- Email: [email protected]
Framingham safety survey
THE JOURNAL OF PEDIATRICS Volume 13 I, Number 3
LETTERS
the age at which children with sickle cell anemia are capable of producing protective antibodies before recommendations on reimmunization beyond the age of 5 years should be made.
Ann B. Bjornson, PhD John M. Falletta, MD Duke Children'sHoo vital and Health Center Durham, NC 27710 9/35/82596 !
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REFERENCES 1. Ran SP, Rajkumar K, Schiffman G, Desai N, Unger C, Miller ST. Anti-pneumococcal antibody levels three to seven years after first booster immunization in children with sickle cell disease, and after the second booster. J Pediatr 1995;127:590-2. 2. Siber GR, Priehs C, Madore DV. Standardization of antibody assays for measuring the response to pneumoeoccal infection and immunization.Pediatr Infect Dis J 1989;8:$84-91. 3. Musher DM, Luchi M J, Watson DA, Hamilton R, Baughn RE. Pneumococcal polysaccharide vaccine in young adults and older bronchitics: determination of IgG responses by ELISA and the effect of adsorption of serum with non-type-specific cell walt polysaccharide. J Infect Dis 1990;161:728-35. 4. Nahrn MH, Siber GR, Olander J. A modified Farr assay is more specificthan ELISA for measuring antibodies to Streptococcus pneamoniae capsular polysaeeharide. J Infect Dis 1996;173:113-8.
Framingham Safety Survey To the Editor: I read with interest the recent report, "Do the Framingham Safety Surveys improve injury prevention counseling during pediatric health supervision visits?" in the October issue of The douJ~a[ of Pediatrics.1 Having played a leading role in the development of the surveys, I was quite interested in this study. From my perspective as a researcher in the field, I found the results to be encouraging, but the interpretation of the results by the authors to be disappointing. To judge the efficacy of the Framingham Safety Survey as a counseling tool, it is necessary from the outset to understand
the purpose of these surveys, namely, to target counseling to specifically identified educational needs. Although the surveys may increase the total amount of counseling in practices that have not previously engaged in counseling, in settings such as that of the authors, where counseling is routinely performed, the total amount of counseling may remain the same or may even decrease. Unfortunately, the majority of the results reported by the authors concern the total amount of counseling delivered to the patients, an outcome that is not central to the purpose of the surveys. To properly gauge the impact of the use of surveys in a practice, it is necessary to measure the number of times individual physicians actually use the surveys as intended. In addition, it is useful to see what proportion of "at risk" answers are addressed in the counseling, keeping in mind that even compliant physicians may set priorities if the clinical circumstances do not permit a complete discussion. The authors did not quantify individual physician compliance, but they did state that of the 98 items identified as at risk by the Framingham Safety Survey, 470/0 of these were not discussed by the physicians. Therefore 53% of the at risk items werein fact discussed by the physicians. Given the rather short period of intervention (4 weeks) and the fact that the physicians had no special orientation to the use of the surveys, this is an excellent result, in excess of what I would have ever thought possible in so brief an interval in multiple busy pediatric practice settings. In our own trials we were able to obtain 82% compliance over a 2-year period. 2 This was confirmed by extensive process evaluations, which included on-site observations by a research worker and involved 2179 parents, 35 pediatricians, and 11 nurses. Given the fact that the physicians participating in this new study were reported to be quite positive about the surveys (77% indicated that the surveys were helpful in educating families about safety), it is quite likely that given more time, the compliance demonstrated might also have increased to the levels we observed over longer periods. Although the authors have not recognized it in their report, they have in fact provided new evidence of both good compliance and high provider satisfaction with this method of
counseling, a result that is quite consistent with existing published data on this issue. In addition, in the commentary on the article by Rivara, 5 a statement is made suggesting that the Framingham Safety Surveys were adopted without extensive evaluation. This is not accurate, because numerous reports in the literature of both process and outcome evaluations are available. It is also important to recognize that the surveys are a means to an end and not the end itself. They function as an organizer and delivery system for the counseling; and in the final analysis, even when used meticulously, the efficacy of the surveys will succeed or fail on the basis of the communication skills of the individual physician. Although this may vary from physician to physician, the literature clearly demonstrates that in 18 studies (including five randomized, controlled studies), physician counseling to prevent injury has improved outcomes for children. 4 Given this information, it is logical to encourage the use of a well accepted method to deliver appropriate injury prevention counseling. The Framingham Safety Surveys have proven to be an effective means to facilitate this effort because the messages are appropriate, and the surveys have been accepted by both parents and providers. Even in the Hansen s t u @ 1 in which the baseline physician counseling was already quite high, more than half of the physicians said they would use the surveys again, a result that confirms what has already been demonstrated about the high rate of acceptability of this particular approach to injury prevention counseling.
