Physician Experience With Pediatric Inpatient Care in Washington State

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Physician

Experience

With

Pediatric

Inpatient

Care

in Washington

State

Sanford M. Meizer, MD*; David C. Grossman, MD, MPH; and Frederick P. Rivara, MD, MPH

ABSTRACT. Objective. To determine the frequency

with which pediatricians and family physicians in Wash-ington State serve as attending physicians for pediatric inpatients.

Design. Retrospective review of statewide hospital dis-charge data.

Subjects. Attending physicians for all patients younger than 18 years of age with nonsurgical diagnoses dis-charged from civilian hospitals in Washington State dur-ing 1989 and 1990.

Results. Using medical rosters, the self-identified spe-cialty of the attending physician was determined for 93% (n = 181 581) of discharges. Pediatricians and family

physicians were listed as attending for 61% and 28%, respectively, of all eligible patients. Statewide, 97% (n

555) of all pediatricians and 86% (n 939) of all family

physicians served as attending physicians for at least one inpatient, including healthy newborns, during the 2-year study period. The median annual number of discharges per physician was 78 for pediatricians and 14.5 for family physicians. Excluding healthy newborns, the median an-nual number of discharges was 25 for pediatricians and 3 for family physicians. Five percent of the physician at-tending group provided inpatient care for 50% of all children hospitalized with diagnoses other than healthy

newborn; 50% of attending physicians cared for 95% of

the patients. In rural hospitals, where family physicians served as attending physicians for 44% of pediatric inpa-tients, children were 3.3 times more likely to receive their

care from family physicians than those hospitalized in

urban centers.

Conclusions. Most pediatricians and family physicians serve as inpatient attending physicians for hospitalized children only infrequently. These findings question whether the emphasis on inpatient care in many

pediat-nc and family medicine training programs remains an

appropriate goal. Pediatrics 199697:65-70; child,

hospi-talized; physician’s practice patterns; medical education;

pediatrics, trends.

ABBREVIA11ONS. CHARS, Comprehensive Hospital Abstract

Reporting System; DRG, diagnosis-related group; ADRG, adjacent DRG.

The present movement for health care reform

un-doubtedly will bring many changes to medical

prac-From the *Depaent of Pediatrics, Children’s Hospital and Medical Cen-ter and the University of Washington, Seattle; the Departments of Pediat-rics and Health Services and the University of Washington, Seattle; and the

Departments of §Pediatrics and Epidemiology, Harborview Medical Center and the University of Washington, Seattle.

Received for publication Aug 29, 1994; accepted Feb 3, 1995.

Reprint requests to (S.M.M.) Children’s Hospital and Medical Center, P0

Box 5371, Mail Stop CH-4L Seattle, WA 98105-0371.

tice and, ultimately, to medical education. One of the

issues currently being debated is the problem of how

to increase the number of primary-care and

general-ist physicians practicing in both the urban and rural

areas of our country.1’2 Medical schools have come

under increasing scrutiny and criticism for their

per-ceived failure to supply primary-care physicians to

meet health care demands adequately.3

Many solutions have been proposed. One is to

develop primary care as an ambulatory specialty

while developing a separate, smaller cadre of

physi-cians to care for hospitalized patients. Recognition of

the different skills needed for inpatient and

outpa-tient practice, a desire to maximize outpatient

pro-ductivity and predictability, medicolegal concerns,

and provider satisfaction would support such an

approach.4 This would entail substantial changes in

postgraduate training, including development of a

dual-track system of training, resulting in a group of

office-based practitioners and a separate cohort of

hospital-based physicians. This approach to

inpa-tient care delivery is controversial, because some

suggest that the continuity of care epitomized by the

primary-care practitioner demands that the same

physician have the ability to provide both inpatient

and outpatient care,5’6 especially in rural areas.

