Patient safety and quality of care continue to loom large in our patients’ and public leaders’ views about health care. Despite widespread interest in providing safe and excellent care by clinicians, many are uncertain how to respond. This course will provide both a framework for thinking about safety and quality and up-to-date information about major initiatives affecting pediatric care. Course content will specifically include updates on government initiatives about patient safety, a national project to reduce errors in hospitals, an improvement project building on comparative data from neonatal intensive care units, and the current status of efforts at quality measurement for health care accountability.

The Serving the Underserved (STUS) SIG meeting will build on the momentum of last year's meeting and will include:

Research/program evaluation in the STUS arena. We will highlight several successful STUS community-based projects with a special emphasis on successful program evaluation. Presenters will highlight lessons learned and academic areas to be advanced in this area. Discussants will review related resources including the AAP Center for Child Health Research and the PROS Network.

STUS curriculum development. There has been a lot of progress with the STUS SIG web-based curriculum over the last year. We will discuss this project and other curriculum development advances in the STUS field.

Community and the underserved. We will follow up last year's program with a discussion of the progress being made in improving care and education in the community. Discussants from the Dyson Initiative and CATCH will be included.

Legislative update. We will review the status of key federal and state legislative efforts regarding health services for underserved pediatric/adolescent populations.

Come and join us as we work to improve health services and STUS related teaching for underserved pediatric and adolescent populations.

Approaches to the diagnosis, prevention, and treatment of chronic conditions in childhood and adolescence have changed greatly with greater survival of most children, even with severe conditions. Thus, for most children, new issues include preparation for adulthood rather than expectation of early death. Community pediatricians have increasing numbers of children with chronic conditions in their practices and thereby face new challenges in the care of these children and their families. Advances in molecular biology and genetics will lead to more effective ways to identify and treat many conditions. At the same time, children and adolescents face a great rise in new epidemics of chronic conditions, with marked increases in obesity, asthma, Type 2 diabetes, mental health conditions (especially ADHD and depression). This session will examine new advances in the biology of chronic conditions, important changes in epidemiology, consideration of important outcomes for children and adolescents with chronic conditions, and new efforts to improve their pediatric care.

Overview

New Morbidities: Clinical and Social Changes in Childhood Chronic Conditions
James M. Perrin, Mass General Hospital for Children, Harvard Medical School, Boston, MA

Prospects for New Treatments
Alan B. Ezekowitz, Massachusetts General Hospital, Boston, MA

Improving the Care of Children with Chronic Illness
Carole M. Lannon, AAP liaison, National Initiative for Children's Helathcare Quality, University of North Carolina, Chapel Hill, NC

Outcomes of Chronic Conditions: What Should We Measure?
Ruth E. K. Stein, Albert Einstein College of Medicine/Children's Hospital of Montefiore, Bronx, NY

The repercussions of violence affect pediatric patients and their families every day. Many residency training programs struggle with how to address this new epidemic. This workshop presents a model of a creative, comprehensive violence assessment and prevention curriculum, encouraging medical educators to explore new teaching methods. We hope to stimulate a lively discussion of educational strategies: didactic presentations, multimedia demonstrations, standardized patient interviews, community resource displays and evaluation methods. Attendees will be trained in case-based role-play scenarios to facilitate learners' communication skills within the patient-physician encounter. The workshop will offer specific didactic outlines and examples of pertinent videotapes and community resource displays as springboards for conversation regarding improvement of resident violence education. The model suggests one evaluation method that reinforces the newly acquired competencies via the creation of learner contracts. Small group discussions will be used to generate new ideas in violence-related curriculum development and evaluation.

Shannon Phillips, Jill Mazurek, Mary Ciccarelli, Marilyn Bull, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN

In 1997, the Residency Review Committee required that all pediatric residents be prepared for the role of child advocate. Last year, our SIG accepted the challenge of developing standards for child advocacy training. We welcome all who are interested in teaching about child advocacy to join us in that task. We are particularly interested in hearing from residents about their experiences - what have you done, what worked and what are the generalizable lessons for other programs. E-mail your thoughts to the co-chairs, David Keller (david.keller@ummed.edu) or Rosalind Vaz (RVaz@lifespan.org). We look forward to seeing you in Baltimore!

