Objective. One goal of the American Academy of Pediatrics' Future of Pediatric Education II Project is to establish guidelines in training physicians to care for children with special health care needs (CWSN). Assessment of current practices in prescribing therapies and devices is necessary to meet this goal. Although much has been written about CWSN, there is a paucity of literature describing pediatricians' preparedness in prescribing such therapies and devices to children with physical disabilities. In an effort to assess physician preparedness, we surveyed pediatric residents nationwide and practicing pediatricians from 2 states, 1 urban and 1 rural.
Methods. A questionnaire aimed at identifying areas of concern regarding preparedness of physicians in practice and in training was prepared and mailed to prospective participants in Ohio and Mississippi. After follow-up mailings to nonresponders, ∼59% responded. Summary statistics were reported as proportions with 95% confidence intervals.
Results. Among those polled, >70% reported no training in prescribing certain durable medical equipment and over 50% reported no training in prescribing certain therapies. In addition, at least 20% reported no training in treating some of the more common childhood physical disabilities. Nearly three fourths of the respondents indicated that they did not believe that they were adequately prepared to take an active role in prescribing therapies and durable medical equipment. Fewer respondents believed that they should be the sole providers of these therapies and durable medical equipment.
Conclusions. The results of the survey indicate a lack of specific training and physician confidence in prescribing therapies and devices to CWSN, establishing the necessity of expanding training programs to better ensure quality health care for special needs children. Although additional ongoing research is necessary to fully evaluate the preparedness of physicians in caring for CWSN, this survey does help to identify areas of physician training that require improvement to provide quality health care for CWSN.
- FOPE II =
- Future of Pediatric Education II Project •
- AAP =
- American Academy of Pediatrics •
- CWSN =
- children with special (health care) needs •
- DME =
- durable medical equipment •
- ABP =
- American Board of Pediatrics •
- ABPM&R =
- American Board of Physical Medicine and Rehabilitation •
- AAPMR =
- American Academy of Physical Medicine and Rehabilitation •
- PM&R =
- physical medicine and rehabilitation
Through the Future of Pediatric Education II Project (FOPE II), the American Academy of Pediatrics (AAP) is developing recommendations that will shape pediatric education and training during the next century.1 As part of FOPE II, pediatric generalist consultants are defining the role and scope of the pediatric generalist in providing health care for children and offering recommendations for pediatric training and delivery of services. In addition, subspecialist consultants are exploring interactions between the pediatric generalist and the subspecialist and suggesting protocols for referral and management of children, including children with special needs (CWSN), who are described as children with a “chronic physical, developmental, behavioral, or emotional condition.”2 Other task force members are reviewing the role of nonpediatrician providers of pediatric care and investigating the relationship between pediatricians and these providers in an effort to improve health care for all children and, specifically, CWSN.
To achieve the goals of FOPE II and ensure that CWSN are being provided quality health care, we must address the question of whether pediatricians are being adequately prepared to assume leadership in prescribing the specialty therapies and durable medical equipment (DME) often required by this population. In an effort to establish the current adequacy of training and the practices of pediatricians in prescribing therapies and DME, we conducted a survey of residents from across the United States and practicing pediatricians in 2 representative states, 1 urban and 1 rural. In the following section, we discuss the methods of data collection and analysis used in the survey. We then summarize responses to questions concerning physician preparedness and interpret the results. Based on these results, we offer some recommendations in the concluding discussion.
We assessed the preparedness of practicing pediatricians and residents in prescribing therapies and DME for CWSN through questionnaires sent to the targeted groups. For practicing pediatricians, the survey collected information on institution of pediatric training, year residency was completed, year of certification by the American Board of Pediatrics (ABP), and type of practice and practice institution. Residents were asked to provide information on institution of pediatric training and present year of residency. Residents and physicians were then asked to provide information on specific training they received during residency and on the adequacy of their training in prescribing therapies and DME common to CWSN.
In a small pilot study, a prototype questionnaire was given to 26 pediatric residents at the University of Mississippi Medical Center in Jackson, Mississippi. The residents were asked to complete and return the questionnaire and provide comments on its administration and suggestions for improvement. Fewer than one half of the questionnaires were returned. The residents expressed no seriously negative comments except for concern about the form's length. After reviewing the responses, we revised and shortened the questionnaire to 10 questions printed on 4 standard typewritten pages. Average time to complete the questionnaire was not calculated, but we believe the form can be completed in less than half an hour.
