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

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.

3rd annual meeting of ECPCP (European Confederation of Primary Care Pediatricians)

THE IMPORTANCE OF PRIMARY CARE PEDIATRICS IN EUROPE:From Concepts to Evidences

Buñuel Álvarez JC, García Vera C, González Rodríguez P, Aparicio

Rodrigo M, Barroso Espadero D, Cortés Marina RB y cols. ¿Qué profesional médico es el más adecuado para impartir cuidados en salud a niños en Atención Primaria en países desarrollados? Revisión sistemática. Rev Pediatr Aten Primaria. 2010;12:s9-s72.

Published in Internet: 31/03/201022, June 2012

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 reviewAuthors: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 J

3rd annual meeting of ECPCP (European Confederation of Primary Care Pediatricians) / 22, June 2012

What medical professional is the most adequate to provide health care to children in primary care in developed countries? Systematic review

http://www.pap.es/files/1116-1430-pdf/sup_21_ingles.pdf

http://pap.es/FrontOffice/PAP/front/Articulos/Articulo/_IXus5l_LjPoo2J2KDAbNm8JCpYgBVPcRGWJA9CjMLzZ8IMZsjMmv_g

Translated by: Domingo Barroso Espadero, Paz González Rodríguez, Ana Benito Herreros, Pilar Aizpurua Galdeano, M.ª Jesús Esparza Olcina, Álvaro Gimeno Díaz de Atauri y Leo Perdikidis Oliveri (members of the Grupo de Trabajo de Pediatría Basada en la Evidencia (Evindece-based Pediatrics Work Group) that belongs to the Asociación Española de Pediatría de Atención Primaria (AEPap/Primary Care Pediatrics Spanish Association) and to the Asociación Española de Pediatría (AEP/Spanish Association of Pediatrics).

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 ReviewJUSTIFICATION

http://www.pap.es/files/1116-1052-pdf/S9-S72_Que%20profesional%20medico%20es%20el%20mas%20adecuado.pdf

Justification for this Systematic Review: In Spain, the presence of pediatricians in Primary Care is frequently and periodically questioned. The increasing scarcity of pediatrics specialist available.

Total absence of studies having as their main objective the comparison, in Primary Care, of the clinical performance by pediatricians, working in Primary Care, versus the clinical practice by general practitioners (GP)/family doctors (FP), providing healthcare for children.

Answering the question, in developed countries, about what medical professional is the most adequate to provide health care to children in primary care. Presentation of the results from a Systematic Review.

Our Systematic Review (SR)Objectives & participants

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.

Purpose of the study: to look into the current situation of the problem, by means of a SR of the literature. Comparison of the clinical practice of primary care pediatricians to the

corresponding same clinical practice of FPs/GPs, regarding the following 9 CATEGORIES with aspects of the health care of children:

1. - Antibiotic (ATB) prescription in respiratory tract infections (RI) of probable viral etiology.2.- Otitis media treatment.3.- Management of asthma in children.4.- Management of fever in children.

5.- Management of children with psychiatric disorders, like depression, obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD)

6.- Immunizations: attitudes, beliefs, coverage and implementation of the official immunization schedules.

7.- Cardiovascular prevention.8.- Other preventive activities.9.- Use of diagnostic tests.

Bibliographic SearchData Bases:

Meta Search Engines:

Databases:

Search Engines:

List of References of the articles

Without language restriction. Until December, 2008.

59 publications : 1 investigation with a before-after study design. 10 cohort studies (many of them retrospective historical cohort studies). 3 cases-control studies. 45 transversal studies (mainly cross-sectional studies) .

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

22, June 2012

Statistical analysis

-Whenever possible, and based on results of every individual study, the following estimators of effect were calculated (if the were not already offered 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 effect size resulting from combining the outcomes by means of using a global estimated combined estimator: the combined OR.

3rd Annual Meeting of ECPCP3rd Annual Meeting of ECPCP / 20ème Congrès

National AFPA

Types of COMPARISONS included

o 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 prevalent medical problems (Ex.: otitis media = OM)

o Attitude of professionals in relation to recommendations (adequateness of the doctors in following recommendations from clinical practice guidelines (CPGs) / degree of adherences to recommendations…)

Types of COMPARISONS included (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 )

Types of COMPARISONS included (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.

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.

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 ),

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.

COMPARISONS (by Categories / Example IV)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…).

COMPARISONS (by Categories / Example V)

Management of children with psychiatric disorders, like depression, obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD)

Comparison of the different attitudes and likelihood of incorporating the recommendations from GPCs for the diagnostic assessment and the treatment of disorders like childhood depression, [selective serotonin reuptake inhibitors (SSRIs) antidepressants prescription / likely to use referrals to the specialist in mental health], also for the attention-deficit/hyperactivity disorder (ADHD) and for other psychiatric disorders.