In the context of these conflicting

recommenda-tions, educators in pediatric and family medicine

training programs must decide how much emphasis

should be placed on inpatient care to prepare

pedi-attic or family medicine residents for a variety of

practice settings. This discussion has been hindered

by a paucity of data on the types of physicians who

provide care for hospitalized children and how often

this type of skill is required of pediatricians or family

physicians. Although previous population-based

studies have analyzed the types of physicians by

specialty providing ambulatory care for children and

adolescents in the United States,7 few investigations

have examined the relative roles of pediatricians and

family physicians in providing inpatient care.

Be-cause the frequency of hospitalization in a pediatric

population is generally low compared with that for

adults,8 the study of an entire population of this

small but important group of patients offers many

advantages in analysis.

Using a statewide hospital discharge database, we

address the questions of: (1) who provides attending

care of pediatric inpatients with nonsurgical

diag-noses in both urban and rural settings in Washington

State, and (2) how frequently pediatricians and

fam-ily physicians provide care as attending physicians

for hospitalized children. We hypothesized that the

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great majority of children hospitalized with

nonsur-gical problems would be cared for by pediatricians

and family physicians. We hypothesized further that

most attending physicians caring for inpatients

would care for only a small number each year,

whereas a small group of physicians would care for

the majority of inpatients. We sought to identify

differences in hospital care for children in urban and

rural settings, hypothesizing that patients in rural

hospitals were more likely to have family physicians

for attending physicians than those in urban

hospitals.

METHODS

TABLE 1. Discharge Diagnoses Among Hospitalized Children and Adolescents Aged 1990 (n = 195441)

Description ADRG

No. of Patients

Code No. (n = 181)

All % Patients Cumulative % % Excluding Healthy Newborns Cumulative %

Healthy neonate with normal newborn diagnosis

Birth weight >2499 g 123 915 629 63.4 63.4 ... ...

Birth weight 2000-2499 g I 759 620 0.9 64.3 ... ...

Neonate without significant operating room procedure, birth weight >2499 g

With minor problems 7 427 628 3.8 68.1 10.7 10.7

With major problems 6 840 627 3.5 71.6 9.8 20.5

With other problems 3 909 630 2.0 73.6 5.7 26.2

With multiple major problems Bronchitis and asthma

I 759 5 277 626 096 0.9 2.7 74.5 77.2 2.6 7.5 28.8 36.3

Simple pneumonia and pleurisy 3 332 089 1.7 78.9 4.8 41.1

Esophagitis, gastroenteritis, and miscellaneous digestive disorders 3 127 182 1.6 80.5 4.5 45.6

Ungroupable I 759 470 0.9 81.4 2.7 48.3

Chemotherapy 1 765 410 0.9 82.3 2.5 50.8

Psychoses I 555 430 0.8 83.1 2.3 53.1

Nutritional and miscellaneous metabolic disorders I 368 296 0.7 83.8 2.0 55.1

Seizure and headache I 359 024 0.7 84.5 2.0 57.1

Laryngotracheitis

Otitis media and upper respiratory infection

I 164 I 178 071 068 0.6 0.6 85.1 85.7 1.7 1.6 58.8 60.4

Kidney and urinary tract infections 1172 320 0.6 86.3 1.5 61.9

Other 26 776 13.7 100 38.1 100

Data Sources

The Washington State Department of Health maintains the Comprehensive Hospital Abstract Reporting System (CHARS), a computerized hospital discharge database including all patients admitted to licensed civilian acute-care hospitals in Washington. The data contain information on individual inpatient discharges, which indude patient diagnoses and demographics, sources of admission, lengths of stay, procedures, payers, E codes and diag-nosis-related groups (DRGs). The individual attending physician for each discharge is identified by that physician’s unique medical license or Medicaid identification number. Attending physicians’ names were linked to the license or Medicaid numbers in CHARS records using data obtained from the state Department of Licens-ing. Self-reported physician specialty and subspecialty identifica-tion, which was not tracked during the study period by the Department of Licensing in Washington, was obtained from sec-ondary sources. These induded county medical rosters, the Wash-ington State Medical Association and University of Washington faculty directory, and listings of physician participants in the Washington-Alaska-Montana-Idaho (WAMI) program, a regional consortium for training and medical care in that four-state area.

