The Rourke Baby Record Infant/Child Maintenance Guide: do doctors use it, do they find it useful, and does using it improve their well-baby visit records?

Background. The Rourke Baby Record (RBR) - http://www.rourkebabyrecord.ca - is a freely available evidence-based structured form for child health surveillance from zero to five years. Family physicians/general practitioners (FP/GPs) doing office based well-baby care in three Ontario Canada cities (London, Ottawa, and Toronto) were randomly sampled to study the prevalence and utility of the RBR and documentation of well-baby visits. Methods. Database with telephone confirmation was conducted to assess the prevalence of use of the RBR. Study Part 1: Questionnaire mailed to a random sample of 100 RBR users. Outcome measures were utility of, helpfulness of, and suggestions for the RBR. Descriptive analysis was employed. Study Part 2: Retrospective chart review of well-baby visits by 38 FP/GPs using student t-tests and factor analysis. Outcome measures were well-baby visit documentation of growth, nutrition, safety issues, developmental milestones, physical examination, and overall comprehensiveness. Results. The RBR was used by 78.5% (402/512) of successfully contacted FP/GPs who did well-baby care in these 3 cities. Study Part 1: Questionnaire respondents (N = 41/100) used the RBR in several ways, and found it most helpful for assessing healthy child development, charting/recording the visits, managing time effectively, addressing parent concerns, identifying health problems, and identifying high risk situations. The RBR was seen to be least helpful as a tool for managing or for referring identified health problems. Study Part 2: Charts from a total of 1,378 well-baby visits on 176 children were audited. Well-baby care provided by the 20 FP/GPs who used the RBR compared to that by the 18 non-users was statistically more likely to include documentation of type of feeding (p = 0.023), discussion of safety issues (p < 0.001), assessment of development (p = 0.001), and overall comprehensiveness (p < 0.001). Well-baby care provided by the RBR users compared to that by the non-users was not more likely to include documentation of measurement of growth (p = 0.097), or physical examination (p = 0.828). Conclusion. The RBR was widely used by FP/GPs in these settings. RBR users found it helpful for many purposes, and had a consistently high rate of documentation of many aspects of well-baby care. The Rourke Baby Record has become a de facto gold standard clinical practice tool in knowledge translation for pediatric preventive medicine and health surveillance for primary care pediatric providers

Management of children’s fever by parents and caregivers: practical measurement of functional health literacy

Functional health literacy is founded on general and numerical literacy and practical skills and is required for the appropriate and effective management of health symptoms in children. This study aimed to assess the health literacy skills of parents and caregivers of preschool-aged children, using a progressive scenario describing a child with fever and presenting tasks relating to selection of a medicine and hypothetical dosing of their child. Participants (n ¼ 417) from 33 childcare- and health-related sites in Sydney, Brisbane, Melbourne and Auckland completed the study. Participants’ responses were largely appropriate regarding actions in response to worsening symptoms, selection of an appropriate product (from a limited range), whereby 84.5% of responses were for a single-ingredient paracetamol product and use of the package directions to state the frequency of dosing (93.1% of frequencies appropriate for paracetamol and 66.7% for ibuprofen). However, in only 50.8% of cases was an appropriate weight-based dose calculated, and doses were not measured to within 10% of the stated dose in 16.7% of cases. Future studies should focus on skill development via educational campaigns for parents and caregivers

Increased Risk of Vascular Events in Emergency Room Patients Discharged Home with Diagnosis of Dizziness or Vertigo: A 3-Year Follow-Up Study

