(
Received July 2, 1970; revision accepted for publication May 7, 1971.)One of the programs described in this report was supported by the Thomas Wilson Foundation of
Baltimore, and the Children’s Bureau. Part of this work was supported by National Institutes of Health
Grants HE 05555 and CH 00276.
ADDRESS FOR REPRINTS: (L.G. ) Department of Epidemiology, Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland 21205.
PEDIATRICS, Vol. 48, No. 5, November 1971
EVALUATION
OF
THE
EFFECTIVENESS
OF
COMPREHENSIVE
AND
CONTINUOUS
PEDIATRIC
CARE
Leon Gordis, M.D., Dr. P.H., and Milton Markowitz, M.D.
From the Department of Medical Ecology, Hebrew University-Hadassah Medical School, Jerusalem, and the Department of Pediatrics, University of Connecticut School of Medicine, Hartford,
the Johmu Hopkins School of Medicine and Sinai Hospital, Baltimore
ABSTRACT. Two controlled studies were
under-taken to evaluate the effectiveness of
comprehen-sive and continuous pediatric care. In the first
study, 220 infants of prirniparous adolescents were randomly allocated to either a comprehensive care
(
CC)
or traditional care (TC)
group. CC infantsreceived all medical care, preventive and
therapeu-tic, in a hospital-based program staffed by a
pedia-trician, public health nurse, and social worker.
Mothers of TC infants were left to obtain care
from emergency rooms, well-baby and outpatient clinics. One year after delivery, each mother was
interviewed and her infant’s medical records
ab-stracted. No differences were found between CC and TC infants in completeness of immunization, utilization of medical resources, morbidity, or mor-tality.
In a second study, it was lwpothesized that
pa-tient compliance with physicians’ recommendations would be favorably influenced by continuous care.
Seventy-seven children on daily oral penicillin pro-phylaxis for history of rheumatic fever (RF) were
studied. For one year, compliance was determined by periodic urine tests for penicillin. Patients were then stratified for age, sex, and compliance and randomly allocated to continuous care ( CC ) or traditional care (TC) groups. CC patients received
all medical care, even for problems unrelated to
RF, from the same two physicians for 15 months.
TC patients continued to receive specialty clinic care, were seen at the RF clinic by different physi-cians and referred elsewhere for all problems unre-lated to RF.
Urine specimens were tested periodically for
penicillin. After 15 months, no differences were
ob-served between CC and TC groups in proportion
of noncompliers or in internal shifts in compliance
which had occurred during the study. Thus, nei-ther of these studies was able to demonstrate that comprehensive and continuous care was more
effective than conventional ambulatory care for
children. Pediatrics, 48:766, 1971, HEALTH CARE,
RHEUMATIC FEvER, PENICILLIN, CHILD HEALTH
SERVICES.
T
HE increasing recognition of themade-quacy of health care available to low
income groups has prompted the initiation and expansion of many comprehensive medical care programs. These programs aim to provide total health care and a con-tinuous relationship of the patient either to a physician or to a health team as a whole. Such programs have been predicated on the assumption that the end results of such care will be superior to those which can be achieved with traditional clinic programs. However, the evidence to substantiate this assumption is generally lacking.1 Since such programs are costly and administratively
difficult to implement, it is necessary to cnit-ically evaluate whether comprehensive and
continuous care is more effective than
tradi-tional methods.
bene-TABLE I
DEMOGRAPHIC AND SOCIAL COMPARABILITY OF
CouPRE-HENSIVE CARE AND REGULAR CARE GRon’s ONE YEAR AVFER DELIVERY (IN PERCENTS) fits of continuous care may be more
mani-fest in chronically ill children than in a well-child population. Since noncompliance has been shown to be a major problem in
the long-term management of such pa-tients,2’3 a second study investigated the cx-tent to which continuous care by physicians could influence compliance in a group of chronically ill children and adolescents.
