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|Wednesday, July 28, 2010
|Chronic Conditions Soaring in Our Kids: Are Pediatricians Prepared?
|by Pediatric Perspectives at 09:36 AM
Tom Peterson, MD, Medical Director, Quality and Healthier Communities
Spectrum Health and Helen DeVos Children's Hospitals
If you feel like you've been seeing more kids with chronic illnesses like obesity, asthma, and behavior and learning disabilities, you probably have. A recent study published in the Journal of the American Medical Association analyzed three cohorts of children ages 2 to 8 years old whose mothers were interviewed as part of the National Longitudinal Survey of Labor Market Experience, Youth Cohort from 1988 to 2006. They found the number of kids with a chronic illness at any time increased from 27.8% in the earliest group to 51.5% in the latest (P<0.001). The good news is that the increase was not static, demonstrating that some chronic conditions resolve.
This study just reconfirms my sense that the future of pediatrics is going to be quite different from the pediatrics most of us were trained to practice. One reason is the shortage of primary care physicians. But the other is the drive from healthcare reform, patients and health plans for us to practice a more patient-centered type of care as the medical problems of our young patients begin to mimic those that adult primary care physicians see. The pediatric system was designed as a preventative system 50 years ago; we focus on immunizations and safety and education. But now we are seeing our system become one that requires we teach management skills, become health coaches, practice motivational interviewing-all skills required to get patients (and their families) to change their lifestyle and manage their chronic health problems.
Bottom line: This is not an acute-care world anymore.
This study clearly shows that we're going to have to manage chronic conditions more and more in the future and that pediatricians will need to know how to manage "adult" diseases. To do that effectively, we need to be part of a team that includes other practitioners, whether specialists, nurses, educators, nutritionists, or physical and mental health therapists. We will need new skills and resources. And we will need to be more directly engaged with other areas of children's environment that directly affects their abilityto self manage their diseases, such as their school, home, and culture.
One problem is that the continuum of care is still very poorly coordinated in our system. Another is that the conditions we're seeing more and more of these days are areas in which we have had very little training: obesity, sleep apnea, hypertension, type 2 diabetes, high cholesterol. We often lack the tools and skills in how to manage a 6-year-old who is extremely obese with two obese parents, who has high cholesterol and high blood pressure. Traditionally we simply sent them to "specialists." This study clearly shows that we can't just keep doing that.
What are your thoughts on the growth in chronic health conditions in our kids? Click "Add Comment" below to join the conversation.
|Tuesday, July 20, 2010
|Whither the Pediatric Hospitalist?
|by Pediatric Perspectives at 09:30 AM
David Duffey, DO, Division Chief, Hospital Medicine
Helen DeVos Children's Hospital
It should come as no surprise that kids entering the hospital today are sicker than they were even 10 years ago. We saw the trend with adults earlier, and now, of course, it's caught up in the pediatric world.
So it should also come as no surprise that more hospitalists today provide care in children's hospitals, something that was rarely seen 10 years ago.
Our job is to bring the medical home concept into the hospital by providing seamless delivery of care between the outpatient and inpatient setting while always communicating closely with a child's primary care physician. With a hospital medicine division, we can ensure that a primary care physician is available 24/7 to respond to any change in a patient's condition; make sure that care is delivered in a timely manner; and provide the services patients-and their families-need when they need it.
The research on the value of adult and pediatric hospitalists finds we can reduce costs and lengths of stay, with patient surveys finding similar rates of satisfaction with hospitalists as with primary care physicians. While a few studies of adult hospitalists find lower mortality rates with hospitalists, the numbers simply haven't been large enough in the pediatric setting to detect a difference.2
One of the keys to quality, we believe, is close collaboration with the primary care physician, who usually knows the child and family best.
In our hospital, it is always up to the community physician whether he or she wants us to handle their patients in the hospital. If so, they typically agree to let us handle any of their patients who are admitted. We contact them at admission and discharge, and provide detailed documentation upon discharge. Physicians who don't use our services have care delivered by residents, but they must provide the attending physician oversight.
Studies in adult and pediatric settings find that most primary care physicians support the use of hospitalists, saying they are satisfied with the care provided and the quality of that care. Some even feel that hospitalists improve the office practice and may, in some instances, increase profitability.2,3
As health care reform brings millions more patients into the health care system, we expect the demand for hospitalists in both the adult and pediatric settings will grow. In the pediatric setting, the growing numbers of children with chronic conditions like diabetes, obesity, and hypertension will also drive the need for generalist physicians who can manage a child's inpatient stay and coordinate among the various specialists.
