Journal Club

February 1, 2009

A review of several recent medical journal articles of interest to pediatricians.

Why do parents go to the ED for nonurgent care?

Studies indicate that at least 58% of visits to pediatric emergency departments (EDs) are for nonurgent conditions. Investigators set out to determine why so many parents don't first go to their child's primary care provider (PCP).

Commentary

This is a small, single-site study, but its results are revealing. Parents are driven to the ED not by lack of knowledge about the severity of their child's condition, it seems, but by systemic barriers to getting care from their PCP. The path of least resistance leads to the ED, instead of the child's medical home. That needs to change.

Social development intervention in childhood has long-term effects

The project, begun in 1981, was conducted in 15 public elementary schools serving children from high-crime areas in Seattle. It focused on an intervention that included teacher training in use of a cognitive and social skills training curriculum; parenting classes in supporting children's academic development and in child behavior management skills; and social competence training for children, including instruction in refusal skills. Children in the intervention group received at least one semester of intervention in grades 1 through 4, and at least one semester in grades 5 and 6-a mean of about four years of intervention exposure. The control group, on the other hand, received no intervention.

Fifteen years later, investigators evaluated the effects in almost 600 participants, who were then 24- and 27-years old. Investigators used self-reports of mental health, sexual behavior, substance use, and crime (they also consulted court records), as well as functioning in school, work, and community.

Overall, by age 27, the intervention and control groups differed considerably on these measures. The intervention group had significantly fewer symptoms of mental health disorders, and were far less likely to have a diagnosed sexually transmitted disease. Intervention was not found to have an effect on either substance abuse or crime, however. Participants in the intervention group also were significantly more likely to be at or above the median in socioeconomic status (educational attainment or household income). Intervention also was associated, though weakly, with more community involvement and volunteerism (Hawkin JD et al: Arch Pediatr Adolesc Med 2008;162:1133).

Commentary

I would like to see an economist's analysis of the long-term financial impact of this program in light of its initial costs. The program's financial benefits include savings from missteps that were avoided, as well as the improved economic attainments of the intervention group. My guess is that return on investment was substantial.