I. EFFECTIVENESS OF COMPREHENSIVE
CARE IN INFLUENCING INFANT HEALTH
MATERIALS AND METHODS Study Population
All infants born to primiparous
adoles-cents less than 18 years of age at Sinai
los-pital of Baltimore over a 3-year period were included in the study. The infants were al-located to either Comprehensive Care or Regular Care groups by randomly assigning the pregnant adolescents to one of these
two groups at the time of the first prenatal
clinic visit. At this time, the adolescents were stratified for age and designated
Corn-prehensive or Regular Care using a table of random numbers. By this method, 120 ado-lescents were assigned to the Comprehen-sive Care group and 117 to the Regular Care group. The data collected at this time included basic demographic and
socioeco-flOIlliC information and details of prenatal
history.
Treatment Groups
A. COMPREHENSIVE CARE: After the
de-livery, both the adolescent mothers and their newborn infants who were assigned to the Comprehensive Care group were regis-tered as patients in the Sinai Family Clinic.
Infants in this group received their medical
care, both preventive and therapeutic, in this hospital-based pediatric clinic staffed
full-time by a pediatrician, pul)lic health
nurse, and social worker. The development
of a personal relationship of the patients to the health team was emphasized. Well-baby visits were scheduled on an appoint-ment basis throughout the first year of life. The pediatrician was available for tele-phone consultations or unscheduled visits
Data
(‘omprehen-sire Care
(N=11O)
Rsgtdar Care (N=11O)
Xonwhite 90% 84%
Age 16 or younger 17 11
Married 38 35
Living with husband ‘24 19
Annual income <$3,000 928 ‘2’2
Infant under mother’s
care at I year of age 70 69
when necessary. Night and weekend cover-age was also provided by the pediatrician and house calls were made when indicated. The public health nurse, working in the clinic and in the patients’ homes, placed great stress on educating the new mothers in many facets of infant care and inten-sively followed up patients who failed to keep scheduled appointments for preven-tive or illness care. Considerable efforts were also expended by the health team to encourage the adolescent to utilize birth control and return to school. Family Clinic patients were not charged for any services or drugs.
B. REGULAR CARE: In contrast to the full
range of services provided to the
Compre-TABLE II
MEDICAL COMPARABILITY OF COMPREHENSIVE CARE
AND REGVLAR CARE GROIP INFANTS
(
IN PERCENTS)Data
Comprehen-sire Care (N=11O)
Regular Care (N=11O)
Registered for prenatal
care by 4th month 40% 40%
Preeclampsia 10 10
Birth weight <5 lb 10 9
Apgar score 7 or less 0 14
Congenital malformations
at birth S 6
Medical complications in
TABLE 111
hEALTh CARE OF’ INFANTS IN FIRST YEAR OF LIFE (IN I’EII(ENTS)
!)ata
(‘oinprehen-sue (are
(N = 110)
Regular Care
(N= 110)
6IC 57%
86 80
74 57
35 41
70 63
16
65 6 Almost two-thirds of the infants in each
group had at least six well-baby visits dur-i4 24 ing the first year of life
(
Table III)
.Al-11 1 though it might have been anticipated that
- Comprehensive Care patients with easy
ac-768
Six or more well-baby visits in first year
Received three DV
immunizations Received three polio
immunizations Vaccinated Received measles
immullization
hensive Care group, mothers of infants as-signed to this group were left to seek well-baby care for their babies at some tradi-tional resource in the community, such as well-baby clinics operated by the Baltimore City Health Department. In times of illness, mothers of these infants could bring their children to any hospital emergency room on clinic or to a private physician. No special follow-up efforts were made with this group during the infant’s first year of life, other than the interview noted below.
One Year Evaluation
As a result of abortions, stillbirths, and dropouts from the study, either prenatally
TA13IE IV
MORBIDITY AND MORTALITY IN FIRST \EAR
OF LIFE (IN PERCENTS)
Corn
prehen-Data sire Care
(.V= 110)
Livehorn, dead 1)y end of first year
Hospitulized in first
year of life 13
Four or more clinic or emergency room visits for sickness
Below 10th percentile for height at I year
Below 10th percentile for
weight at 1 year
or during the first year of life, the final groups each consisted of 110 liveborn in-fants. One year after delivery, the mother of each child in both groups was inter-viewed. She was questioned as to all sources of medical care which she had uti-lized for her infant. In accordance with the mothers’ reports, a careful search then was made of medical records for the infant at Sinai Hospital and at other hospitals in Bal-timore, as well as at city well-baby clinics and private physicians. Data were also ob-tamed concerning delivery and neonatal course in the hospital nursery, infant deaths, hospitalizations, and clinic or emer-gency room visits during the first year of life, as well as immunization records.
