What Medical Professional is the                 Most Adequate for Primary                 Health Care to children and    ...
THE IMPORTANCE OF PRIMARY CARE PEDIATRICS IN EUROPE:              From Concepts to Evidences What Medical Profession is th...
3rd annual meeting of ECPCP (European Confederation of Primary                       Care Pediatricians)THE IMPORTANCE OF ...
3rd annual meeting of ECPCP (European Confederation of Primary                         Care Pediatricians)  THE IMPORTANCE...
What medical professional is the most  adequate to provide health care to children  in primary care in developed countries...
3rd annual meeting of ECPCP (European Confederation of Primary Care                               Pediatricians)  THE IMPO...
Justification for this Systematic Review: In Spain, the presence of pediatricians in Primary Careis frequently and period...
Answering the question, in developed countries, aboutwhat medical professional is the most adequate toprovide health care ...
Objectives & participantsThe aim of this SR is to compare the clinical practice between PED and FP/GP in providing health...
Purpose of the study: to look into the currentsituation of the problem, by means of a SR of theliterature. Comparison of t...
Bibliographic Search                 Data Bases:   Meta Search Engines:   Databases:   Search Engines:   List of Reference...
59 publications : 1 investigation with a before-after study design. 10 cohort studies (many of them retrospectivehistori...
59 papers.TYPES OF INVESTIGATIONS:o Professional mail surveyso Cross-sectional surveys to providers.o Consult of populatio...
22, June 2012
Statistical analysis-Whenever possible, and based on results of every individual study, thefollowing estimators of effect ...
3rd Annual Meeting of ECPCP3rd Annual Meeting of ECPCP / 20ème Congrès               National AFPA
Types of COMPARISONS    includedo   Medication prescription habits:    •(Ex.: antibiotics, patterns of ATB prescription: n...
Types of COMPARISONSincluded (II) Thresholds for adequate referring of children to hospital or  other services. Comparis...
Types of COMPARISONSincluded (III)Some comparisons were made in relation to a reference standard (that could be: a CPG, a...
Types of COMPARISONS (Example)Non-cardiovascular preventive activities.  Health education activities (recommendations,  ...
Types of COMPARISONS(Example II)Cardiovascular prevention. Diagnosis and prevention activities(health education activitie...
COMPARISONS         ( by Categories / Example III )         Classification by categories of the types of         outcome m...
COMPARISONS (by Categories / ExampleIV)Classification by categories of the types of outcome measures used:Management of as...
COMPARISONS (by Categories /Example V)Management of children with psychiatricdisorders, like depression, obsessive compuls...
Types of COMPARISONS included (Example VI)Immunizations: Recommended vaccine and official  immunization schedules. Compar...
RESULTS
Use of antibiotics in upper  airway infections of probable  viral origin (I)Studies conducted by means of consulting  popu...
RESULTS: Use of antibiotics in upper airway infections ofprobable viral origin (meta analysis) 1) Studies conducted by mea...
RESULTS: ATB use for URI (individual, n = 17)SUMMARY OF THE CATEGORY: 17 studies. 10 Population based databases ( 9 of the...
RESULTS: AOM management             (individual studies, n = 10)Ten studies analyzed the attitude of PED andFP/GP in relat...
RESULTS: ASTHMA management (individuals studies, n =3)Table 3. Studies that compare clinical practice of PED vs FP/GP in t...
RESULTS: ASTHMA management (individuals studies, n = 3)    Table 3 in the SR summarizes the    main characteristics of the...
RESULTS: FEVER management (individual studies, n = 3)Table 4 summarizes the main characteristics of the three reviewedstud...
RESULTS: PSYCHIATRIC PROBLEMS (individual studies, n = 3)               Three selected studies(summarized in table 5) Cros...
RESULTS: INMUNIZATIONS (individual researches, n = 16)The main characteristics of the selected studies are summarized in t...
RESULTS: Cardiovascular risk factors (Studies; n: 10)Ten studiesAll studies were cross-sectional design, using surveys, ex...
RESULTS: other PREVENTIVE ACTIVITIES (studies, n = 6)The delivery of other clinical preventive services, besides vaccinati...
RESULTS: Use of Diagnostic Test (studies, n = 10)Ten studies performed some kind of comparison in this field of theclinica...
RESULTS: Use of Diagnostic tests (studies n = 10)
Summarized ResultsResults• On average, FP/GP prescribed more ATB than PED in  upper respiratory tract infections of probab...
Summarized Results In CARDIOVASCULAR PREVENTION: Interventions related to prevention of tobacco consumption and to increa...
Summarized Results IIIUse of a diagnostic test in primary care was better performedby PEDs.•Number of test ordered: PEDs o...
Limitations of the SR•   Few analytical design studies ( no clinical trial, and a absence of prospective    studies)•   St...
Strengths of the SR• This one is the first review (with methodology of  SR) that compares clinical practice between  PEDs ...
DISCUSSION (HIGHLIGHTED POINTS)
Conclusions:The current situation could be summarized in the following highlightedpoints:•A better pattern of drug prescri...
Discussion1. A more rational use of diagnostic tests(e.g. chest x-ray,   GABHS testing or oropharyngeal culture) PEDs orde...
Discussion (INMUNIZATIONS)PEDs → more adequate implementation of vaccination (the mainprimary prevention activity) recomme...
DiscussionAbout psychiatric disorders, GPs were morelikely to prescribe SSRIs for all the diseasesstudied. For some of th...