BACKGROUND: Dizziness and vertigo symptoms are commonly seen in emergency room (ER). However, these patients are often discharged without a definite diagnosis. Conflicting data regarding the vascular event risk among the dizziness or vertigo patients have been reported. This study aims to determine the risk of developing stroke or cardiovascular events in ER patients discharged home with a diagnosis of dizziness or vertigo. METHODOLOGY: A total of 25,757 subjects with at least one ER visit in 2004 were identified. Of those, 1,118 patients were discharged home with a diagnosis of vertigo or dizziness. A Cox proportional hazard model was performed to compare the three-year vascular event-free survival rates between the dizziness/vertigo patients and those without dizziness/vertigo after adjusting for confounding and risk factors. RESULTS: We identified 52 (4.7%) vascular events in patients with dizziness/vertigo and 454 (1.8%) vascular events in patients without dizziness/vertigo. ER patients discharged home with a diagnosis of vertigo or dizziness had 2-fold (95% confidence interval [CI], 1.35-2.96; p<0.001) higher risk of stroke or cardiovascular events after adjusting for patient characteristics, co-morbidities, urbanization level of residence, individual socio-economic status, and initially taking medications after the onset of dizziness or vertigo during the first year. CONCLUSIONS: ER patients discharged home with a diagnosis of dizziness or vertigo were at a increased risk of developing subsequent vascular events than those without dizziness/vertigo after the onset of dizziness or vertigo. Further studies are warranted for developing better diagnostic and follow-up strategies in increased risk patients

Physician perceptions of primary prevention: qualitative base for the conceptual shaping of a practice intervention tool

BACKGROUND: A practice intervention must have its basis in an understanding of the physician and practice to secure its benefit and relevancy. We used a formative process to characterize primary care physician attitudes, needs, and practice obstacles regarding primary prevention. The characterization will provide the conceptual framework for the development of a practice tool to facilitate routine delivery of primary preventive care. METHODS: A focus group of primary care physician Opinion Leaders was audio-taped, transcribed, and qualitatively analyzed to identify emergent themes that described physicians' perceptions of prevention in daily practice. RESULTS: The conceptual worth of primary prevention, including behavioral counseling, was high, but its practice was significantly countered by the predominant clinical emphasis on and rewards for secondary care. In addition, lack of health behavior training, perceived low self-efficacy, and patient resistance to change were key deterrents to primary prevention delivery. Also, the preventive focus in primary care is not on cancer, but on predominant chronic nonmalignant conditions. CONCLUSIONS: The success of the future practice tool will be largely dependent on its ability to "fit" primary prevention into the clinical culture of diagnoses and treatment sustained by physicians, patients, and payers. The tool's message output must be formatted to facilitate physician delivery of patient-tailored behavioral counseling in an accurate, confident, and efficacious manner. Also, the tool's health behavior messages should be behavior-specific, not disease-specific, to draw on shared risk behaviors of numerous diseases and increase the likelihood of perceived salience and utility of the tool in primary care

Dizziness reported by elderly patients in family practice: prevalence, incidence, and clinical characteristics

Background: Although dizziness in elderly patients is very common in family practice, most prevalence studies on dizziness are community-based and include a study population that is not representative of family practice. The aim of this study was to investigate the prevalence and incidence of dizziness reported by elderly patients in family practice, to describe their final diagnoses as recorded by the family physician, and to compare the clinical characteristics of dizzy patients with those of non-dizzy patients. Methods: Data were obtained from the Second Dutch National Survey of General Practice, a prospective registration study which took place over a 12-month period in 2001. We developed a search strategy consisting of 15 truncated search terms (based on Dutch synonyms for dizziness), and identified all patients aged 65 or older who visited their family physician because of dizziness (N=3,990). We used the mid-time population as denominator to calculate the prevalence and incidence, and for group comparisons we used the Student's t and Chi-square test, and logistic regression analysis. Results: The one-year prevalence of dizziness in family practice in patients aged 65 or older was 8.3%, it was higher in women than in men, and it increased with age. In patients aged 85 or older the prevalence was similar for men and women. The incidence of dizziness was 47.1 per 1000 person-years. For 39% of the dizzy patients the family physicians did not specify a diagnosis, and recorded a symptom diagnosis as the final diagnosis. Living alone, lower level of education, pre-existing cerebrovascular disease, and pre-existing hypertension were independently associated with dizziness. Conclusions: Dizziness in family practice patients increases with age. It is more common in women than in men, but this gender difference disappears in the very old. Because a large proportion of dizzy elderly patients in family practice remains undiagnosed, it would be worthwhile to carry out more diagnostic research on dizziness in a family practice setting