clod L. Bass, MD Framingham Union Campus Columbia Metro WestMedical Center Framb~gham, MA O1702-9167 9/35/83569
REFERENCES 1. Hansen K, Wong D, Young PC. Do the Framingham Safety Surveys improve injury prevention counseling during pediatric health supervision visits? J Pediatr 1996; 129:494-8. 2. BassJ,/v[ehta K, Ostrovsky M, Halpern S. Educating parents about injury prevention. Pediatr Clin North Am 1985;233-41.
499
LETTERS
Rivara E Injury prevention and the pediatrician, d Pediatr 1996;129:487-8. Bass JL, Christofel KK, Widome iV[,Boyle W, Scheidt E Stanwick R, et al. Injury prevention counseling in primary care se~ing: a critical review of the literature. Pediatrics 1993;92:544-50.
Reply To the Editor: Dr. Bass is a recognized expert in child i n j u w prevention, and we are flattered that he has carefully read and commented on our study. We believe that we clearly pointed out that the Framingham Surveys were not intended to increase the number of safety issues discussed by physicians (page 497, paragraph 6). Nevertheless, we believed it reasonable to test the hypothesis that a survey attached to the front of a chart might remind a pediatrician to do more injury prevention counseling than if one were not there. In our setting it did not. We have no data to support Dr. Bass's assertion that the surveys would influence pediatricians who had done little or no counseling to begin to do so. Dr. Bass thinks that our finding that 53% of the at risk items were discussed is an "excellent" result. We disagree; what we found is that physicians counseled parents about items for which they were not at risk as frequently as they did for those for which they were. It may be that reinforcing a l r e @ present injury prevention behaviors is a good thing to do, but the purpose of the surveys is to identify behaviors that place children at risk so that physicians can use the information to counsel parents to change these behaviors. In our study we found that about half the time these at risk behaviors were ignored. We do not consider this an excellent result. The issue of orienting physicians to the proper use of surveys and then monitoring and reinforcing their compliance is an important one. The surveys seem self-explanatory and easy to use; indeed, this is one of their attractive features. If it is true that their successful use requires such efforts to be effective, then using them in ordinary clinical practice may not be practical. As noted in our article, the American Academy of Pediatrics, which markets the surveys as part of The Injury Prevention
500
THE JOURNALOF PEDIATRICS SEPXEMBER1997 Program (TIPP), does not specify that such ongoing efforts to ensure compliance are needed for their effective use. Dr. Bass states that the surveys have been "extensively" evaluated. The only evaluations that we could find were those by Dr. Bass and his colleagues in the original development study as part of a research project with ongoing education and compliance monitoring. We would be interested in learning of other evaluations. We agree that counseling by physicians is probably an effective injury prevention strategy. Our study should not be interpreted as in any way suggesting that such counseling is not worthwhile. Others may find that using the Framingham Surveys assists physicians in being efficient and effective counselors; we look forward to seeing the results of these studies.