The questionnaire was then mailed by conventional ground mail services to prospective participants. Using the Graduate Medical Education Directory, 1997–1998,3 214 pediatric residency-training programs were identified, 211 of which were still in existence. A survey was sent to one chief or senior resident at each of these 211 programs under the assumption that these individuals have the most experience in providing information about their programs and that this group of residents is representative of current teaching practices across the United States. Because the results indicated a significant lack of knowledge in the areas of inquiry, picking the most experienced residents for contact in each program seemed to justify the selection.
In addition to surveying residents, we chose 2 representative states, Ohio and Mississippi, to investigate past pediatric training as well as current prescribing practices and practicing pediatricians' reliance on other professionals. Ohio, a more urban state, has a total population of ∼11 million and 2.7 million children under 18 years old.4 Ohio has at least 7 metropolitan areas with populations over 400 000 distributed approximately equidistant throughout the state, leading to a more urbanized association of physicians throughout the state. Ohio is representative of states that have both ABP and American Board of Physical Medicine and Rehabilitation (ABPM&R)-certified residency training programs. Four major cities in Ohio (Toledo, Cleveland, Cincinnati, and Columbus), distributed approximately equidistant throughout the state, have ABPM&R approved residences; and there are 9 ABP-approved residencies throughout Ohio.3 Mississippi, a more rural state with a total population of ∼2.5 million and 700 000 children under 18 years old,4 has only 1 ABP-certified residency program and no ABPM&R-certified training programs within its borders.3Mississippi has only 2 metropolitan areas approaching a population of 300 000 with most other areas well under 100 000. In its 1998 directory,5 the American Academy of Physical Medicine and Rehabilitation (AAPMR) lists 218 members who are physiatrists in Ohio compared with only 15 practicing physiatrists in Mississippi. Comparisons between Ohio and Mississippi pediatricians will help quantify the influence of having available certified training programs and specialists on the pediatricians' therapy and DME prescribing practices. Using the AAP Fellowship Directory, we identified 2062 pediatricians in Ohio and 321 in Mississippi. To balance the information obtained from physicians and residents, a computer-generated simple random sample of 225 physicians from each state was taken. In summary, the survey was mailed to 70% of registered Mississippi pediatricians, 11% of registered Ohio pediatricians and all identified residents across the country. In the event a questionnaire was returned undelivered, a replacement was randomly selected. Two follow-up mailings were sent to those who did not respond to minimize bias introduced by nonresponse.
Of the 211 questionnaires mailed to residents, we received 167 completed surveys, a 79% response rate. Approximately 70% of responding residents reported being in the fourth or fifth year of residency with only 3 in the second year. All states and territories of the United States except Alaska, Guam, Idaho, Montana, Nevada, North Dakota, South Dakota, Wyoming, New Mexico, and Vermont were represented by resident respondents. Thus, the survey provides a reasonable overview of the current pediatric training practices throughout the United States and its territories. Of the 225 surveys sent to practicing physicians in Ohio, 124 were returned for a response rate of 55%. We received 102 questionnaires from Mississippi physicians, a response rate of 45%.
One purpose of this ongoing study was to quantify the training and prescribing procedures of physicians responsible for the care of CWSN. In most instances, responses were categorical and results are reported as proportions with 95% Wilson-type confidence intervals.6 No adjustment was made for multiple confidence interval construction or finite population correction. Where appropriate, proportions were compared using χ2statistics with P < .05 considered statistically significant.
Preparedness of Physicians for Prescribing DME
One specific aim of our study was to quantify the training physicians have received in dealing with patients who require prescriptions for DME. For the purposes of this study, DME included wheelchairs, crutches and canes, braces for upper and lower extremities, spinal braces, and communication devices. Under federal guidelines, prescriptions for these devices must be initiated by physicians and monitored as to suitability for each individual patient.7 ,8 It is of interest, therefore, to determine whether practicing physicians are well trained in prescribing these devices.
