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|Wednesday, April 20, 2011
|The Benefits of a Medical Home
|by Pediatric Perspectives at 09:35 AM
William L. Bush, Pediatrician
Grand Rapids, Michigan
A study published in the online edition of Pediatrics in March found that just half of all children in the United States had access to all components of a medical home. More bad news? Access was highly dependent on race, ethnicity, socioeconomic status, and health.
I personally find such news disturbing and, yes, sad. That's because I can speak firsthand to the benefits of a medical home for both the physician and patients. Our 10-physician practice became a certified medical home two years ago. Since then, we've realized higher reimbursement rates from insurance companies, including Medicaid (about 10 percent across the board), as well as the ability to practice better medicine by providing more preventive-based, comprehensive care.
First, a reminder about what a medical home is. The American Academy of Pediatrics defines a medical home as a model of primary care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective. While it has traditionally been recommended for children with special health needs, it should be the norm for all children.
Why? Improved quality of care. As this study found, children in medical homes are less likely to have unmet medical and dental needs and more likely to have annual preventive medical visits, regardless of preexisting medical conditions. Specifically, the researchers reported, 6.4% of children who were not in medical homes had an unmet medical need compared to just 1.6% of those in a medical home.
It took us only about two weeks to complete the paperwork required by the state's Blue Cross/Blue Shield products and another commercial insurance company. Your mileage may vary depending on your own state/insurance requirements. These days, I think the most important component to becoming a medical home is an electronic medical record system (EMR). With federal money available now for instituting such systems, it's worth exploring if you've been putting it off.
We already had an EMR, but we had to tweak it to meet some of the medical home requirements, such as pharmacy tracking and reminders. Now, however, we can see if the prescriptions we give a parent for their child's asthma gets filled, or easily track refills on medication for attention deficit hyperactivity disorder. On the non-technical side, we now hold monthly asthma group meetings for our asthma patients; meet as a group once a month to review the plethora of reports we obtain from our EMR; and insure that we are following national guidelines in the care we provide.
Overall, we find that less data falls through the cracks since we became a medical home. An unexpected benefit for me is that I never realized how many families took a prescription or lab slip and never filled it. Now we know if they fill it or not and can follow up with a phone call. In the past, we would have just kept moving with the next 100 patients and never looked back.
We've made use of technology in other ways. We provide an online handbook about our practice; enable parents to complete surveys about health and home prior to their visit; and even put up a Facebook page so that if something changes in the office we can let our families know immediately.
I think the days in which pediatricians could run their practice and choose to do their own thing are over. There are so many more protocols and guidelines required. Becoming a medical home, however, requires that you put into place the tools and processes to meet those guidelines, enabling you to provide evidence-based, comprehensive care for your patients and their families.
I really can't think of a single downside!
William L. Bush is a community pediatrician in Grand Rapids, Michigan.
|Tuesday, April 05, 2011
|First-ever Guidelines for Diagnosing and Managing Food Allergies Released: What Do They Mean?
|by Pediatric Perspectives at 11:35 AM
Nancy J. Brooke, MD, Pediatric Allergist/Immunologist
Helen DeVos Children's Hospital, Grand Rapids, Michigan
If it sometimes seems like every other child (or parent) these days claims a food allergy, then you'll understand why allergists like myself were so excited last December when the National Institute of Allergy and Infectious Disease (NIAID) released the first-ever clinical guidelines for diagnosing and managing food allergies.
The guidelines clarify many issues surrounding food allergies, including the potential causes. For instance, we used to tell mothers to delay feeding their infants certain foods and to avoid certain foods while pregnant or breastfeeding. Now we know from the most recent research that it doesn't matter what they eat or don't eat, or what they feed their children. If a child is going develop food allergies, they're going to develop them. This represents a major shift in our understanding of food allergies and in the advice we-and physicians like you-should be giving to patients and their families.
The guidelines also clarify the type of testing we should do for food allergies, recommending only validated, standardized testing. This is the most important change, and the one expected to reduce the number of children diagnosed with food allergies. Currently, the report noted, 50% to 90% of presumed food allergies are not actually allergies. In reality, only about 5% of children have food allergies.
To diagnose allergies and the specific allergen-provoking food(s), the committee recommends:
The skin-prick test (SPT). This test may be used to identify foods that may provoke an allergic reaction, but it is not diagnostic. If this is the only test performed, as is often the case, it can lead to overdiagnosis. It should only be used in patients in whom a food allergy has already been confirmed to identify the specific food(s) responsible for the allergy. Negative SPTs may also occur, so if the history indicates food allergy and the SPT is negative, further testing is warranted.
Allergen-specific serum IgE (RAST). Like the SPT, this test is also not diagnostic and should be limited to identifying the specific foods that provoke an IgE-mediated allergic reaction.
Food elimination diet. Eliminating 1 or a few specific foods from the diet may help diagnose food allergies, particularly non-IgE-mediated food allergies.
Oral food challenges. The DBPCFC is the gold standard for diagnosing food allergies, although may not be covered by insurance.
Tests to avoid: intradermal testing, total serum IgE measurements, atopy patch test; combination of SPT, sIgE and atopy patch tests.
No matter what test you order, however, the cornerstone of diagnosis remains a thorough medical history.
Any strong suspicion of food allergies or food allergy diagnosis should trigger a referral to a clinical allergist/immunologist for further testing and counseling, and to determine if the child requires an epinephrine pen.
And if the child really does have an allergy? Our response hasn't changed: avoid the food!
Post your questions or comments about the new guidelines here and I'll be sure to respond.
Nancy J. Brooke, MD, is a pediatric allergist/immunologist at Helen DeVos Children's Hospital, Grand Rapids, Michigan.