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UPDATES

Violence: The AAP takes a stand

Are pediatricians ready to accept a central role in violence prevention?After two years of study, theAmerican Academy of Pediatrics' Task Forceon Violence thinks the answer has to be Yes. In a statement published inthe January issue of Pediatrics, the Task Force delineates that role interms of clinical practice, public advocacy, medical education, and research.The AAP statement marks the first time that a medical specialty has fullyembraced the idea that violence is a health issue physicians are obligatedto confront, rather than the exclusive province of the criminal justicesystem.

Clinical interventions for violence prevention are divided into fourcategories: nurturing, limit-setting, safety screening, and treatment andreferral. Specific interventions in each category are tailored to the child'sage. In infancy, for example, nurturing interventions include assessingparental bonding and attachment, while by adolescence they are directedat helping families find safe ways to foster teenagers' independence. Inthe area of limit-setting, anticipatory guidance emphasizes positive reinforcementand the avoidance of corporal punishment at all age levels, with a focuson developing family rules and agreed-upon consequences for older childrenand teens. Safety and screening involves assessing for domestic violence,exposure to media and community violence, guns in the home, risks for victimization,and substance abuse. Referral and treatment interventions include parentingprograms, treatment for mental illness, and case management for high-riskyouth.

But clinical interventions are not sufficient, the Task Force concludes.Pediatricians must also advocate for a wide range of public policies thatcan reduce the violence toll, from the provision of affordable, high-qualitychild care to discouraging corporal punishment in homes and schools andreducing or eliminating the availability of handguns. Medical school andresidency training programs must include education in prevention and managementof youth violence, and research protocols must focus on finding out whatprevention and treatment strategies are the most effective. For the manypediatricians who have long been committed to these goals, the Task Forcestatement offers reassurance that they're on the right track. For thosewho haven't thought along these lines before, it may serve as a call toaction.

Organized sports: Good or bad for children?

According to an ad hoc committee set up by the International Federationof Sports Medicine and the World Health Organization, participating in organizedsports leagues can pose some real risks to children's physical and psychologicalhealth. While structured sports teams offer children opportunities for healthfulexercise and socialization, they are also sometimes associated with repetitivestress injuries, catastrophic injury, eating disorders, osteoporosis, highstress levels, and what the committee calls "pathologic socialization."To guard against these potential harms, the committee recommends:

• Special training for coaches in children's physical and psychological development
• Regular monitoring of participants' health and safety by pediatricians and other health professionals
• Attention to participants' nutritional status and the amount and intensity of their training regimens
• Avoidance of sports specialization before 10 years of age.

Pediatricians who want more information can consult theYearbook of YouthSports Safety, published by the National Youth Sports Safety Foundation.The American Academy of Pediatrics is one of the contributors.
To obtain a copy, write to the Foundation at Department YB, 333 LongwoodAve., Suite 202, Boston, MA 02115-5711.

Flying solo

Contrary to most predictions, solo practice is alive and well in today'smedical scene. According to the 1998 Medical Economics Continuing Survey,about half the MDs and DOs in office-based private practice work alone.While solo practice is most typical of general practitioners and generalsurgeons, a sizeable number of pediatricians also practice alone (see table,above.) The median net income for solo practitioners stands at $140,260,up 13.7% since 1993 but still well below that of colleagues who work togetherin small and large groups. The most lucrative practice arrangement, accordingto the survey, is a group of four to nine physicians; 1997 median net incomefor physicians in this category was $214,200. Doctors who practice alonetend to be located in the inner city or in rural areas, older than theircolleagues, in practice longer, and female (56.2%, compared to 49.2% ofmales).

What's happening to managed care?

The nation's health-care system, if such it can be called, seems to bein an endless state of flux. In one form or another, managed care is probablyhere to stay--but the parameters are subject to frequent readjustment. Somerecent items:

• Consolidation threatens to create regional monopolies in the health insurance industry, the New York Times reports. The big six firms--Aetna, Cigna Health Care, Unitedhealth Group, Foundation Health Systems, Pacificare, and Wellpoint Health Networks--dominate markets in the New Jersey, Philadelphia, Dallas, Atlanta, and New York areas. In New Jersey, where the recent merger of Prudential and Aetna gives the new company control of a third of the health insurance market, the Medical Society has called on state and federal antitrust authorities to intervene.
• Incentives for practicing good medicine can be incorporated into managed care organizations. Physicians who participate in HealthPartners, a Minneapolis-based HMO, now receive financial rewards for reaching specific health outcomes in their practices. Agreed-on outcome measures include a 95% pediatric immunization rate and an 80% rate of advising smokers to quit.
• Health plans that offer physicians inducements to limit medically necessary services can be punished. The Texas Department of Insurance has fined Dallas-based Harris Methodist Texas Health Plan $100,000 for breaking a state law barring the practice. In addition, Harris has agreed to pay back physicians who had been penalized for contributing to the HMO's pharmacy deficit or lost bonuses for failing to meet the plan's economic performance requirements.
• Physicians facing competition from hospital-based plans and for-profit chains can find ways to maintain their independence, says Health System Change, a research organization funded by the Robert Wood Johnson Foundation. In Syracuse, NY, physicians are moving away from hospital-focused relationships and joining together in independent practitioner associations (IPAs). In Cleveland, locally based health-care organizations have expanded their specialty services and revived institutions once considered vulnerable. The downside of this expansion in Cleveland has been the development of considerable excess medical capacity. To access additional community reports from Health System Change, visit the organization's website at www.hschange.com.

