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The new world of managed care has brought at least one good idea: We should try to find out if the things we do, particularly the things that cost money, really make a difference in the lives of our patients.
Ask several parents what they want for their children in adulthood, and the answer is likely to be different from parent to parent and from moment to moment. It would be simpler if we merely wanted children to grow up to be healthy. But even meeting a parental request that a child become a healthy adult would mean that we'd have to know how to prevent tobacco and drug use, fast driving, and diving into shallow ponds without looking, not to mention chronic conditions like inflammatory bowel disease and type 1 diabetes mellitus (see articles on pages 45 and 112 of this issue).
The new world of managed care has brought at least one good idea: We should try to find out if the things we do, particularly the things that cost money, really make a difference in the lives of our patients. The studies that result from asking this kind of question are called outcome studies, and their results have begun to challenge some of the assumptions we've made in caring for patients. For example, we may have the same success if we treat acute otitis media for five days instead of 10. Outcome studies have also, in some cases, answered important questions about long-term management of chronic conditions. For example, tight control of serum glucose levels in children with type 1 diabetes mellitus helps avoid some of its long-term complications.
Good health isn't all that parents want for their children, however. They (we) want them to be happy, smart, productive, responsible, and well educated. It's difficult enough to know how parents can ensure all that, let alone how a pediatrician can help. Does talking to parents about setting limits for a toddler help ensure a better disciplined adult? Does referring a fifth grader whose school work is slipping to a child psychologist contribute to a better long-term educational outcome for that child? We'd like to think so, but all we know for sure is that such interventions take time, and time is money.
Of course, we can never expect to know how each aspect of the care we provide for patients will affect their outcomes as adults. While we wait for more studies, we will have to take the time to do what makes sense and hope it also makes sense to the folks who pay.
Julia A. McMillan, MD, Editor-in-chief of Contemporary Pediatrics, is Vice Chair, Pediatric Education, and Director, Residency Training, Johns Hopkins University School of Medicine, Baltimore.
Julia McMillan. What outcome, what price?. Contemporary Pediatrics 1999;10:9.