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).

RESULTS

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.

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)

1) Studies conducted by means of consulting population-based databases.2) Designs compatible with historical cohort studies3) Located in primary care settings and/or hospital emergency settings.

RESULTS: Use of antibiotics in upper airway infections of

probable viral origin (meta analysis)

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)

RESULTS: ATB use for URI (individual, n = 17)

Ten studies analyzed the attitude of PED and FP/GP in relation to diagnosis and treatment of AOM (table 2). Seven were cross-sectional studies and 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)

RESULTS: AOM management (individual studies, n = 10)

Table 3. Studies that compare clinical practice of PED vs FP/GP in the management of asthma.Author/year of

publication/countryDesign/quality Participants Comparison Main outcome Results

Results favor:

Finkelstein JA, 2000.USA27

Cross-sectional, survey to providers.Medium/Low quality.

Sample of PEDs and FPs from three managed care organizations.A total of 407.

Adherence to CPG for asthma.

1.- OR adjusted of clinical essay with beta 2- agonists, X-ray of sinus, thorax X-ray, skin prick test or RAST test.To recommend daily peak flow measurement. To use spirometry in diagnosis (OR FP vs PED)2.- To refer to an asthma specialist according to CPG.

Clinical essay, X-ray, prick, RAST: no significant difference. 0.30 (95% CI 0.10 – 0.50)5.90 (95% CI 2.40 – 14.60)Measurement of four items: compliance of FP with criteria for referral to specialist was appropriate in two and no appropriate in the rest.

BOTH

Kozyrskyj AL, 2006. (Canada)14

Retrospective cohort study.Clinical registers from MHSIP.Medium quality.

32,746 visits in 7791 asthmatic children for wheezing episodes.

To examine the determinants of ATB use.

1.- OR FP vs PED for ATB prescription within 2 days after an ambulatory physician visit for a wheezing episode in children with asthma.2.- ATB within 7 days of the episode (RR)

2.10 (95% CI 1.82 – 2.53)1.25 (95% CI 1.23 – 1.27)

PED

Sun HL, 2006.Taiwan 28

Retrospective cohort study.Clinical registers.Medium quality

222,537 prescriptions in children aged< 16 years.

Prescribing patterns of anti-asthma drugs.

Inhaled beta2-agonist prescription.Inhaled corticosteroids prescription.RR of prescribing only a drug (no significance)Xanthine derivatives prescription.Oral beta-2 agonist prescription.

14.9% FP vs 3.1 % PED (p< 0.05)5.6 FP vs 7.8% PED (p< 0.05)FP vs PED0.76 (95% CI 0.74 – 0.77)0.56 (95% CI 0.53 – 0.59)1.50 (95% CI 1.45 – 1.56)

BOTH

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)

RESULTS: ASTHMA management (individuals studies, n = 3)

Table 4 summarizes the main characteristics of the three reviewed studies:

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)

RESULTS: FEVER management (individual studies, n = 3)

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)

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 and two 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)

RESULTS: Cardiovascular risk factors (Studies; n: 10)

Ten studies All studies were cross-sectional design, using surveys, except one, which was based 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)

RESULTS: other PREVENTIVE ACTIVITIES (studies, n = 6)

The delivery of other clinical preventive services, besides vaccination, as well as other health education activities, was assessed in six studies. Additional information on these services 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)

RESULTS: Use of Diagnostic Test (studies, n = 10)

Ten studies performed some kind of comparison in this field of the clinical practice. Six had a cross-sectional design and four were cohort studies (one prospective and three historical cohort studies). Further details 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)

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 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.

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.

Summarized Results IIIUse of a diagnostic test in primary care was better performed by PEDs.

•Number of test ordered: PEDs ordered fewer chest X-rays motivated by suspicion of pneumonia [Risk Difference (RD) PED vs GP: -6.90; 95% CI: -8.80 to -4.90]; more blood test in the young infant with fever (RD PED vs GP: 12.50; 95% CI: 10.00 to 14.30); and more diagnostic test for streptococcal throat 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)

• 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”

Limitations 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...

Strengths of the SR

DISCUSSION (HIGHLIGHTED POINTS)

Conclusions:

The current situation could be summarized in the following highlighted

points:

•A better pattern of drug prescription (fewer overall prescriptions and better

adapted to the disease being treated. PEDs prescribe fewer ATBs and

performed 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 about

diseases with high incidence and prevalence in children and adolescents (RI,

AOM, OME, fever, bronchial asthma, ADHD and overweight-obesity)

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)

Discussion (INMUNIZATIONS)PEDs → more adequate implementation of vaccination (the main primary prevention activity) recommendations and a better fulfilment of the official immunization calendars.