Discussion  (Cardiovascular Risk preventive activities):PEDs provide more preventive services and more health counseling....
Discussion Consequences of the high incidence of diseases inchildren with a better pattern of medicationsprescription by ...
3rd annual meeting of ECPCP(European Confederation of Primary Care Pediatricians) THE IMPORTANCE OF    PRIMARY CAREPEDIATR...
Main conclusionThe main conclusion is that, in developed countries, primary health care delivered by PEDs result in bette...
Main conclusionMost of the results obtained were studied in outcome variables of greatimportance for physicians, patients ...
Main conclusion:   The Pediatric Primary Care (PPC) is an  essential public health issue. Therefore, the  professionals c...
DiscussionSeveral implications for further research can be drawn from this review. There is a need for observational stud...
In brief:
PAPERS PUBLISHED AFTER THE      Systematic Review*     Synthesized summary of a preliminary      (“at a glance”) overview ...
Number of new articles found: 22(Date of the Bibliographic Search: 22-May-2012)
NUMBER OF COMPARISIONSCONTAINED IN THE PAPERS
USEFUL COMPARISONSDistribution by type of professional that showed        the most adequate performance:
COMPARISONS WIHT A MOST ADEQUATE MEDICAL             PROFESSIONAL(PERCENTAGES IN RELATION TO THE TOTAL NUMBER OF USEFUL CO...
PERFORMANCE OF MEDICAL PROFESSIONAL    (PCP) (Best adequateness expressed in percentages)PROFESSIONAL                  BES...
NUMBER OF COMPARISONS WITH A TYPE OF   PROFESSIONAL SHOWING A MOST ADEQUATEPERFORMANCE (% relate to the total number of us...
The MOST ADEQUATE (by Categories*)           CATEGORIES                   COMPARISONS         COMPARISONS           COMPAR...
LIST OF NEW PAPERS FOUND (researches published after the bibliographic search for the SR) Search Date: 15, May 2012
1.        Huang TT, Borowski LA, Liu B, Galuska DA, Ballard-Barbash R, Yanovski SZ, Olster DH, Atienza AA,          Smith ...
5. Wortberg S, Walter D.Recallsystems in primary care practices to increase vaccination rates    against seasonal influenz...
9.   Food allergy knowledge, attitudes, and beliefs of primary care physicians.     Gupta RS, Springston EE, Kim JS, Smith...
15. Okumura MJ, Heisler M, Davis MM, Cabana MD, Demonner S, Kerr EA. Comfort of general internists and    general pediatri...
18. [Pediatric Otolaryngology at the Public Health System of a city in Southeastern    Brazil].    Guerra AF, Gonçalves DU...
More details & Specifications of thepapers found after the publication ofthe SR. available on demand(unpublished data / Ma...
Pediatric Primary Care In Europe.  The most appropriate medical professional for the task.
Pediatric Primary Care In Europe.  The most appropriate medical professional for the task.
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Pediatric Primary Care In Europe. The most appropriate medical professional for the task.

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Pediatricians: The most suitable medical professionals for the role of pediatric primary healthcare In Europe.
Presentation of the results of a Systematic Review comparing the differences in the clinical practice, the quality of the care delivered, and the results of the performance, in primary healthcare for children and adolescents in Europe, between PEDIATRICIANS and GENERAL PRACTITIONERS/FAMILY DOCTORS.

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Pediatric Primary Care In Europe. The most appropriate medical professional for the task.

  1. 1. What Medical Professional is the Most Adequate for Primary Health Care to children and adolescents in Europe? A Systematic Review.Evidence Based Pediatric Work Group
  2. 2. THE IMPORTANCE OF PRIMARY CARE PEDIATRICS IN EUROPE: From Concepts to Evidences What Medical Profession is the Most Adequate for Primary Health Care to children and adolescents in Europe? A Systematic Review.
  3. 3. 3rd annual meeting of ECPCP (European Confederation of Primary Care Pediatricians)THE IMPORTANCE OF PRIMARY CARE PEDIATRICS IN EUROPE: From Concepts to EvidencesBuñuel Álvarez JC, García Vera C, González Rodríguez P, AparicioRodrigo M, Barroso Espadero D, Cortés Marina RB y cols. ¿Quéprofesional médico es el más adecuado para impartircuidados en salud a niños en Atención Primaria enpaíses desarrollados? Revisión sistemática. Rev PediatrAten Primaria. 2010;12:s9-s72. 22, June 2012Published in Internet: 31/03/2010
  4. 4. 3rd annual meeting of ECPCP (European Confederation of Primary Care Pediatricians) THE IMPORTANCE OF PRIMARY CARE PEDIATRICS IN EUROPE: From Concepts to Evidences What medical professional is the most adequate, in developed countries, to provide health care to children in primary care? Systematic review Authors: Buñuel Álvarez JC, García Vera C, González Rodríguez P, Aparicio Rodrigo M, Barroso Espadero D, Cortés Marina RB, Cuervo Valdés JJ, Esparza Olcina MJ, Juanes de Toledo B, Martín Muñoz P, Montón Álvarez JL, Perdikidis Oliveri L, Ruiz-Canela Cáceres J3rd annual meeting of ECPCP (European Confederation of Primary Care Pediatricians) / 22, June 2012
  5. 5. What medical professional is the most adequate to provide health care to children in primary care in developed countries? Systematic reviewTranslated by: Domingo Barroso Espadero, Paz González Rodríguez, AnaBenito Herreros, Pilar Aizpurua Galdeano, M.ª Jesús Esparza Olcina, ÁlvaroGimeno Díaz de Atauri y Leo Perdikidis Oliveri (members of the Grupo de Trabajo dePediatría Basada en la Evidencia (Evindece-based Pediatrics Work Group) that belongs to theAsociación Española de Pediatría de Atención Primaria (AEPap/Primary Care PediatricsSpanish Association) and to the Asociación Española de Pediatría (AEP/SpanishAssociation of Pediatrics). http://www.pap.es/files/1116-1430-pdf/sup_21_ingles.pdf http://pap.es/FrontOffice/PAP/front/Articulos/Articulo/_IXus5l_LjPoo2J2KDAbNm8JCpYgBVPcRGWJA9CjM
  6. 6. 3rd annual meeting of ECPCP (European Confederation of Primary Care Pediatricians) THE IMPORTANCE OF PRIMARY CARE PEDIATRICS IN EUROPE: From Concepts to Evidences- Our Systematic ReviewJUSTIFICATIONhttp://www.pap.es/files/1116-1052-pdf/S9-S72_Que%20profesional%20medico%20es%20el%20mas%20adecuado.pdf
  7. 7. Justification for this Systematic Review: In Spain, the presence of pediatricians in Primary Careis frequently and periodically questioned. The increasing scarcity of pediatrics specialistavailable. Total absence of studies having as their mainobjective the comparison, in Primary Care, of the clinicalperformance by pediatricians, working in Primary Care,versus the clinical practice by general practitioners(GP)/family doctors (FP), providing healthcare forchildren.