Respondents were asked if they received specific residency training in prescribing the designated equipment, and if so, to indicate how much by circling the hours of training received. Duration was given as a choice of none, 1 hour or less, or >1 hour. Table 1 gives the observed proportions and confidence intervals for those who reported receiving some or no specific training for prescribing each type of DME. Strikingly, over 80% of the total respondents reported no training in prescribing wheelchairs, braces for extremities, spinal braces, and communications devices. In one of the most expensive categories, wheelchairs, only 15% reported having any training. Over two thirds of the respondents did not have training in prescribing crutches and canes, perhaps the most common DME. No more than 5% of respondents received >1 hour of training in any category of equipment, illustrating a potential shortcoming in both past and present physician training.
Next, we asked respondents how they would rate their specific training (including lectures, conferences, grand rounds, etc.) in prescribing the 5 DME categories we listed. Responses were categorized as none, inadequate, or adequate. Table 2lists the results based on the proportion that thought training was adequate. We note that there is some evidence of problems with internal validity because some who answered none to this question indicated they had had specific training in question 1, but the proportion in discordance is small (<4%). A striking sense of inadequate training was evidenced among residents as well as practicing physicians in each state for the various DME categories. The impression of having adequate training was highest for crutches and canes but was only about 11% for the combined groups. For all other DME categories, the overall impression of adequate training was never greater than 7%. This lack of training is in direct contrast to federal guidelines and most state requirements that physicians be the initiators and authorities on appropriateness of equipment prescribed in these areas.
In Table 2, we also give the proportion of those who reported having some training in response to question 1 and who believed that training to have been adequate. Less than one third believed their training adequately prepared them for prescribing crutches and canes. Only approximately one quarter described their training in prescribing expensive items such as wheelchairs, spinal braces, and braces for upper and lower extremities as adequate. Approximately, 20% had confidence in their training to prescribe communications devices.
Preparedness of Physicians for Leading an Interdisciplinary Team
Because both AAP9 and the Joint Commission of Hospital Accreditation10 encourage interdisciplinary team management, we asked whether respondents had received training in leading an interdisciplinary team, how many hours of training they had received, and whether they believed that training was adequate. The respondents showed a significant lack of training as evidenced by the proportions given in Table 3. Nearly two thirds overall reported they had no training in leading a team. However, nearly three fourths of the physicians reported having no training compared with approximately half of the residents (P < .001), implying that there has been a shift in recent years toward training physicians to work with interdisciplinary teams. Also, 31% of the residents surveyed stated they had >1 hour of training compared with only ∼15% of the practicing physicians. Still, only ∼50% of current residents have been exposed to the realities of leading a team, a major emphasis of programs of AAP. Less than one fourth of all respondents indicated they had received >1 hour of training in leading an interdisciplinary team. Only 1 in 5 of all respondents thought their leadership training was adequate, as noted inTable 4. Among those who reported receiving some training, slightly less than half thought the training was adequate.
Preparedness of Physicians for Prescribing Therapies and Modalities
Respondents were asked to describe and rate their specific training, including lectures, conferences, grand rounds, etc., in prescribing the indicated therapies and modalities. The results are given in Tables 3 and 4.
There was a significant difference between residents and physicians with fewer residents reporting they had never received training in these areas. The physicians in both states, however, gave similar responses. Over two thirds of the physicians indicated they had no training in prescribing therapeutic exercises, physical therapy, occupational therapy, and speech therapy. In contrast, over half of the residents indicated that they had some training in these areas. More than 80% of physicians and three fourths of the residents had no training in prescribing modalities. Very few physicians and residents had received >1 hour of training in prescribing therapeutic exercises, occupational therapy and modalities, and less than 1 in 5 reported >1 hour of training in prescribing physical therapy and speech therapy.
Preparedness of Physicians for Treating Children With Special Needs for Specific Disease Categories
Respondents were asked to indicate if they had specific training in each of the listed diagnostic categories involving physical medicine type management. They were then asked to rate the effectiveness of their training in preparing them to manage rehabilitation programs for CWSN after graduation. The results are summarized in Tables 5 and 6.
Residents may receive training in many different areas, particularly the acute medical management of the selected categories, which may or may not indicate ability to handle the long-term care and rehabilitation management surveyed in the follow-up question. Although CWSN initially may be under the management of specialists as well as a general pediatrician, long-term and particularly community-based follow-up care may well fall within the province of the primary care physician. Of the 12 disability categories surveyed, only in cerebral palsy, burns, joint diseases and connective tissue disorders, spina bifida, and traumatic brain injury did more than one half of the respondents indicate receiving >1 hour of training. Cerebral palsy had the highest figures, followed by joint disease and traumatic brain injury. In general for all categories, residents in current training programs showed a slightly greater amount of training than reported by the practicing pediatricians from the 2 states. In rating the effectiveness of their institutions in preparing them to manage postgraduation the rehabilitation program of a child with the selected diagnostic categories, only for cerebral palsy did more than half believe their training was adequate.
