Paediatric Subspecialty Interfacing with Primary Health Care Paediatric Endocrinology & Primary Care Paediatrics Dr. Huen Kwai – fun President The Hong Kong Society of Paediatric Endocrinology & Metabolism

Referral Pattern to a Paediatric Specialist Clinic Respiratory problems 17% Growth & Endocrine problems 16% Neurological problems 16% Heart problems 12% Renal problems 6% NNJ 6% Abdominal pain 3% Others 24% HKMJ Vol 6 No 1 March 2000,24-28

Growth & Endocrine Referrals >55% referrals from Student Health Service >9% referrals from private practitioners >5% referrals from MCHC >2% referrals from A&E ?% referrals from GOPC HKMJ Vol 6 No1 March 2000,24-28

Relationship between General Pediatricians and Subspecialists  No clear consensus to what types and severity of problems, or what aspect of any given chronic problem, should be managed by primary care pediatricians and what should be the domain of the specialist.  Children’s subspecialist services are relatively new compared with equivalent adult services  Research in internal medicine on the outcomes and quality of care provided by generalists and subspecialists is limited and conflicting. Data for pediatric patients is lacking.

Demand for Subspecialist Service  Several studies suggested parents are not confident with generalists level of skill in managing complex illnesses.  Rapid advances in specialist care in past decade  Increased survival of children with previously fatal conditions cause a steady increase in volume of work and demand for specialist services  Access to tertiary services recommended as minimal standards of care ( rising patients’ rights and access to medical information)

Benefits of a Tertiary Centre in Paediatric Endocrinology  Provide comprehensive training program in PE  Improve the quality of care through provision of service standards, development of management guidelines and audit of clinical service  Provide specialized laboratory services e.g. molecular biology, steroid chemistry, tissue culture, etc.  Provide consultation service to other service providers  Co-ordinate and promote collaborative research  Pool resources and expertise in PE  Promote the practice of PE

Primary, Secondary & Tertiary Care in Paediatric Endocrinology  General Paediatricians  General Paediatricians with special interest in Paediatric Endocrinology  Specialists in Paediatric Endocrinology

Relationship between primary, secondary and tertiary care for children and their families (BPA, 1995)

Service Integration  With a specialist to coordinate an expert multidisciplinary team and liaise with consultant paediatricians, primary care providers and community services, children with chronic diseases can lead normal or near normal lives

Success Interface Between Primary Care Paediatricians and Subspecialists 1. Common goals 2. Common criteria for good practice 3. Information, Clinical and Financial bridges to overcome barriers 4. Structured Training Program

Common Goals  Strengthen service providers collaboration with sharing of standards, quality practices, training and development opportunities and patient information among different providers  The ultimate objective is to improve the outcome and quality of care to maximize the benefit to the child with the best utilization of our resources

Criteria for good practice  The Child and Family are central to the process. Total patient care which is patient-centered and addressing needs at home & in the community.  Active participation in training and continuous professional education/development  Participation in shared care according to agreed clinical protocols, including health promotion, prevention and screening activities where appropriate

Criteria for good practice  Participation in clinical management meetings and clinical audit  Participation in community care, out of hours consultation, where appropriate  Contribution to clinical data, research, teaching, and disease surveillance  Installation of good quality infrastructure and participation in quality improvement projects

Bridging the barriers To avoid fragmentation and imbalance of service between Primary care paediatricians and Subspecialists 1. Information bridge 2. Clinical bridge 3. Finance bridge

(1) Information Bridge  Continuity of care achieved through unimpeded flow of clinical information across different providers and across time  Develop suitable IT infrastructure and applications aimed at cross providers usage  All concerned parties must be involved at the very start

Information Bridge  Willing to share medical records with patient’s consent, and standardize data definition and data entry  Ensure system security and maintenance  Government could provide subsidy as incentive for private participation, especially for solo practitioners

