If managed care does what it is supposed to do, we should see a decrease in childhood poisonings and complications over the next 3 years. This is because managed care is growing rapidly, prevention is a man' aged care priority for cost control, and preventing ingestions will reduce costs. Further, keeping a child from ingesting a toxin should lead to reduced costs within the duration of the health maintenance organization's (HMOs) policy to cover that child.
Can poisonings be prevented? In 1989, the American Academy of Pediatrics' (AAPs) Committee on Accident and Poison Prevention recommended the following priorities for counseling parents with preschool children about making the home safe1:
* proper storage and disposal of toxic household products and medications,
* storage of ipecac,
* checking the house and yard for poisonous plants and mushrooms,
* use of child resistant caps, and
* use of poison center telephone stickers.
To that might be added automatically warning parents when you prescribe a potentially toxic substance. Thus, anticipatory guidance to mothers of 6- to 12month-old infants might include something such as: "Your baby is getting to the age when he or she is at risk for taking a poison. Go over your house completely, get rid of old medicines, cleaning supplies, liquor, and other poisons that you will not be using. Then lock the rest of these in a place where your child cannot get them. Tell others the child stays with to do the same."
Does this work? We don't have a lot of data. The fact that parents do not store toxic substances effectively suggests it could, but actual surveys of what parents know and do are less encouraging. A recent study by Brayden et al2 identified behavioral antecedents of pediatric poisoning by interviewing parents who had called the poison control center because their child had ingested a potential toxin. The most common antecedent was improper storage of the toxin: 20 of the 39 who completed the interview described this risk tactor, and 17 of these left the poison within sight of the child. Other less common antecedents were: noncompliance, curiosity, misinterpretation of the substance, improper child monitoring, and child imitative behavior. The bad news is that lack of knowledge about poison prevention methods was not found. Wolf et al1 randomized 336 callers of a poison control center who did not have ipecac into control and experimental groups. The latter were mailed poison control telephone sticken, a $1 coupon for ipecac, one slide-style cabinet lock, and a nine-step checklist for "poison-proofing" the home. The control group received no intervention. Three months later, a blind follow-up telephone interview revealed significantly more intervention parents were using a telephone sticker (78% versus 39% for controls; P <.0001) and at least one slide-lock for poison storage (59% versus 40%; P<.001). However, intervention families were no more likely than controls to have ipecac on hand (57% versus 52%) or to have gone through the house and thrown out old medications and household products (63% versus 68%). Nor was there any difference in repeat ingestions.
The failure of parents to take our advice about locking poisons away isn't too surprising when one considers how hard it is to get families to use automobile restraint devices and bicycle helmets. Nevertheless, we will continue to teach parents about these safety issues (it can't hurt), and anticipatory guidance may work better than offering advice after the accident.
Is it effective to advise parents to keep syrup of ipecac (locked up) in their medicine cabinet and to call the poison control center before giving it following an ingestion? After reading this issue, I will continue to recommend this but its value seems less clear. "Emergency Department Gastrointestinal Decontamination" by Drs Perry and Shannon points out the incomplete effectiveness of ipecac for gastric emptying. Ipecac also delays or eliminates the use of activated charcoal, and complications of using ipecac are not rare. (Incidentally, speaking of complications, make absolutely sure the gastric tube is in the stomach before giving charcoal slurry. Failure to do this can be catastrophic. I know of a case whereby the charcoal found its way into the trachea and it was not possible to retrieve the insoluble slurry.)
Anyway, the switch away from ipecac toward activated charcoal is relatively recent, so we have to wait for the next recommendations from the AAP to see if we should continue advising parents to keep ipecac in the home. We may still do this but perhaps use ipecac more conservatively after ingestions.
Poison centers are our most important resource for preventing and treating poisoning as pointed out in "Emergency Department Gastrointestinal Decontamination" in this issue. But, poison centers are in danger in this era of managed care. As of last year, 38 regional poison centers were certified and another 48 "nonregional" centers were active.3 At first glance, it looks like these poison centers and HMOs would make excellent partners in managed care because both share an interest in prevention at all levels. Actually, one can expect HMOs to use poison control centers extensively because they save money be reducing poisonings, complications, and unnecessary emergency department visits. A recent Massachusetts study estimated that 6500 unnecessary visits were avoided annually by poison center calk, with a net savings of $975,000.4 Closing of a Louisiana poison center coincided with a fourfold increase in self-referral for ingestions at an estimated cost of $1.4 million.5 Because poison control centers provide services without charge, they represent a tremendous value to managed care companies. You can expect HMOs to tap these and other free community services and maximize their use in a similar fashion.
If poison control centers have never been more important, they should be in great shape. They are not because of funding problems. Poison control centers are supported by a combination of grants and donations, but most also depend on space and funding from the medical centers where they are based. In the past, hospitals were better able to support poison control centers. They had more money to spend on public services, and the public relations generated by their poison control centers, etc, gave them some "return on investments." This doesn't work as well in this era of managed care. Hospitals are cutting costs wherever they can to remain competitive. The medical center that has higher overall costs because it supports public service projects such as a poison control center will find itself at a disadvantage in HMO bids. This is especially true if competing hospitals/HMOs use this poison control center to reduce their own cost. So medical centers will find themselves less able to support such public services. Managed care changes everything. A way to overcome this is needed - perhaps something such as taxing managed care insurance companies to help support the poison control centers they use. Lovejoy et al3 describe the increasing financial distress of poison control centers: "A number of centers are today seriously under-funded, several certified centers are at serious risk of closure, and several large, excellent state centers have closed."
This issue has another article that is especially pertinent for the general pediatrician in this era. "The Nontoxic Ingestion" by Dr Wasserman relates to the fact that we often overreact to ingestions that are nonsignificant. Observation of minor ingestions by telephone or follow-up in an outpatient facility as opposed to hospitalization has great potential for cost saving. The author makes the point that even hydrocarbon ingestions can be monitored at home if the patient is asymptomatic (alert and no coughing, choking, or sputtering) and does not develop these signs (or respiratory distress) on observation.
So let's see if managed care works the way it should and poisoning rates drop over the next few years. These kinds of observations may give insight into whether managed care will be a transitional "passing" phase in the history of US medicine or whether unleashing market forces on medicine will turn out to solve access, cost, and quality problems.
1. Woolf AD, Saperstein A, Forjuoh S. Poisoning prevention knowledge and practices of parents after a childhood poisoning incident. Pediatrics. 1994:90:867-870.
2. Brayden RM, MacLean WE, Bonfiglio JF, Altemeier WA. Behavioral antecedents of pediatric poisonings. Clin Pediatr (Phila). 1993;30-35.
3. Lovejoy FH, Robertson WO, Woolf AD. Poison centers, poison prevention, and the pediatrician. Pediatrics. 1994;94:220-224.
4. Chaffee-Bahamon C, Lovejoy FH Jr. Effectiveness of a regional poison center in reducing excess emergency room visits for children's poisonings. Pediatrics. 1983;72:164-169.
5. King WD, Palmisano PA. Poison control centers: can their value be measured? South Med J. 1991;84:722-726.