using radioactive labeled cimetidine at doses of 100 mg/kg indicate that this drug crosses the placental barrier and has thus the potential of producing a systemic effect in utero. Elevated transaminase levels have been reported in adults,1.2and cholestatic jaundice has been observed in children.3This report concerns the finding of liver impairment in an infant born to a mother receiving cimetidine in the last trimester of her pregnancy. Report of a Case.—This male patient was born to a 39-year-old, gravida 4, para 2, still-birth 1 whose

Gordon B. Glade

Papers

Coordination of specialty referrals and physician satisfaction with referral care.

The Pediatric Primary-Specialty Care Interface How Pediatricians Refer Children and Adolescents to Specialty Care

Gatekeeping and Referral of Children and Adolescents to Specialty Care

Evaluation of a learning collaborative to improve the delivery of preventive services by pediatric practices.

Cimetidine in pregnancy: apparent transient liver impairment in the newborn.