  8. 8. Answering the question, in developed countries, aboutwhat medical professional is the most adequate toprovide health care to children in primary care.Presentation of the results from a Systematic Review.Our Systematic Review (SR)Objectives & participants
  9. 9. Objectives & participantsThe aim of this SR is to compare the clinical practice between PED and FP/GP in providing health care to children and adolescents at the primary health-care level.PARTICIPANTS: PED, FP and GP who developed their clinical practice in PC and hospital emergency departments.
  10. 10. Purpose of the study: to look into the currentsituation of the problem, by means of a SR of theliterature. Comparison of the clinical practice of primary care pediatricians to thecorresponding same clinical practice of FPs/GPs, regarding the following9 CATEGORIES with aspects of the health care of children: 5.- Management of children with 1. - Antibiotic (ATB) psychiatric disorders, like prescription in respiratory tract depression, obsessive compulsive infections (RI) of probable viral disorder (OCD), attention deficit etiology. hyperactivity disorder (ADHD) 2.- Otitis media treatment. 6.- Immunizations: attitudes, beliefs, coverage and implementation 3.- Management of asthma in of the official immunization schedules. children. 7.- Cardiovascular prevention. 4.- Management of fever in 8.- Other preventive activities. children. 9.- Use of diagnostic tests.
  11. 11. Bibliographic Search Data Bases: Meta Search Engines: Databases: Search Engines: List of References of the articles Without language restriction. Until December, 2008.
  12. 12. 59 publications : 1 investigation with a before-after study design. 10 cohort studies (many of them retrospectivehistorical cohort studies). 3 cases-control studies. 45 transversal studies (mainly cross-sectionalstudies) .
  13. 13. 59 papers.TYPES OF INVESTIGATIONS:o Professional mail surveyso Cross-sectional surveys to providers.o Consult of population based databases.o Consult of clinical register and medical records (computerized or not)59 researches →173 COMPARISONS
  14. 14. 22, June 2012
  15. 15. Statistical analysis-Whenever possible, and based on results of every individual study, thefollowing estimators of effect were calculated (if the were not alreadyoffered by the authors):  Relative risk (RR) for cohort studies.  OR in case control studies.  Prevalence ratio / Relative Prevalence (RP / PR) in cross sectional studies.With confidence intervals (CI 95%) for each estimator. When if was possible, we calculated the global effectsize resulting from combining the outcomes by meansof using a global estimated combined estimator: thecombined OR.
  16. 16. 3rd Annual Meeting of ECPCP3rd Annual Meeting of ECPCP / 20ème Congrès National AFPA
  17. 17. Types of COMPARISONS includedo Medication prescription habits: •(Ex.: antibiotics, patterns of ATB prescription: number of prescriptions / first-line ATB medication versus second-line or non recommended high-cost antibiotics) •prescriptions of non recommended medications (like decongestants ) •selective serotonin reuptake inhibitors (SSRIs) antidepressants prescription…oThe therapeutic-diagnostic attitudes for prevalentmedical problems (Ex.: otitis media = OM)o Attitude of professionals in relation torecommendations (adequateness of the doctors in followingrecommendations from clinical practice guidelines (CPGs) / degree ofadherences to recommendations…)
  18. 18. Types of COMPARISONSincluded (II) Thresholds for adequate referring of children to hospital or other services. Comparison of outcome on the control of prevalent conditions ( asthma / ADDH) Management of clinical acute presentation symptoms in children (Ex.: fever: health outcomes, management of fever without source; comparison of the degree of compliance with the recommendations, laboratory test ordered…). Attitudes and likelihood of incorporating the recommendations from new GPCs (Ex.: for the diagnostic assessment and the treatment of disorders like ADHD and for other psychiatric disorders )
  19. 19. Types of COMPARISONSincluded (III)Some comparisons were made in relation to a reference standard (that could be: a CPG, an expert consensus, or a laboratory method that confirmed the diagnosis of the disease)Some other compared directly the clinical practice of PEDs and FPs / GPs without a standard reference.