The U.S. rapidly is growing more culturally diverse. In several cities, whites already are in the minority. Culture has a profound impact on pediatrics, affecting multiple aspects of clinical care, including outcomes, processes, quality, satisfaction, obtaining an accurate history, and adherence. Cultural competency is the ability to recognize and appropriately respond to key cultural characteristics that affect clinical care in the major cultural groups seen in your practice. In this workshop, participants will learn about a model of cultural competency that can be applied to any cultural group that might be encountered by the pediatrician. This model is based on five aspects of culture that affect clinical care: 1) normative cultural values; 2) language issues; 3) folk illnesses; 4) parent beliefs; and 5) provider practices. The Latino and African-American cultures will be used to illustrate the most important ways that culture impacts pediatric care, drawing on the rich available literature and the personal experience of the workshop leaders.

Using an evidence-based approach derived from critical studies on Latino and African-American culture, workshop participants will learn and master the cultural competency model. Illustrative cases (including videotapes) will be presented to challenge participants and further solidify their skills. Participants can expect to acquire practical skills for recognizing and appropriately responding to crucial aspects of culture and language that affect pediatric care.

G. Flores and G. Askew, Department of Pediatrics, Boston Medical Center and Boston University Schools of Medicine & Public Health, Boston, MA

This session will provide an introduction to HCUP, a family of databases and tools maintained by the Agency for Healthcare Research and Quality (AHRQ). The objectives of HCUP are to provide data and tools for research on use of health care services in the U.S. HCUP is a partnership among states, industry, and the federal government; currently 26 states contribute data to the project. HCUP includes uniformly formatted administrative databases including state inpatient data, a nationwide sample of inpatient data, a children's inpatient dataset, and ambulatory surgery data. HCUP data provide many advantages for research: (1) all payers including uninsured, (2) all stays within participating institutions, (3) permit state-level analyses, (4) large sample sizes permit studies of subgroups (e.g., minorities, rare diseases or procedures), and (5) charge data.

Recent innovations in dissemination make these data even more accessible. HCUP also includes software and Internet tools to better use these databases, for example, HCUPnet (interactive web-based query tool for HCUP data), free software (HCUP Quality Indicators, performance measures), and clinical groupers (Clinical Classification Software). HCUP has been infrequently used for pediatric research, but recent advances - the Children's Nationwide Inpatient Sample and the Child and Adolescent Clinical Classification Software - will make the databases and tools even more useful to study children's health care issues. Examples of research studies using HCUP data and tools will be used to illustrate applications.

A. Elixhauser, C. Steiner, J. Thompson, Agency for Healthcare Research and Quality, Rockville MD and University of Arkansas for Medical Sciences, Little Rock, AR

The importance of community-based pediatric training was formally recognized when, in 1996, the Residency Review Committee (RRC) for Pediatrics mandated structured educational experiences in community pediatrics. Under the leadership of late Foundation president pediatrician Anne E. Dyson, the Dyson Foundation, launched a program to stimulate innovation in community pediatrics residency training. The ultimate goal of The Dyson Initiative-Pediatric Training in the Community, which allocates $2.5 million over five years to pediatric residency programs, is to expand the repertoire of residency training to include teaching and experiences in community-based medicine and advocacy.

This workshop will focus on curricular changes that can be implemented to strengthen community-based training. Representatives from Dyson Initiative-funded sites will present innovative curricular enhancements, focusing on those changes that need not require a large monetary investment. They will also discuss the faculty development strategies that accompany curricular change. In the second part of the workshop, Dyson Initiative grantees will present their experience with community collaboration. Practical lessons learned from taking the residency outside the hospital/clinic walls will provide participants with insight into this integral facet of community pediatrics.

M. K. Goyal and J. S. Palfrey, The Dyson Foundation, Millbrook, NY and Dept of General Pediatrics, Children's Hospital, Boston, MA

Shaken Baby Syndrome is the most common cause of morbidity and mortality in inflicted, abusive head injury; the leading cause of traumatic death in infancy. Recent medical and legal controversies involving high -profile court cases as well the fact that the syndrome is frequently overlooked or misdiagnosed will be focused issues in this workshop. The workshop is designed to guide the physician through the process of diagnostic evaluation, therapeutic intervention, working with a child protection team response that includes medical, psychosocial, law enforcement and legal components, collection of evidence, preparation for court and aspects of expert testimony.

