Posted On: February 28, 2013

How Parents Choose a Pediatrician in the Internet Age

For most people, the Internet is a primary resource for a range of services from restaurant reviews to insurance policy comparisons. Medical/health apps are popular (and varied in quality and usefulness—see our blog ), as are hospital and doctor rating services.

But when it comes to how parents choose doctors for their children, online resources are a decidedly generational preference. Gender, too, plays a role in how much a parent consults the Internet.

So says a recent survey by the Mott Children’s Hospital National Poll on Children’s Health, a project of the University of Michigan (UM). Only 1 in 4 parents, it says, consider doctor rating sites very important in choosing a practitioner for their children.

Parents younger than 30 (44 in 100) and mothers (30 in 100) were more likely to say that online doctor ratings were very important than older parents (21 in 100) and fathers (19 in 100).

Other results of the poll include:

  • More than 9 in 10 parents rated “accepts my health insurance” as very important.

  • About 65 in 100 parents rated a convenient office location as very important.

  • More than 50 in 100 parents rated a doctor’s years of experience as very important.

  • Nearly 1 in 3 parents who have gone online to view doctors’ ratings said that they have selected a doctor for their children because of good ratings or reviews. Nearly 1 in 3 said they avoided a doctor for their children because of bad ratings or reviews.

  • Very few adults (5 in 100) said they have ever posted ratings or reviews of doctors.

In a UM news release, Dr. David A. Hanauer, a professor of pediatrics at the university who was involved in the polling project, said, “The small percentage of people who actually post reviews suggests that people who depend on online ratings may not be getting an accurate picture of a pediatrician’s care.”

So how much should you rely on online ratings? Dr. Matthew M. Davis, director of the poll, offered this perspective: “[T] here is currently no oversight or regulation for rating websites that collect ‘crowd-sourced’ information about doctors. It is hard to verify the reliability of the ratings or whether they are subject to manipulation.”

But he also pointed out in the news release that word-of-mouth isn’t exactly an objective measure of quality either. And that a personal source of information might be perceived as more directly accountable, and therefore more trustworthy.

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Posted On: February 22, 2013

Fast Food Diet Shows Link to Breathing Problems

Parents generally don’t need a reason to limit their children’s consumption of fast food—everybody knows chicken nuggets, fries and bacon burgers are load with saturated and trans fats, which have been shown to compromise immunity. Now, a new study in the respiratory journal Thorax seems to show a direct cause-and-effect for specific harms of eating too much junk food.

As reported on, the study results show that eating three or more servings of fast food each week is associated with a higher severity of allergic asthma, eczema (skin inflammation) and rhinitis (inflammation of nasal passages) for children in developed nations.

We’ve blogged about the respiratory signs of allergy.

Dietary data was collected from more than 319,000 13- and 14-year-old teens in 51 countries, and more than181,000 6- and 7-year-olds from 31 countries. All of the study’s subjects were involved in the International Study of Asthma and Allergies in Childhood (ISAAC), a collaborative research project involving more than 100 countries and nearly 2 million kids. ScienceDaily says it’s the largest study of its kind.

Parents of the kids were asked about symptoms of asthma (wheezing), rhinoconjunctivitis (runny or blocked nose accompanied by itchy and watery eyes) and eczema (patchy, itchy skin, bleeding blisters), and their weekly diet. They focused on the severity of symptoms over the last 12 months, including frequency and interference with daily life and/or sleep patterns. They also asked about certain foods linked to protective or damaging effects on health.

They included meat, fish, fruits and vegetables; cereals, bread, pasta and rice; butter and margarine; nuts; potatoes; milk; eggs; and fast food/burgers. They asked how often the children ate these foods—never, occasionally, once or twice a week and three or more times a week.

The analysis showed that fast food was the only food category to show the same associations across both age groups. So the authors suggested that "such consistency adds some weight to the possible causality of the relationship."

The study had limitations—relying on one’s memory isn’t the best way to collect objective data—but because the sample was so large and included so many regions, the patterns can’t be ignored.

The relationship between fast food and severity of symptoms for the three conditions was consistent among the teens in all the participating countries, irrespective of gender or family affluence.