Kim Hansen, MD Daphne Wong,MD Paul C. Young,MD University of Utah Health Sciences Center Salt Lake City, UT 84113
water in children with spastic cerebral palsy. It has been previously demonstrated 2 that correlation coefficients are not a satisfactoW technique with which to validate a new method of estimation (here BIA) against a classical method of measurement (here dilution isotopes). An excellent correlation does not guarantee the accuracy of the new method. An analysis of difference against mean is more informativeJ This technique provides both an average difference between the two methods, which is an estimate of the average bias of one method relative to the other, and limits of agreement, which reflect (for any particular individual) how much above or below the measured value of body water (from dilution isotopes) will be the estimated value (from BIA). We think that this information should be provided before validating BIA as a reliable method for estimating water spaces in children with cerebral palsy.
Howard G. Parsons,MD, FRCP(C) S. A. Zamora, MD The Universityof Canary Departnwnt of Pediatrics Canary, Alberta TYN 4N1 Canada
9/35/83568
Bioelectrical impedance analysis for estimation of body water spaces To the Editor: Azcue et al. 1 report resting energy expenditure and body composition measurements in children with spastic cerebral palsy. Total body water and extracellular water were measured with dilution isotopes and bioelectrical impedance techniques. The bioelectrical impedance analysis (BIA) required repeated measurements to reduce the coefficient of variation to 2%. With predictive equations incorporating reactance, resistance, and height, total body water and extracellular water were calculated. The calculated values of body water spaces (from BIA) were compared with the measured values (from dilution isotopes) by using simple linear regression, and high correlation coefficients were reported (r = 0.95 and r = 0.92 for total body water and extracellular water, respectively). Because of the high correlation between BIA and the dilution method, the authors conclude that BIA is a reliable method for estimating total body water and extracellular
9/35/83196
REFERENCES 1. Azcue MP, Zello GA, Levy LD, Penchartz PB. Energy expenditure and body composition in children with spastic quadriplegic palsy, d Pediatr 1996;129:870-6. 2. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;327:307-10.
Reply To the Editor: We read with interest the letter to the editor sent by Drs. Parsons and Zamora, regarding our article about the energy expenditure and body composition of children with spastic quadriplegic palsy. 1 The key issue they raise is that of the prediction of water spaces by bioelectrical impedance (BIA). In our study we used linear regression. We agree that there are alternative methods, such as
LETTERS
the age at which children with sickle cell anemia are capable of producing protective antibodies before recommendations on reimmunization beyond the age of 5 years should be made.
Ann B. Bjornson, PhD John M. Falletta, MD Duke Children'sHoo vital and Health Center Durham, NC 27710 9/35/82596 !
ii
i! !~ !
i
i
ii i
i i i ]
i , +(
i,
i
i
REFERENCES 1. Ran SP, Rajkumar K, Schiffman G, Desai N, Unger C, Miller ST. Anti-pneumococcal antibody levels three to seven years after first booster immunization in children with sickle cell disease, and after the second booster. J Pediatr 1995;127:590-2. 2. Siber GR, Priehs C, Madore DV. Standardization of antibody assays for measuring the response to pneumoeoccal infection and immunization.Pediatr Infect Dis J 1989;8:$84-91. 3. Musher DM, Luchi M J, Watson DA, Hamilton R, Baughn RE. Pneumococcal polysaccharide vaccine in young adults and older bronchitics: determination of IgG responses by ELISA and the effect of adsorption of serum with non-type-specific cell walt polysaccharide. J Infect Dis 1990;161:728-35. 4. Nahrn MH, Siber GR, Olander J. A modified Farr assay is more specificthan ELISA for measuring antibodies to Streptococcus pneamoniae capsular polysaeeharide. J Infect Dis 1996;173:113-8.