Discharge Diagnosis Classification System

Discharge diagnoses were assigned to adjacent DRGs (ADRGs), a modffication of the 3 M All Patient Related DRG grouping.9 In this study, 3 M All Patient Related DRGs were generated from demographic, DRG, and International Classification of Diseases data in the CHARS, then consolidated to ADRGs using the PC

Grouper Software 93.2 (3M Health Information Systems, Murray, UT). Discharge diagnoses were classified as “surgical” if the

pri-mary discharge diagnosis included a surgical procedure and

“healthy newborn” if the final diagnosis was “neonate, >2000 g without significant operating room procedure, with healthy new-born diagnosis.” Discharges classified as “obstetric” included ce-sarean section or vaginal delivery with or without complications, antepartum, postpartum, and postabortion diagnoses with or without operating room procedures, and ectopic pregnancy.

Case Selection

We reviewed the CHARS records of all patients younger than 18 years of age who were discharged from acute-care Washington hospitals from January 1, 1989, to December 31, 1990. Because the study was specifically designed to include only patients with medical diagnoses, all patients with surgical or obstetric proce-dures as the primary discharge ADRGs were excluded, as were cases in which no attending physicians were identified.

Statistical Analysis

After exclusion of surgical and obstetric cases, the frequency distribution of ADRGs and attending physicians by specialty in the study group was determined. Statewide mean and median numbers of discharges per physician were calculated, using as a denominator the number of physicians by specialty in Washington as reported by the American Medical Association.’#{176} Comparison of patient populations by age and physician specialty was per-formed using a‘ test. Hospitals were classified as either urban or

rural using the scheme of the Washington State Department of Health. The study was approved by the University of Washington Institutional Review Board.

RESULTS

There were a total of 220 934 discharges among

patients younger than 18 years old from all licensed

Washington acute-care hospitals during 1989 and

1990. After exclusion of 25 493 discharges with

sur-gical and obstetric procedures as the primary

dis-charge diagnoses, abstracts of the remaining 195 441

discharges were used for the analysis.

There were 181 separate ADRGs assigned to the

population of discharged patients. All discharge

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C

.‘

a-0

I

100

80

40

20

0

50% of attendings cared for 95% ofthe patients

5% of attendings cared for 50% of the patients

- - - - Family Physidans

Pedi#{149}t#{241}dans

- MI Attendings

agnoses with a frequency of greater than 0.5% (n =

17) are listed in Table 1.Normal newborns with birth

weights of more than 2000 g constituted 64.3% of all

discharges. Neonates with birth weights of more

than 2499 g who did not undergo major operating

room procedures but who had major or minor

prob-lems constituted 10.2% of all discharges. After

ex-cluding patients with the two healthy newborn

ADRGs, we found that 50% of patients were

de-scribed by 5% (n = 9) of the ADRGs, and that 80% of

the patients were accounted for by 20% (n = 36) of

the ADRGs. There were 145 ADRGs ranging in

fre-quency from 0.001% to 0.5% assigned to the

remain-ing 20% of patients.

According to the American Medical Association,

there were 10 325 physicians (excluding physicians

in training) in Washington at the midpoint of the

study period (January 1, 1990). This group included

565 pediatricians, 1310 family physicians, and 8450

physicians of other specialties.

Self-reported attending specialties were available

for 93% (n = 181 581) of patient discharges. Of all

Washington physicians, 3975 served as attending

physicians for at least one inpatient during the study

period. Statewide, 97% (n = 552) of all pediatricians,

86% (n = 1129) of all family physicians, and 22%

(n = 2294) of physicians of other specialists served as

attending physicians for at least one pediatric

inpa-tient with a nonsurgical diagnosis during the 2-year

study period.