The pattern among children was less clear-cut, but except for eczema, a fast food diet still was associated with symptoms across all regions and poorer countries, except for current/severe symptoms of asthma. (See our blog about the quality of hospital care for children with asthma.)

This difference, the authors speculated, might have to do with the fact that children have fewer options about their food choices.

Three or more weekly fast food servings were linked to an increase of severe asthma of more than one-third for teens and more than one-quarter for younger children.

But fruit seemed to be protective for both age groups in all regions for all three conditions among younger children, and for current and severe wheezing and rhinitis among the teens. Eating three or more servings of fruit each week was linked to decreased severity of symptoms for both teens and younger children.

Parents who eat healthfully model this habit for children, who will benefit from it their whole life. The occasional fast food meal is not a problem for most people, but if your child has respiratory problems, he or she might be more vulnerable to its negative effects.

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Posted On: February 15, 2013

Hospital Readmission Rates for Children Mirror Those of Adults

Hospital readmissions—patients who have to check back into the hospital unexpectedly within 30 days of going home—have become an important factor in determining the quality of health care, particularly since Medicare is using that data to compensate and penalize hospital performance in its Hospital Readmissions Reduction Program.

But not much attention has been paid to hospital readmissions for children.

A new study, however, has found that trends seen in adult hospital readmissions also apply to pediatric readmissions. Published in the Journal of the American Medical Association (JAMA), the study found that 1 in 15 children discharged from a pediatric hospital is readmitted.

Researchers at Boston Children’s Hospital examined data from the National Association of Children’s Hospitals and Related Institutions for 72 large acute-care children’s hospitals between July 2009 and June 2010.

As reported on, the most common problems that returned young patients to the hospital were anemia/neutropenia (low white blood cell count), ventricular shunt procedures (to drain fluid around the brain) and sickle-cell crises. The incidence of readmission for those complications was comparable to the rate for adults readmitted for heart attack, heart failure and pneumonia.

So, many readmission trends seen in adults also are seen in children—similar rates related to certain conditions. Just like with adults, most pediatric patients are readmitted because they suffer from chronic diseases.

As noted in an editorial accompanying the JAMA study, most children are hospitalized only once in their lives—when they are born. Excluding newborns, every year about 3.6 million people are hospitalized, almost one-third of whom are children. But only a small percentage of children account for the majority of hospital admissions and costs—the ones with complicated medical problems.

Their larger use of health-care resources mirrors that of people on Medicare, whose chronic, complicated problems require more resources, and result in more readmissions.

Rates varied among the hospitals surveyed, and ranged from 4.6 to 8.5 in 100, depending on factors such as differences in hospital and follow-up care and family or community influences on health, the researchers said. Bottom line: There’s room for improvement, but it’s not just about hospitals doing a better job of treating inpatients and communicating with them on discharge, which is known as transition care.

“Community clinicians and organizations have a role to play as well,” said Dr. Mark Schuster, chief of general pediatrics at Boston Children’s Hospital in a statement released with the study. “Parents also need support in being able to stay home with their recuperating children.”

As noted by MedCityNews, this study found results similar to one that examined readmissions in VA hospitals in that a shorter hospital stay was associated with lower rates of readmission. And as you might expect, readmissions are higher for children with no insurance or with public coverage.

Critics of the Hospital Readmission Reductions Program say that you can’t use numbers alone to determine why some hospitals have higher readmission rates than others—some serve populations that lack primary care that might have addressed problems before they became serious enough to require hospitalization, so they’re treating a sicker patient population. Some are located in areas with higher trauma and crime rates, which mean they see more people with critical care issues.

The JAMA editorial acknowledged these complications as they apply to pediatric readmissions. “Until research can demonstrate that hospitals that have high pediatric readmissions are delivering suboptimal quality as opposed to caring for more children with complex social environments that contribute to readmission,” the authors wrote, “physicians and policy makers should not consider pediatric readmissions as a quality indicator: current research only supports it as a marker of health care utilization.”

“Are pediatric readmissions ready to debut as a showcase hospital quality measure?” the writers ask. “At this point, the answer is no. Or at least not yet.”

