- Copyright © 2003 by the American Academy of Pediatrics
When Shari L. Barkin, M.D., FAAP, was a second-year resident at Children’s Hospital in Los Angeles, a 2-year-old child was brought to the emergency room with a gunshot wound to his head.
Despite the efforts of Dr. Barkin and other medical staff, the child, a victim of a drive-by shooting, suffered permanent brain damage.
“Something completely preventable took away his viability,” said Dr. Barkin, who subsequently treated many other children with injuries caused by violence.
These experiences prompted Dr. Barkin to initiate and lead one of two Pediatric Research in Office Settings (PROS) studies that examine the pediatrician’s role in preventing and recognizing violence against children.
Dr. Barkin’s study, called the “Safety Check” study, evaluates the effectiveness of an office-based “intervention to prevent youth violence.” Participating pediatricians are randomly assigned to one of two groups — one group tests new screening and counseling tools for violence prevention and the other tests counseling tools for reading promotion.
A second study, led by Emalee G. Flaherty, M.D., FAAP, examines the way in which pediatricians evaluate injuries for possible child abuse.
“We don’t know much about how physicians in practice evaluate injuries and determine that a particular injury may have been caused by abuse,” said Dr. Flaherty. “We think that there are resources that physicians use that assist them in making good decisions, and we think that there are some barriers that impede good decision-making. Perhaps if these barriers could be identified, they could be minimized or eliminated.”
Both studies — which are actively recruiting clinicians for participation — are among 20 primary care research efforts undertaken by the AAP PROS program since its inception in 1986. Today, the PROS Network relies on the volunteer efforts of more than 1,700 pediatric practitioners from 600 practices in every region of the United States, as well as cities in Canada and Puerto Rico.
The mission of PROS is to “improve the health of children by conducting collaborative, practice- based research to enhance primary-care practice.” The program was spearheaded in 1986 by then AAP President Robert J. Haggerty, M.D., FAAP.
“It has grown from this rather tiny thing into a nationwide collection of people and practices that are able to collect — in a rapid fashion — information on what physicians are seeing in their daily practice,” said Dr. Haggerty.
Richard C. “Mort” Wasserman, M.D., M.P.H., FAAP, director of PROS, said, “PROS is a system to allow pediatricians to learn from what happens in practice.”
Dr. Wasserman noted the PROS study on puberty in young girls (Herman-Giddens ME, et al. Pediatrics. 1997; 99:505-512OpenUrl), which received a tremendous amount of media coverage, sparked debate among physicians throughout the world, and ultimately changed the way that practitioners define “normal” puberty in girls.
That particular research effort was initiated as a result of observations of a PROS practitioner, Marcia E. Herman-Giddens, P.A., Dr.P.H., said Dr. Wasserman. “She herself noticed something. It seemed to her that the girls she was seeing in her practice had some sort of pubertal development at an age younger than what was, at that time, considered normal.”
“The great story here,” said Dr. Wasserman, “is that (the idea) came from a practitioner. PROS then involved other people who knew about the science, did the study, and ultimately published and disseminated the results.”
Another study (Wasserman RC, et al. Pediatrics. 1992; 89:834-838OpenUrl), found that most pediatricians were not screening preschool-age children for vision problems. As a result of the study, the Academy revised its vision screening guidelines and now recommends that screening begin at age 3 (“Eye Examination and Vision Screening in Infants, Children and Young Adults.” Pediatrics. 1996; 98:153-157OpenUrl).
While many PROS projects have been descriptive studies of particular issues, said Dr. Wasserman, most new initiatives are “intervention studies,” which test a particular technique during an office visit.
Dr. Wasserman said the Safety Check study is the first large-scale intervention study for PROS. “It’s a big step forward for the network, and a big step forward in an area that is very troubling to pediatrics,” he said.
Both the Safety Check study and the child injury study are meticulously designed to be practical and easy to integrate into a busy office setting.
In the Safety Check study, the “intervention” takes just one to four minutes during a well-child exam of children between the ages of 2 and 11, said Dr. Barkin. Each practitioner is asked to enroll 30 patients for the study, and if the interventions are conducted “during periods when well-child check exams are most common,” the entire process should take between two and four weeks.
Dr. Barkin and the PROS Network “conducted multiple pilot tests of the intervention to maximize its practicality in the office, as well as incorporating clinicians’ beliefs regarding what would make a difference for children and families.”
Dr. Flaherty said the child injury study is “very easy. We specifically designed it for busy practitioners.”
Each physician is asked to collect information on 40 consecutive child injuries that they see in the office, said Dr. Flaherty. Participating pediatricians will carry “little pocket-sized cards,” fill them out after an office visit and “then send them off to us.”
The questions include information on the child’s age, type of injury and the physician’s level of suspicion that the injury may have been caused by child abuse. If the physician suspects child abuse and reports findings to Child Protective Services, there is another short form to fill out as part of the study.
“We’re hoping that we can make suggestions for education that may help physicians better recognize and manage child abuse injuries,” said Dr. Flaherty, “as well as make recommendations for reallocating resources and making policy changes that may reduce some of the barriers that pediatricians encounter.”
While the studies require a time investment, the rewards are substantial, according to Paul Z. Bodnar, M.D., FAAP, chair of the PROS Steering Committee.
“You get personal feedback, and then once the data is analyzed, you get to see all of the information from the study,” said Dr. Bodnar. “The process allows practitioners to really move pediatrics ahead while still doing their practice.”
Dr. Bodnar, along with other members of the PROS Steering Committee, meets with regional coordinators twice a year to guide and determine future network endeavors.
“It’s a real eye-opening experience every time one goes and meets with sincere people really dedicated to figuring out what the issues are in pediatrics,” said Dr. Bodnar. “The cross-pollination of ideas from across the United States is extremely powerful.”
Practitioners participating in PROS also can participate in the PROS-Net e-mail electronic discussion group, where information is exchanged on studies under way, as well as other pediatric issues and concerns. The PROS Network uses PROS-Net, when necessary, to garner quick feedback on timely issues.
Pediatricians seeking more information about PROS should contact PROS Central at (800) 433-9016, ext. 7623; via e-mail at; or by faxing the coupon to (847) 434-8000.