Sixty-one percent of the discharged patients had

pediatricians, and 28% had family physicians as the

attending physicians. The remaining 11% of patients

had attending physicians from other specialties,

in-cluding internal medicine (1.3%), surgery (0.7%), and

psychiatry (1.8%).

Including healthy newborns, the median number

of discharges per pediatric attending physician per

year was 78.0 (range, 1 to 1327), whereas the median

number of discharges per year among family

medi-cine

attending physicians was 14.5 (range, 1 to 591).

After exclusion of healthy newborns, the median

number of discharges per year was 25 (range, I to

834) for pediatricians and 3 (range, 1 to 232) for

family physicians. Therefore, pediatricians served as

inpatient attending physicians five times more often

than family physicians and eight times more often

for patients with diagnoses other than healthy

newborn.

There were significant differences in the age

dis-tribution of children receiving inpatient care from

pediatricians compared with family physicians. The

mean age of hospitalized patients was 2.7 years for

pediatricians and 4.1 years for family physicians

(P < .0001). Adolescents older than 10 years of age

constituted 22% of the family physicians’ inpatients

compared with 11% of the pediatricians’ inpatients.

The care of inpatients was not evenly distributed

across the group of attending physicians (Figure).

Five percent (n = 197) of all attending physicians cared for 50% (n = 32 469) of all patients hospitalized

with diagnoses other than healthy newborn, while

50% of attending physicians cared for 95% of the

patients in this group. Information regarding

subspe-cialty practice characteristics was available for 178 of

the 197 attending physicians with the highest

num-bers of discharges (accounting for 45% of all

dis-charges; Table 2). Twenty-three percent (n = 41) of

0 10 20 30 40 50 60 70 eo aO 100

.E nom nswms

Cumulative

% Attending

Physicians

Figure. Distribution of pediatric inpatient care among attending physicians in Washington State, 1989 and 1990.

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TABLE 2. Discharges by Practice Setting and Subspecialty Among the 5% of Attending Discharges, State of Washington, 1989 and 1990

Physicians With the Highest Numbers of

Attending Subspecialty Practice Setting Total Discharges,

All Settings

Proportion of All Discharges, Excluding

Healthy Newborns No. of Discharges by Full-time No. of Discharges by

Academic Faculty Community-based Physicians

Hematology/oncology 2 261 1 878

Neonatology 534 2 704

Surgery 528 1 241

General inpatient pediatrics I 306 901

Gastroenterology 425 434

Cardiology 91 286

Pulmonolgy 107 216

Neurology 189 131

Other subspecialty 835 915

No subspecialty identified 0 14 143

Totals 6 276 22 849

4 139 3 238 1 769 2 207 859 377 323 320 1 750 14 143 29 125 6.4 5.0 2.7 3.4. 1.3 0.5 0.5 0.4 2.7 22.0 44.9

the high-volume attending physicians were full-time

academic faculty in regional training centers. This

group provided care for a total of 10% (n = 6276) of

all discharges. The group of community-based

at-tending physicians included a specialty-oriented

cadre of 38 physicians who cared for 14% (n = 8706)

of all discharges. This group included specialists in

neonatology (n = 17), inpatient general pediatrics (n

= 3), pediatric surgery (n 6), hematology and

oncology (n = 5), endocrinology (n = 3), and one

each in pulmonology, intensive care, neurology, and

child psychiatry. The remainder of the

community-based inpatient attending physicians comprised 94

pediatricians and 2 family physicians engaged

pn-manly in general practice. The physicians in this

group served as attending physicians for 14 143

dis-charges or 22% of all inpatients.

Eighty-nine percent (n = 57 976) of all pediatric

inpatients (excluding healthy newborns) received

care at urban hospitals; 11 % (n = 6180) were treated

at rural hospitals (Table 3). The median numbers of

discharges per physician were the same for

pediatri-cians working in urban and rural hospitals, whereas

rural family physicians served as inpatient attending

physicians more frequently than their urban

col-leagues. Pediatric patients in rural hospitals were 3.3

times (44% vs 14%) more likely to have family

phy-sicians attending than patients in urban hospitals.