  20. 20. Types of COMPARISONS (Example)Non-cardiovascular preventive activities. Health education activities (recommendations, counseling, anticipatory guidance) Prevention of medical problems of unintentional injuries or poisoning, Teaching of self-care and self-diagnostic activities (Ex.: testicular self-examination in adolescents, etc.) Use of diagnostic tests.
  21. 21. Types of COMPARISONS(Example II)Cardiovascular prevention. Diagnosis and prevention activities(health education activities / healthy habits promotion and counseling about diet and exercise) on overweight-obesity, on toxic habits (tobacco and alcohol consumption in adolescents, with counseling and active approach to obtain the cessation of consumption). Screening for identification of cardiovascular risk factors in primary care: (Ex.: cholesterol routine screening in the general population, screening for hypercholesterolemia in at risk population); screening of arterial hypertension… Initiation of treatment when indicated (Ex.: hypercholesterolemia ),
  22. 22. COMPARISONS ( by Categories / Example III ) Classification by categories of the types of outcome measures used:Antibiotic prescription (ATB) in respiratory tract infections (RI) of probable viral etiology. Comparison of the likelihood to prescribe and the patterns of prescription of antibiotic (ATB) for upper RI (URI) of probable viral etiology or non-infectious diseases (acute wheezing episodes in children with asthma). Comparison of the type of antibiotic, the prescription habits, the therapeutic- diagnostic attitude for prevalent medical problems like persistent otitis media with effusion (OME), otitis media (OM), or acute purulent rhinitis. Adequateness of the doctors in following recommendations from clinical practice guidelines (CPGs): on ATB treatment, likelihood to prescribe second- line antibiotics or non recommended ATB for frequent infectious diseases like AOM or acute pharyngitis, and for other infections of probable viral origin.
  23. 23. COMPARISONS (by Categories / ExampleIV)Classification by categories of the types of outcome measures used:Management of asthma in children. Comparison of the degree of adherence to the recommendations of an asthma guideline: about diagnosis (peak flow monitoring, use of spirometry for the diagnosis, adequateness of the test ordered), or about the suitability of the treatment and medications prescribed. Comparison of outcome on the control of asthma (visits to hospital emergency department…).
  24. 24. COMPARISONS (by Categories /Example V)Management of children with psychiatricdisorders, like depression, obsessive compulsivedisorder (OCD), attention deficit hyperactivitydisorder (ADHD)Comparison of the different attitudes and likelihood ofincorporating the recommendations from GPCs for the diagnosticassessment and the treatment of disorders like childhooddepression, [selective serotonin reuptake inhibitors (SSRIs)antidepressants prescription / likely to use referrals to thespecialist in mental health], also for the attention-deficit/hyperactivity disorder (ADHD) and for other psychiatricdisorders.
  25. 25. Types of COMPARISONS included (Example VI)Immunizations: Recommended vaccine and official immunization schedules. Comparison of the professionals in the likelihood to administer immunizations and differences in attitudes and beliefs, knowledge and behaviors regarding immunizations (perceptions of the safety of giving immunizations when not specifically contraindicated, percentage of properly immunized children, likelihood to routinely immunize at different type of visits, and likelihood to have protocols for adolescent immunization). Comparison of the degree of adoption of the official recommendation about different current immunization recommendations and standards (adoption of the universal immunization, identification of undervaccinated children, systematically registering vaccinations and using immunization charts for children, vaccination of high-risk children and others).
  26. 26. RESULTS
  27. 27. Use of antibiotics in upper airway infections of probable viral origin (I)Studies conducted by means of consulting population-based databases Data were combined from those studies which met the following requirements: 1) information extracted from registers of databases for health care in which diagnosis and treatment were indicated; 2) studies with design compatible with historical cohort. 3) studies located in primary care.These criteria were met by seven studies.
  28. 28. RESULTS: Use of antibiotics in upper airway infections ofprobable viral origin (meta analysis) 1) Studies conducted by means of consulting population-based databases. 2) Designs compatible with historical cohort studies 3) Located in primary care settings and/or hospital emergency settings. The combined odds ratio was 1.48 (95 % CI: 1.11 to 1.98) indicating that FP/GP have a 1.48 greater probablity of perscribing antibiotics for URI in comparison to PED (59,188 registers)
  29. 29. RESULTS: ATB use for URI (individual, n = 17)SUMMARY OF THE CATEGORY: 17 studies. 10 Population based databases ( 9 of them retrospective cohort studies, 7 of them were combined) The other 7 were cross-sectional studies (surveys) Pulled together, the results about better adherence to standars of ATB prescription for URI favor: 34 comparisons (Best: PED 29) 17 studies: (Best performance: PED 15 / Similar 0/ FP- GP 2)