RESULTS
Comparability of Comprehensive Care and Regular Care Groups
In order to evaluate the impact of the comprehensive care program on the infants registered in it, it was first necessary to de-termine that the Comprehensive Care and Regular Cane groups of infants were corn-parable at the time of admission to the pro-gram in regard to variables which might be likely to influence the outcome of care.
Tables I and II demonstrate that the groups were comparable in terms of a num-ber of demographic, social, and medical factors. Most of the patients in both groups were nonwhite and between 16 and 18 years of age. At the time of the interview, over two-thirds of the infants were living with their mothers; most of the remaining children were being raised by maternal
Regular grandparents. Approximately 60% of the
(N =110) girls in both groups remained unmarried 1
--
- year after delivery. Of those who hadmar-ned, 63 percent of the Comprehensive Cane 3% girls and
54
percent of the Regular Caregirls were living with their husbands.
‘l’ABLE
Co.i ‘AI(A BI LIT )F (‘ONTI N I 0115 AND SI’EcI% LTY
(;I)LIS (ix L’ERCENTS)
Data
(‘ontin 110118
Care
(N =19)
Specialty
Care
(.V=38)
39 33
47 56
35 36
31 33
17
14 3
51 57
33 33
ARTICLES
cess to the physician and to the health team might have had greater frequency of well-baby visits, no significant differences were found between the Comprehensive Care and Regular Cane groups. When complete-ness of immunizations was examined, there were no significant differences in the DPT, measles, and smallpox vaccinations. How-ever, more Comprehensive Cane infants had completed their polio immunizations during the first year of life (p < 0.05). Thus, at the end of 1 year, except for polio immuniza-tions, there were no significant differences between Comprehensive Care and Regular Care infants in utilization of preventive health services.
Morbidity and Mortality
Infant mortality rates in both groups
(
Table IV) were comparable to the rates for Baltimore City as a whole. Although a considerable number of hospitalizations took place during the year, there were no differences in this regard between the two groups. A high frequency of illness visits was encountered in both groups; 65% of the Comprehensive Care infants and 62% of the Regular Care infants had four or more such visits.There were also no differences between Comprehensive Care and Regular Cane in-fants in height or weight percentile
distri-l)utiOnS at 1 year of age. It is of interest,
however, that in both groups 24% of the children were below the 10th percentile for height at 1 year.
II. EFFECTIVENESS OF CONTINUOUS CARE
IN INFLUENCING PATIENT COMPLIANCE
MATERIALS AND METHODS
Study Population
Four criteria were required for admission to the study :
(
1)
Negro child or adolescent with past history of rheumatic fever and/or evidence of rheumatic heart disease and pa-tient at the Johns Hopkins Rheumatic Fe-ver Clinic, (2) on oral penicillin prophy-laxis(
200,000 units penicillin C daily be-fore breakfast) , (3)
regularly attending public elementary or secondary school inMales
Age 13 or older
Noncolnpliers at beginning
of study
have rheumatic heart
disease
Activity restricted by
physician
Never hospitalized for acute
littaick
Never accolnpallied by parent to (lillic
Six or more children in family
Baltimore City, and (4
)
both patient and parents willing to cooperate.Ninety-three patients were admitted to the study, but as a result of dropouts be-cause of graduation from high school, mov-ing or other reasons, 77 patients were in the final study population. In order to obtain baseline data on compliance on each child, urine tests for penicillin were performed at weekly, and then monthly intervals, over a 12-month period. At the end of this time, the patients were stratified for sex, age, and compliance, and randomly allocated to Continuous Care or Specialty Clinic groups as described. Thereafter, the patients were followed for 15 months with urine tests for penicillin. Patients in both groups were charged $2 for a 3-month supply of penicil-un; no charges for medical care were made to patients in either group.