Of the family medicine attending physicians

pro-viding hospital care for pediatric patients, 79% (n =

825) worked in urban hospitals, and 21 % (n = 215)

provided care in rural hospitals. Ninety-three

per-TABLE 3. Annual Discharges (Excluding Healthy Newborns) by Physician Specialty and Hospital Location, State of Washing-ton, 1989 and 1990

Attending Specialty

Pediatrics Family

Medicine

Median Range Median Range

Urban hospital discharges 25* 1-834 3t 1-187

(n = 57976)

Rural hospital discharges 25* 1-187 4.5t 1-213

(n = 6180)

*P = nonsignificant.

tP < .0001.

cent (n = 504) of the pediatric attending physicians

did their inpatient attending work in urban

hospi-tals, whereas only 7% (n = 38) cared for patients in

rural hospitals. Although the total number of

pedia-tricians working in rural areas was low, this group

still provided care for 37% of children discharged

from rural hospitals.

DISCUSSION

The results of our study confirm our hypotheses.

Pediatricians and family physicians care for 89% of

children hospitalized with nonsurgical diagnoses.

Although more than 95% of pediatricians and 85% of

family physicians in Washington care for at least one

inpatient every 2 years, the volume of patients with

diagnoses other than healthy newborn is low.

Among pediatricians, the median number of

inpa-tients is 25 per year. Among family physicians, the

median number of inpatients is 3 per year.

There are few large, population-based studies with

which to compare these case volumes. One

retro-spective study of 4599 randomly selected hospital

discharges in Ohio during 1970 found that the mean

number of hospital discharges (excluding newborns)

per year was 133 for pediatricians and 129 for family

physicians.” In contrast to the present study, 42% of

all pediatric patients in that analysis were

hospital-ized for respiratory diseases. The large difference in

inpatient volumes compared with the present study

likely can be explained by patient sampling

differ-ences and changes in hospital use during the past

two decades.

Our findings are comparable to other more recent

studies. A survey of office-based family physicians

and general practitioners in Washington revealed

that although 81 % provided inpatient care for at least

one patient during a 2-week study period, only 7% of

these patients were younger than 16 years of age.12

Another survey of 1043 pediatricians and pediatric

specialists in general pediatric practice found that

only 28% of the generalists and 65% of the specialists

served as inpatient attending physicians at least

“sometimes.”13

We found that hospital attending responsibility

was not evenly distributed across the pool of

poten-tial providers in the state. A small number of

(5)

patients, and a large number of physicians cared for

very few inpatients during the 2-year study period.

Almost half of the high-volume attending physicians

were pediatric medical subspecialists in academic or

community

practice in areas with high inpatient

vol-umes, such as neonatology, pediatric oncology, or

gastroenterology. The finding that a small group of

specialists constituting 2% of the attending cohort

provided care for 25% of all discharges indicates that

we may have overstated the inpatient volume for

average community-based practitioners. If we had

chosen to exclude the cases under the care of

special-ists from the analysis, the mean number of

dis-charges by community-based generalist

pediatri-cians would have been 20% less.