  30. 30. RESULTS: AOM management (individual studies, n = 10)Ten studies analyzed the attitude of PED andFP/GP in relation to diagnosis and treatment ofAOM (table 2). Seven were cross-sectional studiesand three were historical cohort studies. 10 studies: •17 comparisons (Best: PED 13 / similar 2 / FP-GP 2) •10 studies: (Best: PED 8 / Similar 1/ FP-GP 1)
  31. 31. RESULTS: ASTHMA management (individuals studies, n =3)Table 3. Studies that compare clinical practice of PED vs FP/GP in the management of asthma. Author/year of Results Design/quality Participants Comparison Main outcome Results publication/country favor:Finkelstein JA, 2000. Cross-sectional, Sample of PEDs Adherence to 1.- OR adjusted of clinical Clinical essay, X-ray, prick, RAST:USA27 survey to providers. and FPs from CPG for asthma. essay with beta 2- agonists, X- no significant difference. Medium/Low three managed ray of sinus, thorax X-ray, skin 0.30 (95% CI 0.10 – 0.50) quality. care prick test or RAST test. 5.90 (95% CI 2.40 – 14.60) organizations. To recommend daily peak flow Measurement of four items: A total of 407. measurement. compliance of FP with criteria for To use spirometry in diagnosis referral to specialist was appropriate (OR FP vs PED) in two and no appropriate in the BOTH 2.- To refer to an asthma rest. specialist according to CPG.Kozyrskyj AL, 2006. Retrospective 32,746 visits in To examine the 1.- OR FP vs PED for ATB 2.10 (95% CI 1.82 – 2.53)(Canada)14 cohort study. 7791 asthmatic determinants of prescription within 2 days after 1.25 (95% CI 1.23 – 1.27) Clinical registers children for ATB use. an ambulatory physician visit from MHSIP. wheezing for a wheezing episode in Medium quality. episodes. children with asthma. PED 2.- ATB within 7 days of the episode (RR)Sun HL, 2006. Retrospective 222,537 Prescribing Inhaled beta2-agonist 14.9% FP vs 3.1 % PED (p< 0.05)Taiwan 28 cohort study. prescriptions in patterns of anti- prescription. 5.6 FP vs 7.8% PED (p< 0.05) Clinical registers. children aged< asthma drugs. Inhaled corticosteroids FP vs PED Medium quality 16 years. prescription. 0.76 (95% CI 0.74 – 0.77) RR of prescribing only a drug 0.56 (95% CI 0.53 – 0.59) (no significance) 1.50 (95% CI 1.45 – 1.56) Xanthine derivatives prescription. BOTH Oral beta-2 agonist prescription.
  32. 32. RESULTS: ASTHMA management (individuals studies, n = 3) Table 3 in the SR summarizes the main characteristics of the three reviewed studies. 3 studies. 1 cross-sectional study (survey) / 2 retrospective cohort studies from clinical registers. 14 comparisons (Best: PED 6 / similar or not significance 3 / FP-GP 5) 3 studies: (Best: PED 1 / Similar 2/ FP-GP 0)
  33. 33. RESULTS: FEVER management (individual studies, n = 3)Table 4 summarizes the main characteristics of the three reviewedstudies: Prospective cohort study (Leduc 1982) Zerr et al.( published in 1999) / Cross-sectional survey to providers. Boulis (vignettes / clinical scenarios) / Cross-sectional survey to providers. SUMMARY: 8 comparisons (Best: PED 8 / no differences or no significance 0 / FP-GP 0) 3 studies: (Best: PED 3 / Similar 0/ FP-GP 0)
  34. 34. RESULTS: PSYCHIATRIC PROBLEMS (individual studies, n = 3) Three selected studies(summarized in table 5) Cross- Sectional survey to providers.  13 comparisons (Best: PED 8 / similar or not significance 1 / FP-GP 4)  3 studies: (Best: PED 1 / Similar 2/ FP-GP 0)
  35. 35. RESULTS: INMUNIZATIONS (individual researches, n = 16)The main characteristics of the selected studies are summarized in table 6 (in the SR)This topic was reviewed in 16 studies: 14 cross-sectional descriptive studies andtwo historical cohort studies. 32 comparisons (Best: PED 31 / similar or not significance 1 / FP-GP 0) 16 studies: (Best: PED 15 / Similar 1/ FP-GP 0)
  36. 36. RESULTS: Cardiovascular risk factors (Studies; n: 10)Ten studiesAll studies were cross-sectional design, using surveys, except one, which wasbased on computerized register data. They are described in table 7 in more detail. 35 comparisons (Best: PED 22 / similar or not significance 3 / FP-GP 10) 10 studies: (Best: PED 4 / Similar 3/ FP-GP 3)
  37. 37. RESULTS: other PREVENTIVE ACTIVITIES (studies, n = 6)The delivery of other clinical preventive services, besides vaccination, as well as otherhealth education activities, was assessed in six studies. Additional information on theseservices is shown in table 8. 6 studies. All of them, but one retrospective cohort study (Bocquect, 2005), were cross- sectional studies (surveys)  17 comparisons (Best: PED 12 / similar 2 / FP-GP 3)  6 studies: (Best: PED 4 / Similar 2/ FP-GP 0)
  38. 38. RESULTS: Use of Diagnostic Test (studies, n = 10)Ten studies performed some kind of comparison in this field of theclinical practice. Six had a cross-sectional design and four were cohortstudies (one prospective and three historical cohort studies). Furtherdetails of these studies are provided in the table 9 of the SR. 20 comparisons (Best: PED 12 / no differences or no significance 4 / FP-GP 4) 10 studies: (Best: PED 6 / Similar 1/ FP-GP 4)
  39. 39. RESULTS: Use of Diagnostic tests (studies n = 10)
  40. 40. Summarized ResultsResults• On average, FP/GP prescribed more ATB than PED in upper respiratory tract infections of probable viral etiology (OR: 1.4; confidence interval; 95% CI: 1.1-1.8).• PEDs were more likely to adhere to clinical guidelines recommendations on febrile syndrome management (OR: 9; 95% CI: 3-25) and on ADHD (OR: 5; 95% CI: 3-11). Pediatricians showed, as well, more resolution capacity on other highly prevalent conditions in children and adolescents, such as asthma and AOM.• PED showed higher vaccination coverage than FP/GP in all the studies assessing this result.