Framingham Safety Survey To the Editor: I read with interest the recent report, "Do the Framingham Safety Surveys improve injury prevention counseling during pediatric health supervision visits?" in the October issue of The douJ~a[ of Pediatrics.1 Having played a leading role in the development of the surveys, I was quite interested in this study. From my perspective as a researcher in the field, I found the results to be encouraging, but the interpretation of the results by the authors to be disappointing. To judge the efficacy of the Framingham Safety Survey as a counseling tool, it is necessary from the outset to understand
the purpose of these surveys, namely, to target counseling to specifically identified educational needs. Although the surveys may increase the total amount of counseling in practices that have not previously engaged in counseling, in settings such as that of the authors, where counseling is routinely performed, the total amount of counseling may remain the same or may even decrease. Unfortunately, the majority of the results reported by the authors concern the total amount of counseling delivered to the patients, an outcome that is not central to the purpose of the surveys. To properly gauge the impact of the use of surveys in a practice, it is necessary to measure the number of times individual physicians actually use the surveys as intended. In addition, it is useful to see what proportion of "at risk" answers are addressed in the counseling, keeping in mind that even compliant physicians may set priorities if the clinical circumstances do not permit a complete discussion. The authors did not quantify individual physician compliance, but they did state that of the 98 items identified as at risk by the Framingham Safety Survey, 470/0 of these were not discussed by the physicians. Therefore 53% of the at risk items werein fact discussed by the physicians. Given the rather short period of intervention (4 weeks) and the fact that the physicians had no special orientation to the use of the surveys, this is an excellent result, in excess of what I would have ever thought possible in so brief an interval in multiple busy pediatric practice settings. In our own trials we were able to obtain 82% compliance over a 2-year period. 2 This was confirmed by extensive process evaluations, which included on-site observations by a research worker and involved 2179 parents, 35 pediatricians, and 11 nurses. Given the fact that the physicians participating in this new study were reported to be quite positive about the surveys (77% indicated that the surveys were helpful in educating families about safety), it is quite likely that given more time, the compliance demonstrated might also have increased to the levels we observed over longer periods. Although the authors have not recognized it in their report, they have in fact provided new evidence of both good compliance and high provider satisfaction with this method of
counseling, a result that is quite consistent with existing published data on this issue. In addition, in the commentary on the article by Rivara, 5 a statement is made suggesting that the Framingham Safety Surveys were adopted without extensive evaluation. This is not accurate, because numerous reports in the literature of both process and outcome evaluations are available. It is also important to recognize that the surveys are a means to an end and not the end itself. They function as an organizer and delivery system for the counseling; and in the final analysis, even when used meticulously, the efficacy of the surveys will succeed or fail on the basis of the communication skills of the individual physician. Although this may vary from physician to physician, the literature clearly demonstrates that in 18 studies (including five randomized, controlled studies), physician counseling to prevent injury has improved outcomes for children. 4 Given this information, it is logical to encourage the use of a well accepted method to deliver appropriate injury prevention counseling. The Framingham Safety Surveys have proven to be an effective means to facilitate this effort because the messages are appropriate, and the surveys have been accepted by both parents and providers. Even in the Hansen s t u @ 1 in which the baseline physician counseling was already quite high, more than half of the physicians said they would use the surveys again, a result that confirms what has already been demonstrated about the high rate of acceptability of this particular approach to injury prevention counseling.
clod L. Bass, MD Framingham Union Campus Columbia Metro WestMedical Center Framb~gham, MA O1702-9167 9/35/83569
REFERENCES 1. Hansen K, Wong D, Young PC. Do the Framingham Safety Surveys improve injury prevention counseling during pediatric health supervision visits? J Pediatr 1996; 129:494-8. 2. BassJ,/v[ehta K, Ostrovsky M, Halpern S. Educating parents about injury prevention. Pediatr Clin North Am 1985;233-41.
499
LETTERS
Rivara E Injury prevention and the pediatrician, d Pediatr 1996;129:487-8. Bass JL, Christofel KK, Widome iV[,Boyle W, Scheidt E Stanwick R, et al. Injury prevention counseling in primary care se~ing: a critical review of the literature. Pediatrics 1993;92:544-50.