(2) Clinical Bridge  We need to build up the knowledge and research infrastructure that makes use of the data available, and work hand in hand with the quality side to set agenda for improvement initiatives  We need an over-arching planning framework to coordinate interests of various providers/sectors

Clinical Bridge  The common “currency” in this system should be evidence based clinical protocols that cut across organizational boundaries  Such protocols should be developed through professional leadership and expert input, focusing on important diseases, but also with participation of involved parties to ensure practicability and enhance buy-in  It takes a proper structure and a bit of incentives for this work to be carried forward

Clinical Bridge  Experience within HA – obstacles to progress – either political or financial, or both, arising from hospital and departmental boundaries, particularly impact on budget and spending  Population-based funding and cluster management aiming to move patients from inpatient to ambulatory and primary care setting and to private sector, can lead to more efficient use of available resources

Clinical Bridge  Clinical protocols will provide guidance on the use of the most appropriate setting of treatment for different stages of diseases, and criteria for cross referral  The parallel development of information systems across sectors, system-wide clinical audit and operational research will answer questions of clinical outcome, cost, and policy appropriateness

(3) Finance Bridge  Develop products and incentives that attract patients to go back to their private doctors  Continued linkage with hospital and specialist backup important  Stable patients managed in primary care setting according to clinical protocols.

Finance Bridge  Choice of doctors if they go back to their private GP, while guaranteed of hospital backup if they need them  Incentive system designed to encourage practice of good medicine e.g ‘preferred provider partners’ ‘green lanes’ for referral to specialist care subsidy either in kind or cash

Training Program Principles  Training should lead somewhere – manpower situation and career structure need consideration  Structure and organization of training – integral part of CME / CPD

Proposed Training Profile All Paediatricians – Basic Training  General Paediatrics(2 years)  Neonatology(6 months)  Rotation through 2-3 hospitals  Primary care paediatrics and child health(1 year)  Ambulatory paediatrics(6 months)  Child Assessment Centre (3 months – optional)  Clinical genetics(3 months – optional)  Rehabilitation(3 months – optional)  Intermediate examination

Proposed Training Profile General Paediatricians with special interest in PE  Paediatric endocrinology (2 years)  District diabetic population  Children with primary hypothyroidism  Individuals with delayed puberty  Growth hormone deficiency  Short and tall stature children  Rotation through 2-3 hospitals  Child health and primary care paediatrics (1 year)  Exit examination

Proposed Training Profile Subspecialist in Paediatric Endocrinology  Paediatric Endocrinology (2 – 3 years)  Disorders of the adrenal gland  Ambiguous genitalia  Disorders of pituitary glands  Hyperthyroidism  Complications of diabetes  Early puberty  Hypoglycaemia  Disorders of calcium metabolism  Inborn errors of metabolism  Liaise with adult and paediatric colleagues complex cases.  Research essential 1-3 years, a higher degree MD or PhD desirable

Suggested Flow Chart in Paediatric Training 2 years Core training 1.General Paediatrics 2.Neonatology 1 year Child health and primary care paediatrics - ambulatory paediatrics, assessment center, genetics, rehabilitation etc Intermediate Assessment 3 years General Paediatrics with special interest(s) on primary paediatricsinterest(s) on subspecialties Exit Examination 2 years – Sub-specialties – general advance / sub-specialties

Success Integration of Service  Common vision and mission common objectives and good practice criteria  Clear Role Delineation clear service structure and financial incentives  Appropriate training organized training program  Good communication information and clinical bridges

Priority Areas for Interface in Paediatric Endocrinology 1. Common disorders - Management & referral guidelines *Growth Disorders *Pubertal Disorders 2. New Morbidities – Screening & Management protocols *Obesity *Type 2 Diabetes

Priority Areas for Interface in Paediatric Endocrinology  Health Promotion Programs * Encourage exercise * Balanced nutrition and healthy eating style 4. Public Health Screening Programs * PKU *Maternal iodine deficiency

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