But that doesn’t mean that you can’t help your child get the best possible hospital care. Mindful of the factors that can skew pure numbers, you can find out how many hospitals rate on Medicare’s Hospital Compare site.

Another method of hospital review is described in our previous blog about performance ratings. Also, read my two-part newsletter about how to keep a loved one safe during hospitalization here and here.

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Posted On: February 8, 2013

Electing Early Delivery Is Seldom Wise

It has been nearly 35 years since the American College of Obstetricians and Gynecologists (ACOG) recommended against delivering babies or inducing labor before 39 weeks of gestation, except when there are medical complications, such as the mother's high blood pressure (pre-eclampsia; see our recent blog on the Downton Abbey all-too-real plot line), diabetes or signs that the fetus may be in distress.

So why, then, are an estimated 10 to 15 out of 100 U.S. babies delivered early every year for no medical reason?

That reality is examined in a recent story by Kaiser Health News and the Washington Post. "After 37 weeks, patients really push for it because they are miserable and don't want to be pregnant anymore," Alfred Khoury, director of maternal-fetal medicine at Inova Fairfax Hospital, told KHN/Washington Post. "Or they say, 'My mother is here' or 'I have to be in a wedding.'"

Sometimes, it’s a matter of provider availability. Physicians who work alone or in rural areas might prefer to schedule deliveries before 39 weeks for time-management purposes. That’s a bad idea, but, said Helain J. Landy of the department of obstetrics and gynecology at MedStar Georgetown University Hospital, "The reality of caring for patients, or [doctors'] day-to-day needs, may sometimes interfere with following the guidelines."

In 2012, Patrick Malone represented a family in a medical malpractice lawsuit against a group of obstetricians for brain damage to a baby that resulted from misconceived plans for an early delivery. In that case, the doctor followed outdated medical literature that suggested babies of mothers with gestational diabetes should be delivered early even if monitoring shows the baby is doing fine. Mr. Malone's closing argument of the trial on behalf of both baby and mother can be read here.

Now, poor doctoring and patient ignorance are coming under the control of some government and private insurers, who are discouraging and sometimes penalizing doctors and hospitals for delivering babies early without cause.

It’s a good idea from both a health and financial perspective.

Often, prematurely delivered babies develop problems ranging from breathing and heart disorders to anemia and bleeding in the brain that land them in the neonatal intensive care unit (NICU) where, according to KHN/Washington Post, the average charge is $76,000 per stay. (Learn about NICU injuries in our backgrounder.)

The folks who pay most of that tab also want to avoid subsequent medical costs to treat problems including jaundice, feeding difficulties and learning and developmental issues. Sometimes the health problems of preemies last their whole life.

As reported in the story, UnitedHealthcare, the nation's largest private health insurer, pays hospitals more if they take steps to limit early deliveries without medical cause and show a drop in their rates. And as of July, Medicare, which pays for disabled women to give birth, will require hospitals to report their rates of elective deliveries before 39 weeks. Hospitals might be penalized beginning in 2015 if their rates remain high.

Some insurers refuse to pay for unnecessary early deliveries at all. The South Carolina Medicaid program and BlueCross/BlueShield of South Carolina don’t reimburse providers for performing early deliveries without medical cause. Those two insurers cover more than 8 in 10 births in that state. Several other states either have or are considering such policies.

We’re reluctant to endorse such sweeping measures because individuals have different needs. But unnecessary early delivery is never a good idea.

Even without official prodding, some hospitals have taken steps to curtail elective early deliveries, and some simply won’t perform them. After St. Joseph Medical Center in Houston stopped performing them in 2011, NICU admission rates for babies born between 37 and 39 weeks dropped 25 percent in the first year.

Unfortunately, sometimes brawn works better than brain in encouraging practitioners to curb elective early births. One study mentioned by KHN/WP found that educating doctors about the risks was less effective in reducing rates of early deliveries than having medical staff simply prohibit the practice.

But some physician groups don’t like being told how to practice medicine.

"We oppose the legislative control of medicine," said Jeanne Conry, president-elect of ACOG told KHN/WP. Conry says her organization has developed its own "clear, effective guidelines" laying out clinical markers for determining when early delivery might be appropriate.