The uneven distribution of inpatient care

respon-sibilities may be a reflection of several forces. The

national trends toward decline in hospital

admis-sions and length of stay may make inpatient

attend-ing responsibility a less-attractive

time

commitment

and economic investment for community-based

phy-sicians. For physicians with busy outpatient

prac-tices, the unpredictable nature of inpatient care may

encourage referral to hospital-based physicians. The

increasing trend of subspecialization in pediatrics

has led to a reduction in the types of illnesses treated

and procedures performed by generalists. As a

re-suit, physicians may not apply for or be eligible for

hospital privileges to treat certain illnesses. For

ex-ample, in many areas, mildly sick term newborns

increasingly have become the province of

neonatol-ogists, leading to the exclusion of generalists.’4

Our

study also underscores the difference in

prac-tice patterns in rural areas, compared with urban

centers. Although only 12% of the pediatric

inpa-tients were treated in rural hospitals, they constitute

a sector in which the family physician plays a

signif-icant role in the care of children. In this study,

chil-dren in rural hospitals were three times as likely to

be under the care of family physicians than those in

urban settings, a finding that is consistent with

pre-viously reported national survey data.’5 The finding

that rural pediatricians had the same inpatient

vol-ume as their urban colleagues suggests a direction

for further research regarding the appropriate

train-ing and deployment of pediatricians to serve as

in-patient attending physicians and consultants in rural

areas, which frequently face a lack of pediatric

providers.’0

One limitation of this study was that we were

unable to validate the identity or self-reported

spe-cialty of the attending physician status in the

dis-charge abstracts. We recognize that there is potential

for incorrect attribution of attending responsibility

among some high-volume specialists or teaching

fac-ulty attending physicians. Another potential

limita-tion was the classification of physicians as specialists.

Previous surveys have shown that subspecialty

training does not predict subspecialty practice, and

there exists a wide mix of specialty and general

practice among both those trained in specialties and

those without specialty training.’6 Because the

data-base did not allow us to identify care provided by

consultants, we chose to exclude surgical cases to

focus on attending care by pediatricians and family

physicians. However, by excluding surgical cases,

our study may have underestimated the total volume

of inpatient care provided by pediatricians and

fam-ily physicians, who may serve as medical consultants

rather than attending physicians in surgical cases.

Although we describe a single population

experi-ence, these data are derived from a state that is

undergoing rapid transition in the health care

envi-ronment, including an increase in managed care, the

consolidation of health systems, and regionalization

of pediatric health care delivery. Because some

fea-tures of this environment may reflect national health

care trends, we think that this study has important

implications for primary care and generalist training

in many settings throughout the United States. A

disproportionate amount of time may be spent

train-ing pediatric and family medicine residents to treat

hospitalized patients when many of these physicians

(especially those in generalist practice) will spend

very little, if any, of their clinical

time

in this activity.

A recent survey of graduates from a pediatric

resi-dency program revealed that most alumni thought

that too little training time had been devoted to

primary-care topics, and

too

much time had been

spent on inpatient rotations.’7 Similar sentiments

may be expressed on behalf of family physicians,

who, in the present study, cared for one pediatric

inpatient every 4 months. Yet, residency programs

are charged with the training of physicians to work

in a wide variety of practice settings with vastly

different responsibilities. For example, rural

hospi-tals are highly reliant on family physicians to care for

pediatric inpatients; these physicians must be

pre-pared to care for ill children with a variety of

com-mon diagnoses in this setting. Conversely, inpatient

practices in some urban settings may be moving

toward the model of care in Canada and Britain, in

which inpatients are cared for by a few

hospital-based generalist physicians.

Leaders in academic pediatrics and family

med-icine must address whether training in inpatient

care should be reorganized to reflect the realities of

today’s practice environments. Reorganization

may lead to the restriction of inpatient training in

areas such as intensive care. However, decreasing

resident exposure to inpatient care is not the only

answer. The content of training may need to be

targeted such that time spent rotating on inpatient

medicine services is focused on the care of patients

with the most common pediatric diagnoses. An

increased proportion of the care of patients with

rare diseases should be delegated to those fellows

training in those subspecialties.

We conclude that the use of a population-based

hospital discharge database is useful in the study of

inpatient practice patterns of child health care

pro-viders. Although pediatricians have more experience

with inpatient pediatric care than family physicians,

we also demonstrate that the care of patients is

highly skewed, with a large proportion of physicians

caring for few inpatients annually. These findings

should stimulate the debate about the proportion of

time that pediatric and family medicine residents

(6)

devote to the care of inpatients, particularly those with rare or infrequent conditions.