Whom Do Physicians Believe Should Make the Final Decision Regarding Prescribing Therapies and DME?
To determine the prescribing practices of physicians, we asked the respondents who they believe should make final decisions regarding the appropriateness and type of therapy or equipment listed and who should formulate ordering guidelines (ie, would the respondent take full responsibility or would he or she rely on the experience and reputation of another professional). The list included the therapies and DME described in Table 7. Table 7 lists 1) all pediatricians who reported taking an active role in prescribing therapies and DME, including those who may work in conjunction with another professional, such as a therapist or specialist physician; and 2) those pediatricians who believed that the sole responsibility of prescribing was theirs.
Strikingly, no more than 28% of the total respondents felt comfortable in taking an active role in prescribing any category and no greater than 20% believed their training was adequate to be the sole decision makers. Approximately one fourth of those polled indicated they believed they should prescribe therapies (physical, occupational, or speech). Approximately 1 in 5 would take sole responsibility for prescribing speech therapy, whereas ∼15% would prescribe physical therapy or occupational therapy. Less than 15% felt comfortable prescribing spasticity management and therapeutic exercises with ∼7% taking sole responsibility. Among the common DME, the respondents were more comfortable with wheelchairs than braces, but very few believed they have the training to take sole responsibility for these devices. Feasibility of gait training and neurolytic procedures would be prescribed by only ∼5% of the respondents, most of who stated that they felt confident in making the sole decision in these cases.
CWSN have been defined as children “who have or are at risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”2 CWSN may require special or enhanced medical and nursing services (eg, physician subspecialties, hospitals specializing in the care of children, and enhanced preventive and primary services), therapeutic services (eg, physical, speech, or occupational therapy; mental health services; and home health and nursing services), family support services (eg, family counseling and education, comprehensive case management and care coordination, and respite care), equipment and supplies (eg, DME and assistive devices), and related services (eg, early intervention, special education, transportation, and social services).2
The incidence and prevalence of children with physical disabilities and/or requiring DME or therapy is difficult to come by. In most studies, neuromuscular or limb impairments and congenital or acquired brain or spinal abnormalities are co-mingled with other chronic disabilities, such as hematologic, endocrine, respiratory, cognitive-learning, or behavioral disabilities. It has been estimated that up to 31% of children under 18 years old, or nearly 20 000 000 children in the United States, had 1 or more chronic conditions in 1988, and 30% of these children had 2 or more chronic conditions.11 Thus, practicing physicians may well anticipate having at least a portion of their practice devoted to children with special needs. In a study of primary care physicians' patterns of care for children with chronic illnesses in a region of New York State, Pless et al12 found that 7.4% of all children seen had 1 or more chronic conditions.
Because of their training and professional commitment to quality health care for their patients, the AAP recognizes pediatricians as the most appropriate providers of primary health care for infants, children, adolescents, and young adults.13 ,14 The AAP has issued policy statements in which it encourages pediatricians to become knowledgeable concerning the treatment of CWSN and to participate in early interventions to the greatest benefit of these children.15–17 AAP notes that pediatricians “are asked to support or prescribe therapeutic intervention, such as physical and occupational therapy” for CWSN,18 and it “encourages pediatricians to learn about the developmental needs of children with special needs to participate in early intervention.”15
However, with the exception of 2 brief statements on motor disabilities,18 ,19 commentary on the physical medicine aspects of these children, who often have co-morbidity of physical as well as cognitive and behavioral disabilities, is absent from most AAP policy statements. Although training in the management of behavioral and cognitive disabilities seems to be well addressed, training in physical medicine and the role of the physician in managing physical disabilities seem to be poorly appreciated by the pediatric community. For example, the AAP developed a proposal for a new continuing medical education course for primary care pediatricians designed to promote family-centered, community-based, coordinated care for CWSN and their families.20 Notably, the proposed course offered scant discussion of the role of the physician in ordering and supervising appropriate DME, such as orthotic devices and prosthetics, or therapeutic services, such as physical, occupational or speech therapy, other than brief mentions of the role of the primary care physician in care coordination.20 Little detailed description of the training requirements, knowledge base needed, or practical aspects of providing this supervision was provided. The proposal described CWSN as biologically or environmentally at risk, having behavioral problems, or experiencing developmental delay (which was defined to include only fine motor impairments).20 It mentioned Down syndrome, fetal alcohol syndrome, attention deficit disorder, and conduct disorder but made no mention of common physical impairments, such as cerebral palsy, myelodysplasia, or traumatic brain injury.