Continuous Care Group
El
Before After20
CONTINUOUS
SPECIALTY
CLINIC
CARE GROUP GROUP
770
(J)
w
-J
0
0
z
0
z
I-z
Ui0
Ui
a-FIG. 1. A comparison of percent of noncompliance in the Continuous Care
and Specialty Clinic groups before and after the study period.
roster l)ut provi(le(l cross coverage when
the other was not available. They were in-structed to handle all medical problenis in addition to rheumatic fevcr at the time of
the clinic visits and the patients were urged to contact one of these I)llYsiciaIls for prol-lems arising at nonclinic hours. A calling card ‘as distributed to the patients, listing both doctors’ names and the telephone number. In addition, a telephone exchange was utilized to increase PhYSiciaI accessi-l)ilitV. Covcrage Fy these pllysicians was available to this group of patients
through-out the veek, inclu(lmg nights and week-ends.
Specialty Clinic Group
Patients in this group continued to
re-ceive tile 5ITIC type of care as previously in
the Rheumatic Fever Clinic. They were
seen approximately every 2 months and at
the time of each visit, the attending or
houSe staff piysiciais assigned to the clinic
saw the patients in order of their arrival at
the clinic. Specialty Clinic patients were in-frequently seen by the same physician on repeat visits. Care was directed to their rheumatic fever and, when present, to their rheumatic heart disease. Patients were tn-counaged to continue prophylaxis and given appropriate prescriptions. However, in cOn-trast to the Continuous Care group, Spe-cialty Clinic patients did not receive care for other problems in the Rheumatic Fever Clinic. Patients with such problems or hay-ing medical difficulties at times other than
the clinic hours, were either referred to
other specialty or general clinics, or were obliged to find cane on their own in the hos-pital’s pediatric clinic, emergency service, or other nonhospital medical resources in the community such as private practitioners.
Measurement of Compliance
REMAINED BECAME BECAME REMAINED
NON- NON- COMPLIERS COMPLIERS
COMPLIERS COMPLIERS
FIG. 2. Shifts in compliance in Continuous Care and Specialty Clinic groups. method of determining compliance in
pa-tients on oral penicillin prophylaxis.
Ini-tially, tests were performed each week. It was sul)Sequently determined that
compli-ance could be estimated with almost the
same degree of accuracy from monthly
specimens, as from weekly ones. For this
reason, after the first 5 months of the study, the procedure was changed to provide for
monthly urine collections. During this pe-nod, urine specimens were collected by a
health aide who was a member of the study team. Specimens were collected on a ran-domized schedule at home or at school,
de-)eIlcliflg on where tile child could be
lo-cattd. ilk’ I)iltiellts did not know the rca-SOilS for the urine colk’ctioiis or the
collec-tion schedule.
Definition of Noncompliance
The percent of urine specimens positive for penicillin was determined in each
pa-tieiit. In ap)roximately OIle-tllind of the
pa-tients, less than 3:3% of the urine specimens \‘erc P0Siti7e. For I1rpos’s of comparison and data analysis, these 1)atiellts ere clas-sified noncomplicrs and all others as
corn-pliers. This classification is based n prehm-mary data which suggest that patients who
take their oral penicillin over 33% of the time may be relatively well protected against streptococcal infections.5
Measurement of Medical Care Input
Careful records were kept of all patient-physician contacts, both by phone and in person, in both groups. Information was thus available Oil the number of contacts during clinics, as well as at nonclinic hours. The nature of the problem prompting the contact was also noted. In addition, at the end of the study period the physicians were asked to complete a questionnaire on their patients which asked for general informa-tion concerning the patients’ social and medical background. Two physicians among those involved in providing care for the Specialty Clinic group also completed
such questionnaires.
RESULTS
Comparability of Study Groups
Thirty-nine patients were included in the Continuous Care group and 38 in the Spe-cialty Clinic group. Although the groups
were initially stratified for age, sex, and
van-ables could have been affected by the 16 study dropouts. For this reason, the final groups were compared in terms of these factors, as well as in terms of a number of other factors previously shown to be related to compliance.3 The results are shown in Table V. There were no significant differ-ences between the groups in regard to the three factors for which the Continuous Care and Specialty Clinic groups were stratified. Insofar as the other factors are concerned the groups were also
compana-ble, except that fewer of the Continuous Care group patients had been treated with-out hospitalization for their acute attack of rheumatic fever. This difference between the two groups would be expected to in-crease the risk of compliance in the Contin-uous Care group.