ACKNOWLEDGMENTS

We acknowledge the contribution of Robert Soderberg from the Harborview Injury Prevention Research Center, Ron Lemire, MD, from the University of Washington WAMI

(Washington-Alaska-Montana-Idaho) program, and Gregg Bennet and Lance

Pill-chowski of Health Care Business Services, Bellevue, WA, who provided valuable assistance in the data analysis. We are grateful to Fred Connell, MD, and Roger Rosenblatt, MD, for their reviews of an earlier draft of this manuscript. We also appreciate the contribution of Sunny Schlehr, who provided assistance in the preparation of the manuscript.

REFERENCES

1. Association of American Medical Colleges. AAMC policy on the gen-eralist physician. Acad Med. 1993;68:717-724

2. Health Resources and Services Administration Council on Graduate

Medical Education. Improving Access to Health Care Through Physician

Work Force Reform. Directions for the 21st Century. Washington, DC:

Department of Health Services; 1993. Third report.

3. Alpert JJ. Primary care: the future for pediatric education. Pediatrics.

199086:653-659

4. Means VJ,Nazarian LF. Inpatient care: the general pediatrician’s future.

Pediatr Rev. 1990;12:165-166

5. Geyman JP. Hospital practice of the family physician. J Fam Pract. 19798:911-912

6. The American Academy of Pediatrics. Task force report on the future

role of the pediatrician in the delivery of health care. Pediatrics. 1991; 87:401-409

7. Starfield B,Hoekelman PA, McCormick M, et al. Who provides health care to children and adolescents in the United States? Pediatrics. 1984; 74:991-997

8. US Public Health Service, National Center for Health Statistics. Health, United States, 1988. Washington, DC: US Government Printing Office;

1989. US Dept of Health and Human Services publication (PHS) 89-1232 9. Averill RF, Goldfield N, Steinbeck BA, Muldoon J, Beaudry PH. All

Patient Diagnosis Related Groups (APR-DRGs). Murray, UT: 3 M Health Information Systems; 1993

10. American Medical Association. Physician Characteristics and Distribution in the United States. Chicago: American Medical Association; 1992 11. Garg ML, Shipper JK, McNamara MJ, Mulligan JL. Primary care

phy-sicians and profiles of their hospitalized patients. Am I Public Health. 1976;66:390-392

12. Rosenblatt RA, Moscovice IS. The hospital role of family physicians.

West JMed. 1985;143:537-540

13. McCrindle BW, Starfield B, DeAngelis C. Subspecialization within

pe-diatric practice: a broader spectrum. Pediatrics. 199290:573-581 14. Harper RG, Sia CG, Spinazzola R, Wapnir RA, Orner 5, Harper R.

Limitation of private attending pediatricians neonatal intensive care

privileges in level ifi institutions throughout the United States.

Pediat-rics.199494:190-193

15. Braden J, Beauregard K. Health Status and Access to Care of Rural and Urban Populations. National Medical Expenditure Suruey Research Findings 18. Rockville, MD Agency for Health Care Policy and Research; 1994.

Agency for Health Care Policy and Research publication 94-0031 16. Brotherton SE. Pediatric subspecialty training, certification, and

practice: who’s doing what. Pediatrics. 199494:83-89

17. Liebelt EL, Daniels AR, Farrell MK, Myers RC. Evaluation of pediatric

training by the alumni of a residency program. Pediatrics. 199391: 360-364

THE FILE DRAWER EFFECT

Statistics can tell us when published numbers truly point to the probability of a

negative result, even though we, in our hopes, have mistakenly conferred a

positive interpretation. But statistics cannot rescue us . . . when we publish positive

results and consign our probable negativities to nonscrutiny in our file drawers.

Gould SJ. Cordelia’s Dilemma. Natural History. 1993.

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1996;97;65

Pediatrics

Sanford M. Melzer, David C. Grossman and Frederick P. Rivara