Another proposal sponsored by the American Board of Pediatrics and the American Board of Psychiatry and Neurology suggested creating a subspecialty in neurodevelopmental disabilities. After review, the AAPMR (personal communication with permission of the author regarding application of a subspecialty certificate in neurodevelopmental disabilities. From: J. R. Swenson, President of the AAPMR. Letter to: B. S. Schneidman, Associate Vice President of the American Board of Medical Specialties. February 24, 1997) raised concerns, saying the proposal “does not adequately address functional limitations, disability, and societal barriers as key elements in the management of these children.” AAPMR added that the proposal did not specifically address the training and knowledge base needed by physicians to deal with the complex diagnostic, treatment, and rehabilitative services requisite to ensure the optimal health care of CWSN. AAPMR believed these areas of physical needs as well as physiatry should be considered for incorporation into such a subspecialty.
The findings of Pless et al12 suggested most primary care physicians do not play a major role in the management of children with chronic illness with respect to counseling, advising or coordinating other services. The authors concluded “there may be serious deficiencies in medical education or the system of health care in which these doctors function or both. One cannot escape the conclusion that medical education at the undergraduate and postgraduate level has failed to prepare the respondents for the provision of much more than symptomatic treatment for these children.”12 Similarly, in a survey to clarify the roles of primary and consulting physicians in the care of children with spina bifida, Kanthor et al21suggested “there was no clear pattern of whose responsibility it was to provide the counseling, coordination, and supportive care, and for many children this care was not provided. Primary physicians contributed little more than acute-illness and well-child care.” A previous inquiry of pediatric residency program directors suggested that residents had little exposure to children with physical disabilities and only limited contact with physiatrists.22Our data seem to further and more specifically confirm these earlier impressions of a lack of adequate training and the uncertainty of physician responsibility in many basic issues of caring for CWSN.
Through a few policy statements and articles, the AAP has provided physicians with some guidance in physical disability management.18 ,19 ,23 It is recognized that the child's medical home should serve as the primary coordinator of medical care,13 and the AAP has published recommendations for pediatricians on how to manage CWSN in The Medical Home and Early Intervention: Linking Services for Children with Special Needs(1995)24 and Managed Care and Children With Special Needs (1997).9 The section by the AAP on Home Health Care has encouraged greater pediatrician involvement in home health, including management of therapies and technology for CWSN.25 The AAP also recommends that the physician's role in the care of CWSN be expanded within schools so that “medical services [are] defined to encompass diagnosis, evaluation, consultation, and the medical supervision of those other services which are by stature, regulations, and/or professional traditions the responsibility of a licensed physician”.16 Supporting the concept of interdisciplinary team and care coordination with the physician playing a central role, the AAP encourages pediatricians to work with teams including parents, children, educators, therapists, and other specialists. However, as shown by our survey, many physicians have little or no training in interdisciplinary team functioning.
The little emphasis placed by the AAP on physical disabilities and previous reports of inadequate training confirmed and expanded by our results point to an alarming shortcoming in the present state of pediatric training, specifically, a clear lack of adequate training in prescribing therapies and DME. Physicians may not be adequately prepared to provide the best care for the large numbers of children with special health care needs that may appear in their practices.12 ,18 ,23 ,26 Despite the emphasis of the AAP on a central role for the pediatrician, evidence shows that nonphysician providers are assuming greater responsibility for their prescription.27–29 Triezenberg29 stated, “In recent years, the profession of physical therapy has increased its role in patient care. These changes can be seen by examining the changes that have been made in the practice acts of half or more of the states to give physical therapy some degree of autonomy in practice.” This is particularly noteworthy because most state and federal guidelines require a physician's prescription for initiation of therapies and DME, despite increasing autonomy by other professions. Government regulatory agencies increasingly are focusing on preventing fraud and abuse caused by inappropriate physician initiation and supervision of therapies, DME, and home health care.7 ,8Although the best interests of the child are always paramount, the less than knowledgeable physician assumes a major risk for adverse legal action, especially when approving recommendations and prescriptions devised by others like signing a blank check. While considering the advice of other professionals, the physician must be able to distinguish what is appropriate in each case.