Covered topics will include epidemiology, history taking, physical exam, differential diagnosis, laboratory, radiological and diagnostic testing, crime scene investigation, forensic evidence and the legal response. Factual educational material will be presented with varied audiovisual formats including videotapes of perpetrators as well as demonstrations of the physical dynamics of shaking. The audience will have the opportunity to directly participate through the utilization of role modeling, mock investigation and courtroom trial.

M. Frogel and D. Esernio-Jenssen, Schneider Children's Hospital, New Hyde Park, NY and M. Fisher, Special Victim's Bureau, District Attorney's Office, Queens, NY

This symposium will address a topic of considerable public debate, especially as it relates to research involving human subjects, among these clinical trials using children as subjects, and research involving gene therapy. A recent two-day meeting at NIH was devoted to this subject and it is likely that there will be new and more explicit guidelines promulgated by HHS. The symposium will address these issues from the perspective of academic pediatrics and pediatric research, in particular with regard to the impact on education at both the undergraduate and graduate levels and the availability of appropriate tests and therapies for children. The role of professional societies, such as the sponsoring members of the PAS meeting, will be examined. The symposium is planned to allow at least 30 minutes of interactive discussion between the members of the panel and the audience.

Check for information on this SIG on our website at www.aps-spr.org in early 2001.

In the late 1990s, there has been an epidemic of schoolyard shootings. Yet data seem to show that the rate of juvenile violence is decreasing. Why the discrepancy? Can adolescents who are prone to commit violent crimes be identified ahead of time? Why do they commit such crimes. Are we "teaching" our children how to kill? What role do the media play in these crimes?

This workshop will employ an informal approach to answering at least some of these questions, using data, case vignettes, role playing and video clips.

Dr. Strasburger is a nationally known expert on children, adolescents, and the media. Lt. Col. Dave Grossman is an Army Ranger, a West Point Psychology Professor, and a Professor of Military Science who wrote the Pulitzer-Prize-nominated book, On Killing, and the recent book, Stop Teaching Our Kids to Kill. He was a consultant after the Jonesboro, AR, Paducah, KY, Springfield, OR, and Littleton, CO school shooting incidents and testified in the trial of Timothy McVeigh.

Vic Strasburger, M.D., Professor of Pediatrics, Univ. of New Mexico School of Medicine and Lt. Col. Dave Grossman, U.S. Army (Ret.)

This symposium will provide a broad overview of the state of the pediatric AIDS pandemic. The results of recent trials investigating approaches to prevention and treatment of vertical HIV transmission in the developing world will be discussed. Collaborative approaches and opportunities for partnership in international pediatric AIDS treatment, education, and research will be highlighted.

Approaches to Prevention of Mother-to-Child HIV Transmission in the Developing World
Lynne M. Mofenson, National Institute of Child Health and Human Development, Rockville, MD

Discussion

Hormones regulate critical biological functions including neurologic growth, sexual differentiation, and organ maturation, through intricate signaling mechanisms. Pregnant women, infants, and children are increasingly exposed to chemicals in the environment that mimic or block hormones, often at very small doses. Exposure to these endocrine disruptors occurs at home, in the workplace and the community, and even as a consequence of medical care. This session will review the growing evidence of adverse health effects due to exposure to endocrine disruptors and discuss new research efforts that will help fill in the gaps in our knowledge in this area.

Overview
Philip John Landrigan, Center for Children's Health & the Environment, Mt. Sinai School of Medicine, New York, NY

Evidence of Endocrine Disruption: Lessons from Wildlife
Louis Guillette, University of Florida, Gainesville, FL, University of Florida, Gainesville, FL

NHANES: A Rich Source of National Pediatric and Adolescent Exposure Data
Elaine Gunter, NHANES Laboratory, Centers for Disease Control & Prevention, Atlanta, GA

Biomarkers in Endocrine Disruptor Research
Cynthia F. Bearer, Case Western Reserve University, Cleveland, OH

Discussion

1) Ongoing research projects
Descriptions of innovative educational and clinical programs