Just the facts

If you've ever wondered how your prescribing habits stack up againstthose of your colleagues, the 1998 Contemporary Pediatrics Fact Book cananswer your questions. Here are some highlights:

• Antibiotics are the most frequently prescribed medications, as you might have supposed. In 1997, the big three were Trimox (9,251,000 prescriptions filled), amoxicillin (4,931,000), and Augmentin (4,807,000).
• Asthma medications come next, led by albuterol liquid (3,359,000 prescriptions filled).
• Stimulant medications used to treat ADHD are in third place, with 2,816,000 prescriptions for methylphenidate and another 1,118,000 for Ritalin.
• When it comes to OTC products, the recommendations your colleagues make most often are for:
• Non-aspirin analgesics, specifically acetaminophen (an average of 37.8 recommendations per week) and ibuprofen (26.8 recommendations per week)
• Nutritional products including baby food (20.7 recommendations per week), baby cereal (19.8), and infant formula (33)
• Remedies for coughs (19 recommendations per week) and colds (20.3)
• Sunscreens and blockers (15.8 per week)
• Diaper rash ointments (13.5 per week)
• Allergy relief products (13 per week)
• Vitamins for infants (11.4 per week) and toddlers (12 per week).

Resources for parents

Families with seriously ill or disabled children need all the informationthey can get, and they often turn to their pediatrician for guidance onresources they can consult. One possible source is the series of patient-centeredguides published by O'Reilly and Associates. These paperbacks provide amix of medical information, practical advice on day-to-day problems, andemotional support via first-hand accounts of families in similar situations.A book called Pervasive Developmental Disorders; Finding a Diagnosis andGetting Help, for example, describes how the diagnosis is made, outlinestreatment options, offers practical advice on what insurance will pay forand what school systems provide, and includes a wide range of family stories.Other titles of pediatric interest include Childhood Cancer, Your Childin the Hospital, Hydrocephalus, and Childhood Leukemia. To order a catalog,call 800-998-9938 or send an E-mail to patientguides@oreilly.com.

Calendar:

March 5­7, Primary Medicine Today (Pri-Med) South, Fort Lauderdale,FL, and April 9­11, Primary Medicine Today (Pri-Med West), LongBeach,CA. For more information, visit the Pri-Med website at www.pri-med.com.To register, call 847-4PRIMED.

March 17­21, Society for Adolescent Medicine Annual Meeting, LosAngeles, CA. Contact program coordinator, 816-224-8010.

April 1,Adolescent medicine certification examination registration deadline.For more information, call the American Board of Internal Medicine at 800-441-2246or E-mailrequest@abim.org.

­Judith Asch-Goodkin

EYE ON WASHINGTON:

On January 19, with his impeachment trial in full swing in the Senate,President Clinton delivered a State of the Union address packed with programsthat--if Congress goes for them--would have a major impact on the healthand well-being of children and families. His proposals include:

• A federal civil suit to recover damages from the tobacco industry for the costs to Medicare of smoking-related illnesses
• Authority for the FDA to regulate the tobacco industry
• Tax credits for stay-at-home parents
• An extension of the Family Leave Act to include smaller employers
• A patients' bill of rights
• Tax credits for families caring for disabled and chronically ill children
• A Children Exposed to Violence initiative that would fund training for police and court personnel who deal with crimes against children and expand the definition of murder to include death resulting from a pattern of abuse
• Requirements that school districts receiving federal funds improve or shut down their worst-performing schools, impose higher standards on teachers, issue report cards on school performance, and implement sensible discipline policies.

In other federal actions last month:

The Department of Health and Human Services approvedSCHIPplans from Vermont, Alaska, and New Mexico. That brings the total numberof state and territorial plans approved thus far to 49, with plans fromTennessee, Hawaii, and Guam currently under review.

The Food and Drug Administration announced it may requirepediatric studies for certain already marketed drugs, unless manufacturersvoluntarily provide the information. The FDA will seek the advice of anexpert panel to develop a prioritized list of marketed drugs and biologicsfor which such studies would be required.

The Centers for Disease Control and Prevention has tracedan outbreak of listeriosis to certain lots of hot dogs and packaged meatfrom the Bil Mar Foods plant, a division of
Sara Lee. The implicated products have been recalled.

The Agency for Health Care Policy and Research is callingfor grant applications for projects that advance their research priorities,including studies on improving the quality of children's health care. Formore information about the AHCPR grants program, visit the agency's websiteat www.ahcpr.gov, or call 301-594-1398.

The US Court of Appeals for the Eighth Circuit is consideringa case that will determine whether health-care institutions run primarilyby Christian Scientists should be reimbursed with Medicare and Medicaidfunds. The AAP believes such reimbursement encourages the denial of appropriatemedical care to children and has filed a friend-of-the-court brief in thecase.The American Nurses Association and the Iowa Medical Society joinedthe AAP in filing the brief.

UPDATES.

Contemporary Pediatrics

1999;0:013.