  41. 41. Summarized Results In CARDIOVASCULAR PREVENTION: Interventions related to prevention of tobacco consumption and to increasing physical exercise → better accomplished by FP/GP. Obesity screening and treatment, hypercholesterolemia screening, and blood pressure measurement → more frequently accomplished by PEDs.• In OTHER PREVENTIVE ACTIVITIES: PEDs were more active than GPs in counseling about preventing accidents, intoxications and rickets. FP/GP → more active in preventing toxic consumption.
  42. 42. Summarized Results IIIUse of a diagnostic test in primary care was better performedby PEDs.•Number of test ordered: PEDs ordered fewer chest X-raysmotivated by suspicion of pneumonia [Risk Difference (RD)PED vs GP: -6.90; 95% CI: -8.80 to -4.90]; more blood test inthe young infant with fever (RD PED vs GP: 12.50; 95% CI:10.00 to 14.30); and more diagnostic test for streptococcalthroat infection in sore throat (OR GP/FP vs PED: 0.46; 95% CI:0.32 to 0.66).•Higher probability of finding an abnormal result, among the x-ray ordered by PEDs than among those ordered by GPs (RR:2.6; 95% CI: 1.1 to 6.6)
  43. 43. Limitations of the SR• Few analytical design studies ( no clinical trial, and a absence of prospective studies)• Studies based on clinical records were a minority (22)• Mostly cross-sectional designs (self-administered questionnaires with low response rates) . The percentages of responders usually not distributed equally between PEDs and FPs/GPs: (PEDs responded more often)• The general level of quality of the studies.• In most of the studies the research was not designed for this comparison (between the clinical practice of PEDs and FPs/GPs ) as theirs main outcome variable.• SR about an under investigated problem, in general terms, (not at all studied in Spain)• “Conflict of interest”
  44. 44. Strengths of the SR• This one is the first review (with methodology of SR) that compares clinical practice between PEDs and FPs / GPs in PPC (Pediatric Primary Care)• In most studies retrieved the objective of the researchers was not to determine what type of professional (PEDs or GP / FP) provided better clinical services to children and adolescents.• Despite the heterogeneity inter-studies found, it could be seen a clear trend towards PED performing better...
  45. 45. DISCUSSION (HIGHLIGHTED POINTS)
  46. 46. Conclusions:The current situation could be summarized in the following highlightedpoints:•A better pattern of drug prescription (fewer overall prescriptions and betteradapted to the disease being treated. PEDs prescribe fewer ATBs andperformed better in other like psychotropic drugs)•PEDs adhere better to the recommendations of clinical practice guidelines(CPG). A higher degree of compliance with the recommendations aboutdiseases with high incidence and prevalence in children and adolescents (RI,AOM, OME, fever, bronchial asthma, ADHD and overweight-obesity)
  47. 47. Discussion1. A more rational use of diagnostic tests(e.g. chest x-ray, GABHS testing or oropharyngeal culture) PEDs order fewer diagnostic tests and “have a better aim when firing a shot” (more pathologic findings and more positive results).2. PEDs show lower percentages of referral to the specialized attention level in diseases with high incidence and prevalence. (higher resolution capacity of PEDs for diseases that pose a major economic and care burden for health systems)
  48. 48. Discussion (INMUNIZATIONS)PEDs → more adequate implementation of vaccination (the mainprimary prevention activity) recommendations and a betterfulfilment of the official immunization calendars. PEDs took advantage more frequently of acute illness visits foradministering vaccines. Had fewer assumptions about false hypotheticalcontraindications for immunization. Better at immunization information registering and at trackingundervaccinated children and adolescents. All the studies agreed in that, if PEDs are responsible for thisactivity (Vaccination), it is carried out in a more complete way.
  49. 49. DiscussionAbout psychiatric disorders, GPs were morelikely to prescribe SSRIs for all the diseasesstudied. For some of them, these drugs are notindicated at all (enuresis, ADHD).A high degree of awareness of therecommendations of a CPG about the ADHD,and a better compliance with them by PEDs
  50. 50. Discussion (Cardiovascular Risk preventive activities):PEDs provide more preventive services and more health counseling. Cardiovascular Risk preventive activities: It could be concluded that FPs were more likely to perform preventive activities in the absence of overweight and obesity (diet, smoking and exercise counselling) but PEDs were more likely to  Detect obesity/overweight and to solve them.  Order a cholesterol screening test when positive family history of hypercholesterolemia was noticed.  To record smoking by a parent, as a problem for the child.
  51. 51. Discussion Consequences of the high incidence of diseases inchildren with a better pattern of medicationsprescription by PEDs: • Significant impact on the pharmaceutical budget • Less generation of antimicrobial resistances • Fewer iatrogenic factors.
  52. 52. 3rd annual meeting of ECPCP(European Confederation of Primary Care Pediatricians) THE IMPORTANCE OF PRIMARY CAREPEDIATRICS IN EUROPE: From Concepts to Evidences 22, June 2012 -Our Systematic Review - Conclusions
  53. 53. Main conclusionThe main conclusion is that, in developed countries, primary health care delivered by PEDs result in better immunization practices and better compliance with guidelines of frequent diseases than those delivered by GPs/FPs.