The identification and measurement of health care quality for children with chronic conditions is a pressing need shared by clinicians, health plans, consumers and Federal, State and local health agencies. Available methods vary widely in the definition of chronic condition used and cost of administration. The goal of this workshop is to outline alternatives for identifying and measuring quality for children with chronic conditions and an approach that is expected to be used in National health plan monitoring systems (HEDIS) as well as the National Medical Expenditures Panel Survey (MEPS). Two parent survey based and administrative/diagnostic based method for identifying children with chronic conditions will be compared in terms of their appropriateness for alternative applications such as case identification, quality improvement, quality assessment, comparing performance of providers and/or health plans or community health assessment. Results from a 16 sample, multi-State, multi- health plan study testing and comparing these methods will be used as a basis for recommendations. Real life examples of using the identification and measurement tools for prevalence's estimation, case identification, quality improvement and performance comparison will be provided.

C. D. Bethell, D. K. Read, The Foundation for Accountability, P. Newacheck, UCSF Institute for Health Policy Studies, R. E. K. Stein, Albert Einstein College of Medicine, J. Fowler, University of Massachusetts, J. Thompson, Arkansas Children's Hospital

The participation of children in research is a double-edged sword. Children are vulnerable and need protection, yet their participation is critical to ensure improvements in the medical care of this same population. The fundamental question is how to balance the need for protection and access in a manner that is ethically sound and yet pragmatically feasible.

In this workshop, we will look at various recent publications in pediatric journals and present several vignettes to explore ethical and policy issues regarding the participation of children as human subjects. Through the scenarios, we will discuss such issues as: 1) the questions raised by the need to balance access versus protection; 2) the potential impact on this balance of the new NIH and FDA policies that went into affect in the late 1990s; 3) ethical issues regarding consent to participation (e.g., should adolescents be able to consent to research without parental participation?); and 4) ethical issues in research design (e.g. when are placebos morally justifiable?). For each vignette and journal article, the workshop leaders will then present where there is and is not consensus between bioethicists.

L. F. Ross, J. D. Lantos, G. Koren, S. Leikin, University of Chicago, Chicago IL (LFR, JDL), University of Toronto, Toronto Canada (GK), Office of Human Protection Research, Department of Health and Human Services, Washington, DC (SL--probable).

The medical home model of care is described as accessible, family-centered, comprehensive, continuous, coordinated, compassionate and culturally-competent. Components include attention to mental health, parent support, education, religious and spiritual support, access to specialists, and finances.

Community pediatrics recognizes economical, educational, environmental, social, political and family forces that impact on child health. Service integration and advocacy are seen as key to the medical model and the practice of community pediatrics. The role of the interdisciplinary team proposes new avenues for effective health care delivery. Translating these concepts into reality as part of program design is challenging. Integrating residency education, program evaluation, and promoting sustainability require a deliberate process. This workshop will address the key components of innovative programs providing improved access to care for children and adolescents. The panelists will review the literature, summarize the experience of the broad-based community partnerships of the Community Access to Child Health Programs (CATCH) and the experience of the recipients of the APA Health Care Delivery Award. The extent to which these models reflect evidence-based practice will be discussed. Specific resources to develop programs will be shared with the workshop participants.

D. Laraque, J. Cox, M. LoFrumento, T. Tonniges, K. Capitulo and the APA Health Care Delivery Committee. Mt Sinai Medical Center, NY; Children's Hospital, Boston; Franklin Pediatrics, NY; American Academy of Pediatrics

This workshop will enable participants to begin using public use files from the Medical Expenditure Panel Survey (MEPS), a large national study of health care use and expenditures, health status, access to care and insurance. The design of the survey will be reviewed and examples of past uses of the survey for pediatric research will be discussed to demonstrate the potential uses of the MEPS for children's health care issues and policy interventions. Participants will become familiar with the content of public use files, including person-level files, condition files, and event files, such as ambulatory care, hospital, emergency room, and prescribed medication files. The workshop will also cover the basics of setting up an analytic file for research from public use files and the use of appropriate software. Time will be allotted for questions. This workshop is designed for health services researchers who have a background or interest in using national surveys. Some familiarity with statistical software (SAS, SPSS, etc.) would be helpful. Analysts whose primary interest is in local area analysis or clinical research would not benefit from this workshop.