So tell us: What can we, as pediatric hospitalists, do to improve our communication with primary care physicians? If you're a hospitalist, what kind of systems do you have in your hospital to insure adequate communication?
Click "Add Comment" below to join the conversation.
David Duffey, DO, is the division chief of Hospital Medicine at Helen DeVos Children's Hospital in Grand Rapids, Michigan.
•1. Landrigan CP, Conway PH, Edwards S, Srivastava R. Pediatric hospitalists: a systematic review of the literature. Pediatrics. 2006;117(5):1736-1744.
•2. Srivastava R, Norlin C, James BC, Muret-Wagstaff S, Young PC, Auerbach A. Community and hospital-based physicians' attitudes regarding pediatric hospitalist systems. Pediatrics. 2005;115(1):34-38.
•3. Freed GL, Dunham KM, Switalski KE; Research Advisory Committee of the American Board of Pediatrics. Assessing the value of pediatric hospitalist programs: the perspective of hospital leaders. Acad Pediatr. 2009; 9(3):192-6.
|Tuesday, July 13, 2010
|Phthalates: What’s the Story?
|by Pediatric Perspectives at 02:13 PM
George Steinhardt, MD, Pediatric Urologist
Urologic Consultants, PC
Helen DeVos Children's Hospital
Have you been getting questions about phthalates? Seeing more infants with cryptorchidism and other genital abnormalities? Then listen up.
For those who don't know, phthalates are man-made chemicals used to soften plastics. They are found in most items we use these days, from water bottles to shampoos, carpeting, and even shower curtains. They disrupt endocrine systems by stimulating estrogen receptors and, in boys, at least, are thought to cause genital deformities via maternal transmission.
A recent 60 Minutes investigation brought new scrutiny to the issue of phthalates and highlighted what we've known and have been seeing for quite some time. Namely, that the higher the serum levels of these chemicals in mothers, the greater the risk of genital deformities in their male offspring. For instance, we presented a study a couple of years ago at the American Urological Association meeting showing that maternal levels of polychlorinated biphenyls (PCBs) were significantly higher in mothers of boys with undescended testicles than in mothers of boys without (P=0.026).
As a pediatric urologist, I'm seeing significant increases in all male genital defects, including hypospadia, curvature of the penis, testicle torsion, cryptorchidism and, in particular, epididymal cysts. Adult urologists report higher rates of male infertility and testicular cancer.1
When we screened 2,200 boys with scrotal ultrasounds here at Helen DeVos, we found that 35% of those older than 15 years of age had epididymal cysts. To date, we have only seen these cysts in the offspring of women who took DES during pregnancy. But DES hasn't been on the market since 1967. So now we suspect that undue estrogen stimulation during pregnancy from endocrine disrupters like phthalates may be causing these cysts. The results of this study should be published in an upcoming issue of the Journal of Urology. 2
Unfortunately, there's not much women can do about past exposure. These chemicals break down very slowly and accumulate in fat. In our study on cryptorchidism, we found that all the women we studied had some level of these chemicals in their blood, even those whose sons had normal testicular development.
Given the increased rates of congenital deformities, it is important that pediatricians and other community physicians be extremely thorough in the newborn testicular/genital exam. Undescended testicles are easy to miss. They should also be on the lookout for prenatal torsion; we're seeing an increase in our patients. About a third of the surgeries our group does for undescended testicles are related to torsion.
Beyond that, we just have to hope that the growing body of scientific evidence linking these chemicals to birth defects and other medical and cognitive problems will eventually lead to their demise.2-4
So what are you seeing in your practices? Leave a comment and let me know. (Click "Add Comment" at the end of this post.)
George Steinhardt, MD, is a urologic consultant at Helen DeVos Children's Hospital in Grand Rapids, Michigan
1. Main KM, Skakkebaek NE, Virtanen HE, Toppari J. Genital anomalies in boys and the environment. Best Pract Res Clin Endocrinol Metab. 2010 Apr;24(2):279-89.
2. Posey AQ, Ahn HJ, JunewickJ, Chen JJ, and Steinhardt GF. Rate and associations of epididymal cysts in pediatric scrotal ultrasounds. In press.
3. Bouchard MF, Bellinger DC, Wright RO, Weisskopf MG. Attention-deficit/hyperactivity disorder and urinary metabolites of organophosphate pesticides. Pediatrics. 2010;125(6):e1270-7.
4. Sagiv SK, Thurston SW, Bellinger DC, et al. Prenatal Organochlorine Exposure and Behaviors Associated With Attention Deficit Hyperactivity Disorder in School-Aged Children Am. J. Epidemiol., 2010; 171: 593 - 601.