  54. 54. Main conclusionMost of the results obtained were studied in outcome variables of greatimportance for physicians, patients and health service managers, sincesmall variations in the provision of those care services can haveenormous impact fact in terms of health or otherwise.No cost analysis study was identified in the conducted search, comparingthe clinical practice between PEDs and FPs / GPs. However, theassessed data suggest that the health care provided by PEDs in PC couldbe cost saving for those health systems which have PEDs in their primarycare settings.
  55. 55. Main conclusion:  The Pediatric Primary Care (PPC) is an essential public health issue. Therefore, the professionals chosen to perform it out should be those most qualified and trained to provide care to children and adolescents.With these findings in mind, it seems to be recommendable to maintain the PED in the PC teams, and to strengthen their specific role as the children’s first contact point with the health care system .
  56. 56. DiscussionSeveral implications for further research can be drawn from this review. There is a need for observational studies (cohort or case control) in which differences in clinical practice between PEDs and GPs should be compared in specific areas such as drug prescription, institutional CPG implementation, and the percentage of referrals to emergency department or specialized attention.
  57. 57. In brief:
  58. 58. PAPERS PUBLISHED AFTER THE Systematic Review* Synthesized summary of a preliminary (“at a glance”) overview (no rigorous methodological analysis applied) What medical professional is the most adequate to provide health care to children in primary care in developed countries? Systematic reviewBibliographic Search terms and search strategic offered for consult (pdf) on demand: pediatricwordl@gmail.com
  59. 59. Number of new articles found: 22(Date of the Bibliographic Search: 22-May-2012)
  60. 60. NUMBER OF COMPARISIONSCONTAINED IN THE PAPERS
  61. 61. USEFUL COMPARISONSDistribution by type of professional that showed the most adequate performance:
  62. 62. COMPARISONS WIHT A MOST ADEQUATE MEDICAL PROFESSIONAL(PERCENTAGES IN RELATION TO THE TOTAL NUMBER OF USEFUL COMPARISONS FOUND)
  63. 63. PERFORMANCE OF MEDICAL PROFESSIONAL (PCP) (Best adequateness expressed in percentages)PROFESSIONAL BESTFP / GPEqual 6 13 Best performance by type ofPediatricians 72 professionalUSEFUL COMPARISONS: 91 PediatriciansCOMPARISIONS THAT FAVOR: NumberFP / GP 6 76%EQUAL 13PEDIATRICIANS 72 EqualNOT USEFUL 6 14% FP / GP 7%TOTAL (Useful comparisons): 91
  64. 64. NUMBER OF COMPARISONS WITH A TYPE OF PROFESSIONAL SHOWING A MOST ADEQUATEPERFORMANCE (% relate to the total number of useful comparisons)
  65. 65. The MOST ADEQUATE (by Categories*) CATEGORIES COMPARISONS COMPARISONS COMPARISONS MOST ADEQUATE (best : FP / GP) (best: PED) (Similar) N of papers (n of Number Number Number comparisons)ALLERGIES 1 (16) 1 15 PEDOMA / URTI / PHARINGITIS 3 (6) 4 2 PEDChild Abuse 2 (16) 14 2 PEDASTHMA 1 (12) 2 9 1 PEDReferral 2 ( 3) 2 1 PEDImmunizations 5 (8) 7 1 PEDPSYCHIATRIC Problems 2 (8) 2 4 2 PEDPreventive Activities (CARDIOV) 1 2 PED(2)Preventive Activities (Other**) 3 (8) 8 0 PEDChronic diseases 1 (5) 1 3 1 PEDAntibiotics 1 (7) 4 3 PED  *All the comparisons have been incorporated to one, and only one Category, but, in fact, many of them could apply to more than one (Ex: Asthma + immunizations)  ** Two of the papers of the Category “Preventive Activities” were about dental health.
  66. 66. LIST OF NEW PAPERS FOUND (researches published after the bibliographic search for the SR) Search Date: 15, May 2012
  67. 67. 1. Huang TT, Borowski LA, Liu B, Galuska DA, Ballard-Barbash R, Yanovski SZ, Olster DH, Atienza AA, Smith AW. Pediatricians and family physicians weight-related care of children in the U.S. Am J Prev Med. 2011 Jul;41(1):24-32. PMID: 21665060 http://www.ncbi.nlm.nih.gov/pubmed/21665060 2. Paediatric asthma outpatient care by asthma nurse, paediatrician or general practitioner: randomised co Kuethe M, Vaessen-Verberne A, Mulder P, Bindels P, van Aalderen W. Prim Care Respir J. 2011 Mar;20(1):84-91. PMID: 21311842 Related citations (Reviewer remark: not clear if the “pediatricians” were PCP) 3. Cadieux G, Abrahamowicz M, Dauphinee D, Tamblyn R. Are physicians with better clinical skills on licensing examinations less likely to prescribe antibiotics for viral respiratory infections in ambulatory care settings? Med Care. 2011 Feb;49(2):156-65. Erratum in: Med Care. 2011 May;49(5):527-8. PMID: 21206293 http://www.ncbi.nlm.nih.gov/pubmed/21206293 4. Abbas S, Ihle P, Heymans L, Küpper-Nybelen J, Schubert I. Differences in antibiotic prescribing between general practitioners and pediatricians in Hesse, Germany. Dtsch Med Wochenschr. 2010 Sep;135(37):1792-7. Epub 2010 Sep 7. German. PMID: 20824600 http://www.ncbi.nlm.nih.gov/pubmed/20824600