Proportion of Noncompliers
Figure 1 demonstrates that there were no differences between the Continuous Care and Specialty Clinic groups in the propon-tion of noncompliers by the end of the study, nor were there any differences be-tween the patients of the two physicians in the Continuous Care group. As seen in Fig-nrc 2, the Continuous Care and Specialty Clinic groups were not different in regard to internal shifts which took place within the study period. Twenty-eight (72%) of the 39 Continuous Care patients did not change in compliance status compared with
24
(
63%) of the 38 Specialty Clinic pa-tients. Ten (25%) of the Continuous Cane patients changed from compliers to non-compliers during the study. One Continu-ous Care patient and two Specialty Clinic patients changed from noncompliens to compliers during the study period. Thus, the data do not suggest that continuous care influenced patient compliance in this group.Evaluation of Physician Input
A record was kept of all patient-physician contacts made outside the regular clinic hours, whether by phone or direct visit. This record was kept for the Continuous Care group only since patients in the Spe-cialty Clinic group were not provided this
option and had to seek their services else-where. Sixteen (41%) of the Continuous Care patients contacted their physicians at times other than the Rheumatic Fever Clinic sessions.
At the close of the study, parents of chil-dren in both groups were asked to identify their physicians by name. In the Specialty Clinic group, identification was considered correct if the parents could name any phy-sician who had taken care of their child dan-ing the study period. Only 16% of these correctly identified a physician compared with 57% of the Continuous Cane group.
Both physicians in the Continuous Care group and physicians from the Specialty Clinic group who had the most contacts with the patients were given questionnaires concerning their patients. Five questions concerning clear and important character-istics of the patients were asked, such as presence of rheumatic heart disease and limitation of physical activity. Each child was then rated in terms of how well his physician knew him by the end of the study period as measured by the questionnaire. The questionnaires of 33% of the Continu-ous Care patients reflected excellent knowl-edge on the part of their physicians corn-pared to only 7% of the Specialty Clinic group.
DISCUSSION
As new methods of providing medical cane are developed, there is a critical need for evaluating their effectiveness through carefully designed, randomized, controlled studies in which two on more approaches to providing medical cane are compared si-multaneously. Two such studies have been described in this report and neither has demonstrated measurable differences be-tween patients provided comprehensive or continuous pediatric cane and those neceiv-ing regularly available episodic ambulatory care.
Definition of Comprehensive and Continuous Care
care and whether such care was, indeed, provided by the programs. In the first study, all health care, both preventive and therapeutic, was provided for both the ado-lescent mother and her infant. The young mothers were encouraged to consult the members of the health team for all
prob-lems including those relating to child
rear-ing, social difficulties, completion of school-ing, and intrafamily relationships. Physician rotation in the infant care study was an-ranged so that patients in the program saw no more than two physicians during the 1 year follow-up period of the study. More important, however, is the fact that the physician was continuously available to
them in person or by phone, even at non-clinic hours and in fact, phone consultations were very frequent. His efforts were sup-plemented by a team of public health nurses and social workers who were also available to the patient and exerted
inten-sive efforts in health education and in
as-sisting the young mother in the care of her
child. In the absence of any universally ac-cepted definition of comprehensiveness, the care just described was defined as compre-hensive for the purposes of this study.
In the study of patient compliance, conti-nuity of cane was provided by two physi-cians rather than by a health team. Services of one of the two physicians were available at all hours for any medical or health-re-lated problem which the patient might de-velop. This availability was emphasized by the installation of a separate phone line and the distribution of calling cards for the
physicians. The physicians themselves
em-phasized their availability and encouraged the patients to call them for problems other than rheumatic fever. Nevertheless,
avail-ability in and of itself is not sufficient with-out physician-patient interaction. The data presented here suggest that by the end of tile study more of the parents of children in
the Continuous Care group knew their physicians by name and that the physicians
in the Continuous Care group were supe-nor to the Specialty Clinic group in knowl-edge of their patients. Nevertheless, al-though the latter difference existed
be-tween the two groups, the data indicate that even in the continuous care group, the physicians’ knowledge of their patients was not optimal.
