Previous studies of appointment reminders among general pediatric patients have been done exclusively among low socioeconomic populations in clinics with low continuity of care and using block scheduling methods. This study of mailed computer-generated appointment reminders took place in a setting with patient demographics and practice techniques similar to those of many private pediatric practices. During a 6-month period, 901 appointments that were made more than 7 days prior to the scheduled date were randomly assigned to receive reminder postcards or to serve as controls. The overall broken appointment (no-show) rate was reduced from 19% in the control group to 10% in the reminder group, representing a 48% reduction (P = .0002). The magnitude of reduction of no-shows was similar for appointments scheduled more than 14 days prior to the appointment time (39%) as well as those scheduled more recently (58%). Equivalent results were seen with well-child appointments (47%) as with other visits (50%). Both lower and higher socioeconomic groups demonstrated similar results. The mailed postcards cost $0.20 each and were highly cost effective, generating an estimated $7.50 for each $1 spent during the study. With reductions similar to those found in this study, computer-generated appointment reminders are likely to be cost effective in other practices if current no-show rates are greater than 2% to 4%.

ABSTRACT: Changes in the normal hormonal regulation of linear growth which lead to growth failure in children with chronic renal failure (CRF) are not well understood. Previous studies indicate that serum levels of growth hormone and IGF-I and II are normal or elevated in this population; and that serum levels of poorly defined inhibitors of IGF action are increased. Using a recently developed RIA for the 25-kD IGF-binding protein (IGF-BP25), we report significant elevations of this protein in children with CRF when compared to age- and sex-matched controls. IGF-BP25 levels correlate positively with IGF-binding activity in both populations, indicating that the RIA reflects levels of bioactive protein. Although the variation of serum IGF-BP25 with chronologic age and IGF levels are preserved in CRF, the quantitative interrelationships are disrupted. Levels of the 53-kD IGF-binding protein, an IGFbinding protein derived from the high mol wt IGF complex, were also found to be elevated in the CRF population and, unlike in the control population, did not vary with age or IGF levels. IGF-BP25 has been shown to inhibit IGF mitogenic action in vitro. Our finding of elevated levels of IGF-BP25 in children with CRF suggests that this protein may play a role in the growth retardation of pediatric chronic renal failure. The significance of the elevated IGFBP53 levels in CRF remains uncertain.

Previous attempts to predict resident clinical performance based solely on measures of cognitive skills have been uniformly unsuccessful. For the past 8 years, a formative residency evaluation system has been used that includes yearly comprehensive oral in-training examinations (OITEs) assessing each resident's performance in the three areas of professional competence: cognitive, psychomotor, and affective. The results of these examinations and scores received on the written in-training examination (WITE) given by the American Board of Pediatrics were compared with faculty ratings received during the subsequent year of residency. No significant correlation was found at any level of training between WITE scores and clinical performance. Analysis based on clinical setting did not improve these results. Oral in-training examination scores, however, were highly correlated with clinical performance ratings. In addition, with oral in-training examination scores, the "problem" interns--those whose clinical performance rating placed them in the lower 10% of interns--were predicted with a high degree of significance, sensitivity, and specificity. Predictions based on WITEs were not significant. Simultaneous evaluation of all three areas of professional competence should be done when predictions of resident performance are attempted. The OITE is a powerful formative evaluation tool, providing valuable learning experiences as residents are objectively assessed while they perform patient-centered tasks that represent critical skills in the practice of medicine. It allows early detection and possible amelioration of future problems in the clinical performance of a resident.

Yearly oral in-training examinations that assess resident performance in the three domains of professional competence (cognitive, psychomotor, and affective) given over a seven year period correlated highly with subsequent resident clinical performance and also predicted with a high degree of significance, sensitivity, and specificity those "problem" interns whose clinical performance placed them in the lower 10% of interns. Scores received on written in-training examinations were not significantly correlated with clinical performance and did not identify "problem" residents.