PEDs took advantage more frequently of acute illness visits for

administering vaccines.

Had fewer assumptions about false hypothetical

contraindications for immunization.

Better at immunization information registering and at tracking

undervaccinated children and adolescents.

All the studies agreed in that, if PEDs are responsible for this

activity (Vaccination), it is carried out in a more complete way.

DiscussionAbout psychiatric disorders, GPs were more likely to prescribe SSRIs for all the diseases studied. For some of them, these drugs are not indicated at all (enuresis, ADHD).

A high degree of awareness of the recommendations of a CPG about the ADHD, and a better compliance with them by PEDs

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.

Discussion Consequences of the high incidence of diseases in children with a better pattern of medications prescription by PEDs:

• Significant impact on the pharmaceutical budget

• Less generation of antimicrobial resistances

• Fewer iatrogenic factors.

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 Review- Conclusions

22, June 2012

Main conclusionThe 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.

Main conclusion

Most of the results obtained were studied in outcome

variables of great importance for physicians, patients and

health service managers, since small variations in the

provision of those care services can have enormous impact

fact in terms of health or otherwise.

No cost analysis study was identified in the conducted search, comparing the clinical practice between PEDs and FPs / GPs. However, the assessed data suggest that the health care provided by PEDs in PC could be cost saving for those health systems which have PEDs in their primary care settings.

Main conclusion:

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.

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.

DiscussionSeveral 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.

In brief:

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 review

Bibliographic Search terms and search strategic offered for consult (pdf) on demand:pediatricwordl@gmail.com

Number of new articles found: 22(Date of the Bibliographic Search: 22-May-2012)

NUMBER OF COMPARISIONS CONTAINED 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 COMPARISONS FOUND)

PERFORMANCE OF MEDICAL PROFESSIONAL (PCP) (Best adequateness expressed in percentages)

PROFESSIONAL BESTFP / GP 6Equal 13Pediatricians 72

USEFUL COMPARISONS: 91

COMPARISIONS THAT FAVOR: Number

FP / GP 6EQUAL 13PEDIATRICIANS 72NOT USEFUL 6

TOTAL (Useful comparisons): 91

FP / GP7%

Equal14%

Pediatricians76%

Best performance by type of professional

NUMBER OF COMPARISONS WITH A TYPE OF PROFESSIONAL SHOWING A MOST ADEQUATE

PERFORMANCE (% relate to the total number of useful comparisons)

The MOST ADEQUATE (by Categories*)CATEGORIES

N of papers (n of comparisons)

COMPARISONS (best : FP / GP)

Number

COMPARISONS (best: PED)Number

COMPARISONS (Similar)Number

MOST ADEQUATE

ALLERGIES 1 (16) 1 15 PED

OMA / URTI / PHARINGITIS 3 (6) 4 2 PED

Child Abuse 2 (16) 14 2 PED

ASTHMA 1 (12) 2 9 1 PED

Referral 2 ( 3) 2 1 PED

Immunizations 5 (8) 7 1 PED

PSYCHIATRIC Problems 2 (8) 2 4 2 PED

Preventive Activities (CARDIOV) 1 (2)

2 PED

Preventive Activities (Other**) 3 (8) 8 0 PED

Chronic diseases 1 (5) 1 3 1 PED

Antibiotics 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.

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 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: 21665060http://www.ncbi.nlm.nih.gov/pubmed/21665060

2.Paediatric asthma outpatient care by asthma nurse, paediatrician or general practitioner: randomised controlled trial with two-year follow-up.Kuethe M, Vaessen-Verberne A, Mulder P, Bindels P, van Aalderen W.Prim Care Respir J. 2011 Mar;20(1):84-91.PMID: 21311842Related 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: 21206293http://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: 20824600http://www.ncbi.nlm.nih.gov/pubmed/20824600

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: 20455199Related citations

http://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, O'Riordan MA, Bass NE.Pediatrics. 2010 Jan;125(1):82-7. Epub 2009 Dec 14.PMID: 20008424 [PubMed - indexed for MEDLINE] Free Article ARTICLE 9Related citations

8. 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]

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: 19969619

10. Barriers to vitamin D supplementation among military physicians.

Sherman EM, Svec RV.Mil Med. 2009 Mar;174(3):302-7.PMID: 19354096

11. 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: 19047252

13. 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: 18922502Related citations

14. 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

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: 18661191http://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: 18329351Related citations

17. 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/18343252 18. 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: 17980021Related citations

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: 19959346

21 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.

More details & Specifications of the papers found after the publication of the SR. available on demand (unpublished data / May, 2012)

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