Quality of hospital care for sick newborns and severely malnourished children in Kenya: A two-year descriptive study in 8 hospitals

BACKGROUND: Given the high mortality associated with neonatal illnesses and severe malnutrition and the development of packages of interventions that provide similar challenges for service delivery mechanisms we set out to explore how well such services are provided in Kenya. METHODS: As a sub-component of a larger study we evaluated care during surveys conducted in 8 rural district hospitals using convenience samples of case records. After baseline hospitals received either a full multifaceted intervention (intervention hospitals) or a partial intervention (control hospitals) aimed largely at improving inpatient paediatric care for malaria, pneumonia and diarrhea/dehydration. Additional data were collected to: i) examine the availability of routine information at baseline and their value for morbidity, mortality and quality of care reporting, and ii) compare the care received against national guidelines disseminated to all hospitals. RESULTS: Clinical documentation for neonatal and malnutrition admissions was often very poor at baseline with case records often entirely missing. Introducing a standard newborn admission record (NAR) form was associated with an increase in median assessment (IQR) score to 25/28 (22-27) from 2/28 (1-4) at baseline. Inadequate and incorrect prescribing of penicillin and gentamicin were common at baseline. For newborns considerable improvements in prescribing in the post baseline period were seen for penicillin but potentially serious errors persisted when prescribing gentamicin, particularly to low-birth weight newborns in the first week of life. Prescribing essential feeds appeared almost universally inadequate at baseline and showed limited improvement after guideline dissemination. CONCLUSION: Routine records are inadequate to assess newborn care and thus for monitoring newborn survival interventions. Quality of documented inpatient care for neonates and severely malnourished children is poor with limited improvement after the dissemination of clinical practice guidelines. Further research evaluating approaches to improving care for these vulnerable groups is urgently needed. We also suggest pre-service training curricula should be better aligned to help improve newborn survival particularly

An exploratory qualitative assessment of factors influencing childhood vaccine providers' intention to recommend immunization in the Netherlands

<p>Abstract</p> <p>Background</p> <p>Under the Dutch national immunization program (NIP), childhood vaccination is not mandatory, but its recommendation by childhood vaccine providers (CVP) is important for maintaining high vaccination coverage. We therefore examined factors related to providers' intentions to recommend vaccinations to parents of young children.</p> <p>Methods</p> <p>We conducted four focus group discussions with nurses and physicians who provide vaccines to children 0-4 years old in diverse regions of the Netherlands. Three groups represented CVPs at child welfare centers (CWCs) serving the general population, with the fourth representing anthroposophical CWCs. Elements of the Theory of Planned Behaviour (TPB) were used to design the groups; thematic analysis was used to structure and analyze the dataset.</p> <p>Results</p> <p>Four main themes emerged, including 1) perceived responsibility: to promote vaccines and discuss pros and cons with parents (although this was usually not done if parents readily accepted the vaccination); 2) attitudes toward the NIP: mainly positive, but doubts as to NIP plans to vaccinate against diseases with a low perceived burden; 3) organizational factors: limited time and information can hamper discussions with parents; 4) relationship with parents: crucial and based mainly on communication to establish trust. Compared to CVPs at standard CWCs, the anthroposophical CWCs spent more time communicating and were more willing to adapt the NIP to individual cases.</p> <p>Conclusions</p> <p>Our qualitative assessment provides an overview of beliefs associated with providers' intention to recommend vaccinations. They were motivated to support the NIP, but their intentions to recommend vaccinations were affected by the perceived relevance of the vaccines, practical issues like limited time and by certain types of resistant parents. These results will inform future studies to test the magnitude and relative impact of these factors.</p

Profiling Dizziness in Older Primary Care Patients: An Empirical Study

The diagnostic approach to dizzy, older patients is not straightforward as many organ systems can be involved and evidence for diagnostic strategies is lacking. A first differentiation in diagnostic subtypes or profiles may guide the diagnostic process of dizziness and can serve as a classification system in future research. In the literature this has been done, but based on pathophysiological reasoning only