The compliance study did not evaluate the potential effectiveness of other health professionals such as public health nurses, social workers, and community health aides, in addition to the physician, in modi-fying patient behavior. Indeed, such per-sonnel might be effective even in the ab-sence of a continuous physician-patient re-lationship.67 The asymptomatic nature of the disease studied and the provision of comprehensive care by physicians without ancillary services may account in part for the divergence of these results from those of Katz, et a!. who demonstrated that adult patients with rheumatoid arthritis did in-deed benefit from comprehensive care pro-vided by a health team.8 The present data indicate only that the continuous relation-ship to the patient of a physician providing care was not effective in influencing the pa-tient’s compliance.
Measures of Effectiveness
dif-774
ferences in child health in a family health cane program.1#{176}
Similar rates of hospitalization during the
first year of life were encountered in both groups. A close review of the hospitaliza-tion data indicated that in neither group were hospitalizations for social reasons but, in general, reflected true medical diagnostic and therapeutic problems. When causes of hospitalization were analyzed, the groups did not differ in the proportions hospital-ized for acute and for chronic problems. It should be pointed out, however, that the absence of any differences in hospitaliza-tion rates could be misleading. It is possible that better case finding in the comprehen-sive care group could be balanced by more severe disease untreated in early stages in the Regular Care group and both leading to hospital admissions. The result could then be equivalent hospitalization rates in both groups as a consequence of very different factors. However, the small number of hos-pitalizations for each cause in both groups did not permit an analysis to exclude this possibility.
The failure to demonstrate any effect of comprehensive cane must be viewed within the specific limitations of this study. Even if the outcome of comprehensive care is in-deed superior, it may well be difficult to discern any effects of such cane in normal infants. The population studied was there-fore limited to first-born infants of adoles-cents both to control for birth order and maternal age and also because such infants seemed likely to be at high risk for prob-lems associated with relative maternal inex-penience and immaturity. In such a group, any effects of comprehensive care in in-fancy might be easier to demonstrate. Nev-entheless, comprehensive and continuous cane could perhaps have a more pro-nounced effect in children who are chnoni-cally ill, and other end points may more di-rectly reflect differences in effectiveness of care than changes in morbidity. For these reasons, the second investigation was car-ned out.
The second study was designed to corn-pare continuous care with episodic cane by measuring changes in compliance in rheu-matic fever patients. This measure was Se-lected for a number of reasons. First of all, although changes in health per se might be the most desirable end points in such a study, they are frequently dependent as much or more on socioeconomic and other factors than they are on the quality of med-ical care and its organization.1’ Differences in outcome may also be affected by differ-ences in compliance. For example, in the group of children studied, outcome could be measured in terms of changes in mci-dence of streptococcal infections. However, streptococcal infection rates would be de-pendent not only on the medical care itself, but also on differences in compliance and environmental conditions such as degree of crowding. Compliance, too, is affected by factors unrelated to the format of cane it-self; however, these factors have been stud-ied in detail3 so that it was possible to strat-ify the study population for such variables before randomly allocating patients to ci-then comprehensive or specialty clinic groups. In this way, it was possible to mini-mize any effect of such variables. There-fore, instead of changes in outcome, mea-sunement of compliance itself seemed likely to be the most sensitive indicator of re-sponse to differences in patterns of medical care organization.
should therefore be studied in children with other chronic illnesses in which failure to take medication may be promptly mani-fested by some exacerbation of symptoms. The observations in this study might not hold, for example, for diseases such as epi-lepsy or juvenile diabetes.
Quality of Care
Any comparison of comprehensive or continuous care with another pattern of medical care organization such as specialty clinics must consider the question of whether tile differences or lack of
differ-ences observed between the groups could
reflect not the organization per se, but rather differences in the quality of medical care provided as indicated, for example, by astuteness and accuracy of diagnosis and appropriateness of the therapy prescribed. The difficulties in both concept and mea-surement which are involved in studying the quality of medical care have been ex-tensively reviewed by Donabedian.11’12 The present studies were not designed to assess
quality of care but only to determine whether differences in organization and
provision of care would be reflected in de-monstrable changes in infant health or in patient compliance. Nevertheless, the factor of quality cannot he fully separated from the format of cane.
Ill tile infant care study, it was
antici-pated that if differences in quality did exist
in tile care received by the two groups, they would probably be in the direction of bet-ter quality of care in the comprehensive care program which is based in an active,
university-affiliated, teaching hospital. If so, a i)ias would he introduced in favor of the Comprehensive Care group which would tend to exaggerate differences in outcome between the two groups. Thus, the absence of any demonstrable difference between the
group appears to become even more
stnik-ing.