The question arises as to what steps can be taken to improve the training of pediatricians to enable them to play a greater role in the management of CWSN′s physical needs in addition to their behavioral needs, which already seem to be well-addressed in training programs. We would recommend that under the FOPE II project of the AAP, training in caring for CWSN be expanded to include an emphasis on physical medicine and rehabilitation (PM&R). This could be done through continued interaction with traditional professional resources, such as pediatric neurologists, developmental pediatricians, and pediatric orthopedists. For example, many developmental pediatricians have had training and are skilled in physical medicine disciplines and are a valuable resource. However, developmental medicine traditionally has tended to have a greater emphasis on behavioral management issues, and physical medicine management may vary between programs. Other nonphysician professionals, such as physical and occupational therapists, speech/language pathologists, educators, and child life/recreational therapists, also have valuable insight and information to share with pediatricians in training. However, we would emphasize the importance of physician training by physicians knowledgeable in physical disabilities and with the doctor's perspective on the responsibilities of ordering and supervising therapies and DME.
Pediatric residents should be encouraged to seek the advice of PM&R departments and/or physiatrists available at many major training centers. Although the majority of PM&R departments are adult-oriented, a number have at least 1 or more pediatric physiatry specialist who could make a significant contribution to a pediatric training program. These departments are probably underutilized at present. In our survey, 60% of the practicing pediatricians in Ohio and 55% of those in Mississippi noted that their academic training facilities had a PM&R department, indicating that a majority had this potential resource available to them. Only 44% of the Ohio practicing pediatricians and 31% of those in Mississippi indicated they had interacted with this department, however, whereas 62% of the residents in current training programs indicated they had. In addition, a combined pediatric-PM&R residency training program has been developed over the past decade and is currently active in 17 academic medical centers.3 The interaction of residents and these programs could also offer valuable opportunities for training and knowledge sharing.
Our survey suggests a current lack of coordination between these various resources and both the practicing pediatrician and pediatrician in training and an overall shortfall in pediatrician preparedness to handle all aspects of managing the care of CWSN. Although behavioral and cognitive issues related to CWSN are being addressed by current efforts and should continue to be an important part of physicians' training, greater emphasis must be put on training in the physical medicine aspects of caring for CWSN to make physical issues equally important. Otherwise, we risk undermining the quality care these children deserve.
- Received April 14, 1999.
- Accepted June 25, 1999.
Reprint requests to (R.C.S.) Children's Rehabilitation Center, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216-4505. E-mail:
↵‖ Christine S. Stencil worked as a private research assistant.
This was a nonfunded and unsupported research project. No grants, equipment, drugs, technical, or other assistance was obtained for this project.
- ↵Executive Summary: Future of Pediatrics Education II Project Task Force meeting, Renaissance Washington Hotel; May 5, 1977; Washington, DC. Available at: http://www.aap.org/profed/execusumm.htm Accessed March 18, 1998
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- ↵Population Estimates Program, Population Division, US Bureau of the Census, Washington, DC. Available at: http://www.census.gow/statab/www/state/ms.txt (oh.txt). Accessed April 5, 1998
- ↵American Academy of Physical Medicine and Rehabilitation. Membership Directory. Chicago, IL: American Academy of Physical Medicine and Rehabilitation; 1998
- ↵American Medical Association. Medical Management of the Home Care Patient: Guidelines for Physicians. 2nd ed. Chicago, IL: American Medical Association; 1998
- ↵Department of Health and Human Services, Office of Inspector General. Special fraud alert: physician liability for certifications in the provision of medical equipment and supplies and home health services. Federal Register. January 12, 1999:4:1813–1816
- ↵American Academy of Pediatrics. Managed Care and Children With Special Health Care Needs. Elk Grove Village, IL: American Academy of Pediatrics; 1997
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- Copyright © 2000 American Academy of Pediatrics