N. A. Krauss, R. M. Weinick, and J. S. Banthin Center for Cost and Financing Studies, Agency for Healthcare Quality and Research, Rockville, MD USA

There is a growing body of research examining the prevention of child abuse and neglect. The link between domestic violence and child maltreatment has become increasingly clear, with important implications for pediatricians. Recent studies have demonstrated the potential impact that various strategies could have on the incidence of abuse and neglect. This symposium will present new information regarding the use of home visitors and the role of physicians in identifying and preventing abuse. The presenters will also discuss the need to establish child abuse prevention as a higher priority for funded research and as a major public health concern.

A National Call to Action To End Child Abuse
David Chadwick, Director, Emeritus Center for Child Protection, Children's Hospital, San Diego, CA, Emeritus, Center for Child Protection, Children's Hospital, San Diego, CA

Domestic Violence, Child Maltreatment, and the Pediatrician's Role
Howard Dubowitz, Professor of Pediatrics, Chief, Division of Child Protection, University of Maryland School of Medicine, Baltimore, MD

Building Systems To Improve Preventive Care: Linking Home and Office-based Prevention
Peter A. Margolis, Children's Primary Care Research Group, University of North Carolina School of Medicine, Chapel Hill, NC

Preparing Physicians To Identify and Prevent Abuse
Desmond K. Runyan, Professor and Chair of Social Medicine, University of North Carolina School of Medicine, Chapel Hill, NC

The Pediatric Environmental Health Special Interest Group is again invites your participation at our annual session at the Spring Pediatric Academic Societies Meeting in Baltimore. Our agenda will include the following:

1. Educational /Training session - Toxic Effects of Herbal Remedies - - Michael Shannon, M.D.
2. Pediatric Environmental Health Training during Pediatric Residency Programs - examples from the field
3. New Ambulatory Pediatric Association Environmental Health Fellowship - a status report
4. Environment Health and the Underserved - collaborative opportunities
5. Research Presentations

SIG Business

The objective of this workshop is to address key issues concerning the use and safety of dietary supplements in infants and children. There is a growing body of evidence that nutrients and other bioactive components of foods play a significant role in health promotion and disease prevention in adults and this information has increased the use of dietary supplements in infants and children. However, little is known about the interaction between the use of many of these supplements and developmental physiology and behavior in children. Such knowledge is critical when evaluating either the justification or safety of this trend. Topics to be addressed at the workshop include: 1) Current usage patterns among infants, children and adolescents; 2) Evidence-based justification for dietary supplement use at various developmental stages; 3) Age-dependent factors influencing bioavailability, pharmacology and safety; 4) Behavioral factors that impact attitudes and beliefs about dietary supplements; 5) Biomarkers for the assessment of efficacy and safety; and, 6) Identification of research needs.

P. M. Coates, D. J. Raiten and M. F. Picciano, Office of Dietary Supplements, National Institutes of Health & Office of Prevention Research and International Programs, National Institutes of Child Health and Human Development, Bethesda, MD

Asset Based Community Development (ABCD), a community building approach promoted by John McKnight and Jody Kretzmann, can be an important skill in community pediatrics. ABCD stresses identifying and mobilizing community assets to improve well-being. CATCH developed an educational curriculum to teach pediatricians the fundamentals of mobilizing communities. The Northern California CATCH Committee and the ABCD Institute presented this curriculum to pediatricians and their community partners with the support of Sierra Health Foundation.

The goals of this workshop are to introduce the CATCH curriculum, present ABCD concepts, and establish a basic framework for community building activities. This workshop includes an overview of the whole CATCH curriculum and presentation of two components: asset mapping and forming partnerships. In asset mapping, participants learn about the potential of associations and how to identify these untapped community resources for improving children's health. The participants then develop strategies to mobilize these community partners for a potential community-based project in the second session. The other components of the curriculum, setting goals and objectives and evaluating results, will be described in the overview.

Arnold Gold, Diane Littlefield, Carol Pandak and Richard Pan; Fremont-Rideout Health Group, Yuba City, CA; Center for Collaborative Planning, Public Health Institute, Sacramento, CA; Dept. of Community Pediatrics, American Academy of Pediatrics, Elk Grove Village, IL; UC Davis, Dept. of Pediatrics, Sacramento, CA.