  68. 68. 5. Wortberg S, Walter D.Recallsystems in primary care practices to increase vaccination rates against seasonal influenza. Dtsch Med Wochenschr. 2010 Jun;135(22):1113-7. Epub 2010 May 7. German. PMID: 20455199 Related citationshttp://www.ncbi.nlm.nih.gov/pubmed/20455199 6. Otto O, Peleg R, Press Y. Streptococcal pharyngitis among children: comparison of attitudes between family physicians and pediatricians. Harefuah. 2009 Aug;148(8):511-4, 573.[Article in Hebrew]http://www.ncbi.nlm.nih.gov/pubmed/19899252 7. The choking game: physician perspectives. McClave JL, Russell PJ, Lyren A, ORiordan MA, Bass NE. Pediatrics. 2010 Jan;125(1):82-7. Epub 2009 Dec 14. PMID: 20008424 [PubMed - indexed for MEDLINE] Free Article ARTICLE 9 Related citations8. Gundogdu Z, Gundogdu O.Parental attitudes and varicella vaccine in Kocaeli, Turkey. Prev Med. 2011 Mar-Apr;52(3-4):278-80. Epub 2011 Jan 26. PMID:21277890Parental attitudes and varicella vaccine in Kocaeli, Turkey.[PubMed - indexed for MEDLINE]
  69. 69. 9. Food allergy knowledge, attitudes, and beliefs of primary care physicians. Gupta RS, Springston EE, Kim JS, Smith B, Pongracic JA, Wang X, Holl J. Pediatrics. 2010 Jan;125(1):126-32. Epub 2009 Dec 7. PMID: 1996961910. Barriers to vitamin D supplementation among military physicians. Sherman EM, Svec RV. Mil Med. 2009 Mar;174(3):302-7. PMID: 1935409611. Discussion of maternal stress during pediatric primary care visits. Brown JD, Wissow LS. Ambul Pediatr. 2008 Nov-Dec;8(6):368-74. Epub 2008 Oct 25. PMID: 19084786 [PubMed - indexed for MEDLINE]12. Primary care physician perspectives on reimbursement for childhood immunizations. Freed GL, Cowan AE, Clark SJ. Pediatrics. 2008 Dec;122(6):1319-24. PMID: 1904725213. Physician perspectives regarding annual influenza vaccination among children with asthma. Dombkowski KJ, Leung SW, Clark SJ. Ambul Pediatr. 2008 Sep-Oct;8(5):294-9. Epub 2008 Aug 20. PMID: 18922502 Related citations14. Comfort level of pediatricians and family medicine physicians diagnosing and treating child and adolescent psychiatric disorders. Fremont WP, Nastasi R, Newman N, Roizen NJ. Int J Psychiatry Med. 2008;38(2):153-68. PMID: 18724567 [PubMed - indexed for MEDLINE] ARTICLE 16
  70. 70. 15. Okumura MJ, Heisler M, Davis MM, Cabana MD, Demonner S, Kerr EA. Comfort of general internists and general pediatricians in providing care for young adults with chronic illnesses of childhood. J Gen Intern Med. 2008 Oct;23(10):1621-7. Epub 2008 Jul 26. PMID: 18661191 http://www.ncbi.nlm.nih.gov/pubmed/18661191 16. Chatterjee JS, Mahmoud M, Karthikeyan S, Duncan C, Dover MS, Nishikawa H. Referral pattern and surgical outcome of sagittal synostosis. J Plast Reconstr Aesthet Surg. 2009 Feb;62(2):211-5. Epub 2008 Mar 10. PMID: 18329351 Related citations17. Feder HM Jr, Collins M. How Connecticut primary care physicians view treatments for streptococcal and nonstreptococcal pharyngitis. Clin Ther. 2008 Jan;30(1):158-63.http://www.ncbi.nlm.nih.gov/pubmed/1834325218. Training pediatric health care providers in prevention of dental decay: results from a randomized controlled trial. Slade GD, Rozier RG, Zeldin LP, Margolis PA. BMC Health Serv Res. 2007 Nov 2;7:176. PMID: 17980021 Related citations
  71. 71. 18. [Pediatric Otolaryngology at the Public Health System of a city in Southeastern Brazil]. Guerra AF, Gonçalves DU, Werneck Côrtes Mda C, Alves CR, Lima TM. Rev Saude Publica. 2007 Oct;41(5):719-25. Portuguese. PMID: 17923892 [PubMed - indexed for MEDLINE]20 [Vaccination practices following the end of compulsory BCG vaccination. A cross- sectional survey of general practitioners and pediatricians]. Wattrelot P, Brion JP, Labarère J, Billette de Villemeur A, Girard-Blanc MF, Stahl JP, Brambilla C.Arch Pediatr. 2010 Feb;17(2):118-24. Epub 2009 Dec 2. French. PMID: 1995934621 Awareness and knowledge of child abuse amongst physicians - a descriptive study by a sample of rural Austria. Kraus C, Jandl-Jager E.Wien Klin Wochenschr. 2011 Jun;123(11-12):340-9. Epub 2011 May 4.PMID: 21538034.22. - Starling SP, Heisler KW, Paulson JF, Youmans E. Child abuse training and knowledge: a national survey of emergency medicine, family medicine, and pediatric residents and program directors. Pediatrics. 2009 Apr;123(4):e595-602.Child abuse training and knowledge: a national survey of emergency medicine, family medicine, and pediatric residents and program directors.
  72. 72. More details & Specifications of thepapers found after the publication ofthe SR. available on demand(unpublished data / May, 2012) pediatricworld@aol.com

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