In the compliance study, quality of care
as distinct from organizational pattern was
held relatively constant since all the
physi-cians involved in both groups were experi-enced senior residents at Johns Hopkins and were judged at the outset of the study to meet high standards of pediatric compe-tence. Nevertheless, the practice of medi-cine in a continuous care framework may in itself have a positive effect on the medical standards of these physicians, and could thereby conceivably influence the results of the study.
It is likely that compliance would be less prone than an outcome measurement such as morbidity to be affected by differences in the medical competence of the physicians. However, even if the results are affected by differences in quality of medical care, the effect would be expected to be in the direc-tion of higher quality of care in the Contin-uous Cane program and would thus tend to exaggerate the differences between the two groups. This lends even more weight to the absence of any detectable differences be-tween the two groups.
I MPLICATIONS
SUMMARY
The effectiveness of comprehensive and continuous pediatric care was evaluated in two prospective, randomized, controlled studies. In the first study, 220 infants born to pnimiparous adolescents were randomly allocated to either comprehensive care or traditional care. Comprehensive care in-fants received all medical cane during their first year, both preventive and therapeutic, in a hospital-based pediatric program staffed by an interdisciplinary health team. Mothers of traditional cane infants were obliged to seek care at one of the usual re-sources available in the community such as well-baby clinics, pediatric clinics, and emergency rooms. Assessment of both groups after 1 year demonstrated no differ-ences between them in completeness of im-munizations, utilization of medical re-sources, morbidity, or mortality.
In the second study, the effectiveness of continuous care by physicians in improving compliance in chronically ill children was evaluated by studying changes in compli-ance with medical recommendations in 77 children and adolescents who were
receiv-ing daily oral antistreptococcal prophylaxis. After appropriate stratification, the patients were randomly allocated to either continu-ous cane on specialty clinic groups. Continu-ous care patients received all medical care, even for problems unrelated to rheumatic fever from the same two physicians for 15 months. Specialty clinic patients continued to receive cane in the rheumatic fever clinic and were referred elsewhere for any prob-lems unrelated to their history of rheumatic fever. After 15 months, no differences were observed between continuous care and spe-cialty clinic groups in the proportion of noncompliens or in internal shifts in compli-ance which had occurred during the study.
Thus, within the limitations described, neither study has demonstrated compre-hensive and continuous pediatric care to be superior to traditional episodic cane insofar
as the objective and quantifiable measures of monbidity, utilization, and patient corn-pliance are concerned.
REFERENCES
1. White, K. L. : In Bergman, A. B., ed. : Assess-ing the Effectiveness of Child Health Ser-vices, Report of the Fifty-sixth Ross
Confer-ence on Pediatric Research. Columbus,
Ohio: Ross Laboratories, p. 66, 1967. 2. Gordis, L., Markowitz, M., and Lilienfeld,
A. M. : Studies in the epidemiology and pre-ventabiity of rheumatic fever. IV. A quanti-tative determination of compliance in chil-dren on oral penicillin prophylaxis. PEDIAT-iucs,43:173, 1969.
3. Gordis, L., Markowitz, M., and Liienfeld, A. M. : Why patients don’t follow medical ad-vice: A study of children on long term anti-streptococcal prophylaxis.
J.
Pediat., 75:957, 1969.4. Markowitz, M., and Gordis, L. : A mail-in
tech-nique for detecting penicillin in urine:
Ap-plication to the study of maintenance of
prophylaxis in rheumatic fever patients.
PE-DIATRICS, 41:155, 1968.
5. Markowitz, M. : Eradication of rheumatic
fe-ver: An unfulfilled hope. Circulation, 41:
1077, 1970.
6. Lewis, C. E., and Resnik, B. A.: Nurse clinics
and progressive ambulatory patient care. New Eng. J. Med., 277:1236, 1967.
7. Silver, H. K., Ford, L. C., and Day, L. R. : The pediatric nurse practitioner program : Ex-panding the role of the nurse to provide in-creased health care for children. J.A.M.A., 204:298, 1968.
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