The Human Genome Project is impacting every aspect of medicine. Dr. Craig Venter, President of Celera Genomics, one of the chief architects of this venture, will discuss the accomplishments of the human genome project and implications for future impact on health and disease in this special one-hour state of the art lecture.

Sequencing the Human Genome
J. Craig Venter, President, Celera Genomics, Rockville, MD

Supported in part by an educational grant from the Columbus Children's Hospital, Columbus, OH

Advances in molecular genetics and high through-put analytical chemistry like tandem mass spectrometry (MS/MS) are enabling technologies that permit expanded newborn screening for presymptomic diagnosis of disorders not previously feasible. The prototype genetic disease for which newborn screening is now available is cystic fibrosis. The group of metabolic diseases that can now be diagnosed by MS/MS includes medium chain acyl-CoA dehydrogenase (MCAD) deficiency and related disorders of fatty acid oxidation. This symposium will address the issue of whether these diseases should be added to expanded newborn screening profiles. If so, what is the sensitivity and specificity of the currently available tests? If included in expanded screening programs, who should do the testing and how? What are the implications for genetic counseling? Should any of the new approaches be adapted to preconceptual testing? What important policy issues are created by this new capacity? There is substantial variation among states currently on screening programs. Should there be national guidelines? Who should decide about expanded screening? How will these new tests be paid and by whom?

Newborn Screening for Cystic Fibrosis: An Opportunity To Give Every CF Patient a Healthy Start
Philip M. Farrell, Dean and Alfred Dorrance Daniels Professor on Diseases of Children, University of Wisconsin Medical School, Madison, WI

Public Policy Issues in Expanded Newborn Screening
Bradford L. Therrell, Director and Professor, National Newborn Screening and Genetics Resource Center, University of Texas Health Science Center, San Antonio, TX

The roles of nature and nurture in shaping behavior are complex and our understanding of them is constantly expanding. Exciting recent findings have given us new perspectives on biologic influences on brain functioning and subsequent behavior. Genetic conditions can be reflected in clearly identifiable behavioral phenotypes. Prenatal exposure to nicotine can have effects that are measurable in adolescence, and low level exposure to environmental toxins are impacting cognitive and behavioral functioning of the current generation. Three outstanding speakers will discuss these advances in our knowledge of neuroscience and their implications for the identification and treatment of a variety of neurodevelopmental conditions.

Overview
Daniel Lee Coury, Children's Hospital, Columbus, OH

Fragile X Syndrome: A Model of Gene-Brain Behavior Relationships
Randi J. Hagerman, University of California at Davis Medical Center, Sacramento, CA

Tobacco, Nicotine and Fetal Brain Damage: The Smoking Gun in ADHD and SIDS
Theodore Slotkin, Duke University Medical Center, Durham, NC

Neurotoxicity of Low-Level Exposure to Pesticides and PCBs
Philip John Landrigan, Center for Children's Health & the Environment, Mt. Sinai School of Medicine, New York, NY

Discussion

The role of experience and the environment in early child development has long been appreciated, but it has been likened to loading software on a computer.  Recent research in neurobiology suggests that early experiences are not only loading software but actually changing the hard wiring of the brain.  Many of the brain’s pathways are in place by three years of age.  What are the implications for this research?  Do these pathways continue to change and evolve with experience? What are the effects of early insults on brain development? This program will focus on the Institute of Medicine Report From "Neurons to Neighborhoods".  The speakers will focus on what is known about the neurobiology of brain development and the implications this research has on child development programs.  The session will highlight how the current knowledge of brain development will impact future research as well as how it may translate into public policy.

Overview
Barry S. Zuckerman, Boston University School of Medicine, Boston, MA

The Critical Period Viewpoint and a More Complete View of the Effects of Experience on the Brain
William Greenough, University of Illinois College of Medicine, Chicago, IL

Early Biologic Insults on Brain Development
Betsy Lozoff, University of Michigan, Ann Arbor, MI

Neurons to Neighborhood: Translating the Science to Policy and Program
Deborah Phillips, Georgetown University, Washington, DC

Discussion