And as one obstetrician noted, when states or insurers get involved, doctors may hesitate to deliver early even when there are clinical reasons to do so. "Outcomes are best when there is a doctor-led process, rather than a legislative or payment mandate," he said.

Even the March of Dimes, that notable champion of safe birth practices, is wary of using financial rewards or penalties. "Payment is a really big hammer, and we want to have a comfort level with a policy so we don't cause unintended consequences [such as making doctors reluctant to perform early deliveries even when they are needed],” Cindy Pellegrini, a March of Dimes executive told KHN/WP.

Some doctors welcome the oversight, as one obstetrician said, to help "us all do the right thing" and make it easier to educate women.

But decades after the ACOG guidelines, only 1 in 3 hospitals reports rates of elective early deliveries at or below the goal of 5 in 100, according to the Leapfrog Group, an organization of businesses focused on patient safety. Many still have rates higher than 15 in 100.

Some of the resistance, unfortunately, might be because NICUs are profit centers for many hospitals.

The best way to address the wisdom of full gestation is to educate patients. There’s some work to do there—one survey from a couple years ago involving 650 women who had recently given birth found that half considered it safe to deliver before 37 weeks.

If you are expecting, or expecting to be expecting, make sure you and your obstetrician are on the same page regarding the optimum time for delivery. Do not accept any reason other than medical necessity for inducing labor before the due date, or otherwise delivering prematurely. It’s bad medicine with potentially lifelong consequences.

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Posted On: February 1, 2013

Feds Say Childhood Vaccine Schedule Is Safe and Effective

Despite the proven effectiveness of childhood vaccines for measles, polio and whooping cough, many parents are leery of giving them to their children for fear of causing more problems than the vaccines solve.

The evidence for the use of vaccines has been overwhelming, and now there’s new information to support the wisdom of vaccinating children. According to a widely reported story, including on NPR, scheduling children to be immunized 24 times by the age of 2 is safe and effective. The latest research was conducted by the Institute of Medicine (IOM).

The IOM is is an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision makers and the public. The agency spent a year reviewing all available scientific data to reach its conclusion.

The IOM committee reviewed several medical conditions, including autoimmune diseases (including diabetes), asthma, hypersensitivity, allergies, seizures, epilepsy, child developmental disorders including autism, and other learning disorders, communications disorders, intellectual disabilities and even rare disorders like Tourette's syndrome, which can cause odd tics and body movements and inappropriate outbursts. None of the conditions the committee examined could be linked to the vaccination schedule.

Parents should be reassured, one of the committee members told NPR. But its report also said that the research about the timing and number of vaccines isn't as complete as it could be. The IOM can’t say for certain, for example, if it’s just as safe and effective if vaccines are spread out over a longer period than the current span.

“Once the schedule has been set, though, no one has studied whether moving the vaccine forward two weeks or backward two weeks or adding two vaccines together or splitting them apart would be better than the current schedule," one committee member told NPR.

The committee recommends additional research to analyze the health outcomes of children who don’t get vaccines as soon as they are recommended either because they get sick and can't get a vaccine on schedule or because their parents are concerned about the safety of getting multiple vaccines simultaneously, and decide to space them out.

“Preliminary research,” according to the NPR story, “does show [that] children who don't get vaccinated on time are hospitalized more often than children who are immunized according to federal guidelines.”

Still, some parents aren’t buying into the science.

The National Vaccine Information Center (NVIC), a nonprofit whose mission is “the prevention of vaccine injuries and deaths through public education and to defending the informed consent ethic in medicine,” said the IOM committee considered only about 40 studies, which it feels is insufficient to draw the conclusion about safety.

The NVIC says it does not advocate for or against the use of vaccines, and supports the availability of vaccines, and the right of consumers to make “educated, voluntary health care choices.”

According to federal health officials, most parents follow the recommended vaccine schedule, and 9 in 10 children are fully vaccinated by the time they enter kindergarten. Only about 1 in 100 parents refuse all vaccines.

For a thoughtful essay that respects the highly charged feelings on both sides of the vaccine issue, see our post from last year, “A Doctor’s Advice to Parents About Vaccines,” and our newsletter from last year, “Vaccines: The Neglected Shot of Prevention.”

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