Reply To the Editor: Dr. Bass is a recognized expert in child i n j u w prevention, and we are flattered that he has carefully read and commented on our study. We believe that we clearly pointed out that the Framingham Surveys were not intended to increase the number of safety issues discussed by physicians (page 497, paragraph 6). Nevertheless, we believed it reasonable to test the hypothesis that a survey attached to the front of a chart might remind a pediatrician to do more injury prevention counseling than if one were not there. In our setting it did not. We have no data to support Dr. Bass's assertion that the surveys would influence pediatricians who had done little or no counseling to begin to do so. Dr. Bass thinks that our finding that 53% of the at risk items were discussed is an "excellent" result. We disagree; what we found is that physicians counseled parents about items for which they were not at risk as frequently as they did for those for which they were. It may be that reinforcing a l r e @ present injury prevention behaviors is a good thing to do, but the purpose of the surveys is to identify behaviors that place children at risk so that physicians can use the information to counsel parents to change these behaviors. In our study we found that about half the time these at risk behaviors were ignored. We do not consider this an excellent result. The issue of orienting physicians to the proper use of surveys and then monitoring and reinforcing their compliance is an important one. The surveys seem self-explanatory and easy to use; indeed, this is one of their attractive features. If it is true that their successful use requires such efforts to be effective, then using them in ordinary clinical practice may not be practical. As noted in our article, the American Academy of Pediatrics, which markets the surveys as part of The Injury Prevention
500
THE JOURNALOF PEDIATRICS SEPXEMBER1997 Program (TIPP), does not specify that such ongoing efforts to ensure compliance are needed for their effective use. Dr. Bass states that the surveys have been "extensively" evaluated. The only evaluations that we could find were those by Dr. Bass and his colleagues in the original development study as part of a research project with ongoing education and compliance monitoring. We would be interested in learning of other evaluations. We agree that counseling by physicians is probably an effective injury prevention strategy. Our study should not be interpreted as in any way suggesting that such counseling is not worthwhile. Others may find that using the Framingham Surveys assists physicians in being efficient and effective counselors; we look forward to seeing the results of these studies.
Kim Hansen, MD Daphne Wong,MD Paul C. Young,MD University of Utah Health Sciences Center Salt Lake City, UT 84113
water in children with spastic cerebral palsy. It has been previously demonstrated 2 that correlation coefficients are not a satisfactoW technique with which to validate a new method of estimation (here BIA) against a classical method of measurement (here dilution isotopes). An excellent correlation does not guarantee the accuracy of the new method. An analysis of difference against mean is more informativeJ This technique provides both an average difference between the two methods, which is an estimate of the average bias of one method relative to the other, and limits of agreement, which reflect (for any particular individual) how much above or below the measured value of body water (from dilution isotopes) will be the estimated value (from BIA). We think that this information should be provided before validating BIA as a reliable method for estimating water spaces in children with cerebral palsy.
Howard G. Parsons,MD, FRCP(C) S. A. Zamora, MD The Universityof Canary Departnwnt of Pediatrics Canary, Alberta TYN 4N1 Canada
9/35/83568
Bioelectrical impedance analysis for estimation of body water spaces To the Editor: Azcue et al. 1 report resting energy expenditure and body composition measurements in children with spastic cerebral palsy. Total body water and extracellular water were measured with dilution isotopes and bioelectrical impedance techniques. The bioelectrical impedance analysis (BIA) required repeated measurements to reduce the coefficient of variation to 2%. With predictive equations incorporating reactance, resistance, and height, total body water and extracellular water were calculated. The calculated values of body water spaces (from BIA) were compared with the measured values (from dilution isotopes) by using simple linear regression, and high correlation coefficients were reported (r = 0.95 and r = 0.92 for total body water and extracellular water, respectively). Because of the high correlation between BIA and the dilution method, the authors conclude that BIA is a reliable method for estimating total body water and extracellular
9/35/83196
REFERENCES 1. Azcue MP, Zello GA, Levy LD, Penchartz PB. Energy expenditure and body composition in children with spastic quadriplegic palsy, d Pediatr 1996;129:870-6. 2. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986;327:307-10.
Reply To the Editor: We read with interest the letter to the editor sent by Drs. Parsons and Zamora, regarding our article about the energy expenditure and body composition of children with spastic quadriplegic palsy. 1 The key issue they raise is that of the prediction of water spaces by bioelectrical impedance (BIA). In our study we used linear regression. We agree that there are alternative methods, such as