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1989;84;242PediatricsBernard E. Kreger and Joseph D. Restuccia
ProtocolAssessing the Need to Hospitalize Children: Pediatric Appropriateness Evaluation
http://pediatrics.aappublications.org/content/84/2/242
the World Wide Web at: The online version of this article, along with updated information and services, is located on
ISSN: 0031-4005. Online ISSN: 1098-4275.PrintIllinois, 60007. Copyright © 1989 by the American Academy of Pediatrics. All rights reserved.
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
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242 HOSPITALIZATION EVALUATION
Assessing the Need to Hospitalize Children:Pediatric Appropriateness Evaluation Protocol
Bernard E. Kreger, MD, MPH, and Joseph D. Restuccia, DPH
From the Health Care Research Unit, Section of General Internal Medicine, UniversityHospital, and the Evans Memorial Department of Clinical Research, Boston UniversitySchool of Medicine, Boston, Massachusetts
ABSTRACT. Rapidly increasing hospital costs have ne-cessitated use review of hospitalized patients to improvethe appropriateness (medical necessity) of hospital use.The development and testing of the Pediatric Appropri-ateness Evaluation Protocol, an objective, criteria-basedinstrument intended to assist physicians and use review-ers in making decisions regarding appropriateness ofpediatric hospital admissions and days of care, are de-scribed. Pediatrics 1989;84:242-247; hospital use, pediat-
nc appropriateness evaluation protocol.
ABBREVIATIONS. AEP, Appropriateness Evaluation Protocol;EMPSRO, Eastern Massachusetts Professional Services ReviewOrganization.
For many years, those who provide, administer,and pay for health care in the United States have
recognized the need for a valid and reliable methodof assessing the use of hospital beds. Criteria basedon diagnoses have proven burdensome, both be-
cause of their sheer number and because of medicaladvances that result in frequent changes in pre-ferred treatment modalities for particular diag-noses. Instead, the Appropriateness Evaluation
Protocol (AEP), developed during the past decade
by the Boston University Health Care ResearchUnit, has met the demands of the health care sys-tern in providing useful, objective generic criteriafor assessing the appropriateness (medical neces-sity) of hospitalization in an acute care facility. In
several trials conducted by researchers at the
Received for publication Jun 10, 1988; accepted Sep 2, 1988.
Reprint requests to (J.D.R.) 720 Harrison Aye, Suite 1102,
Boston, MA 02118.PEDIATRICS (ISSN 0031 4005). Copyright © 1989 by theAmerican Academy of Pediatrics.
Health Care Review Unit and elsewhere, its validity
and reliability have been confirmed. The AEP is
now a major instrument used by hospitals, HMOs,
peer review organizations, Medicaid agencies, andprivate insurers to screen cases concurrently for
physician advisor review and to profile retrospec-
tively provider practice patterns.’1’The AEP was designed originally to apply only
to adult patients hospitalized in medical and sur-
gical services in acute care institutions. We thought
that different criteria might be needed to monitor
pediatric, obstetric, and psychiatric inpatient care,as well as various sorts oflong-term or chronic care,
including rehabilitation services. Medicaid, lookingfor a method to evaluate pediatric care, providedthe primary impetus for the development of a pe-
diatric AEP. In this article, the iterative process of
the design and testing of this instrument are de-scribed, in particular, the modifications to the orig-
inal criteria to tailor them to the special problems
encountered in the hospitalization of children.
METHOD
The first step in evolving the pediatric AEP was
the application of the standard (adult) AEP criteria
to children. It had already been determined through
our validation studies that approximately 95% oftruly appropriate use of acute beds by adults wouldbe identified by these AEP criteria: thus, only ap-proximately 5% of these truly appropriate caseswould require special mention (called “overrides”in AEP parlance) because no criteria were satis-
fled.’ In addition, groups that were using AEP sinceits inception had reported back to us that they tried
applying adult criteria to the pediatric inpatients
and found them useful. We, therefore, enlisted thehelp of the Quality Assurance Unit of Children’sHospital Medical Center, Boston, for a formal test
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PEDIATRICS Vol. 84 No. 2 August 1989 243
of applicability as the first step in the developmentof the Pediatric AEP.
An independent review of 50 medical records ofrecently discharged patients was done by two nurse
reviewers trained in AEP and experienced in pedi-
atric care. Besides applying the adult AEP criteria,the nurses provided detailed documentation of de-ficiencies in the application of the criteria to these
pediatric patients. The deficiencies in the AEP
adult instrument identified through this reviewwere codified and discussed with pediatricians fromboth Massachusetts and elsewhere. Exact phra-
seology for new criteria and modifications of exist-ing criteria were arrived at by consensus. Thechanges to existing criteria consisted primarily ofdifferent physiologic values indicative of a suffi-ciently severe illness in a child to warrant hospital-
ization. The new criteria consisted of special pedi-atrics clinical situations not commonly found
among adult inpatients. Based on this new set ofcriteria, a new pediatric AEP instruction manual
for reviewers was created.
The following changes characterize the pediatricsversion of the AEP (Appendix 1): (1) The instru-ment applies to children 6 months of age and older,
with physiologic measurements taken at admissionsuch as BP, pulse, and various laboratory test re-sults being stratified according to subgroup of age.
(Originally, the instrument included children as
young as 2 years of age, but it was confirmed withsubsequent use that the instrument may be used
with even younger infants. (2) Hematocrit <30%as an admission criterion represents a child in
potential trouble, usually with leukemia or its treat-ment. (3) Need for lumbar puncture was added, to
allow for those locales where such a procedure isimpractical on an outpatient basis. (4) Special pe-diatrics situations, often a combination of medicaland social problems, were added to the admissioncriteria: failure of (or history of noncompliancewith) outpatient therapy, documented or suspected
child abuse, or need for special observation (as infailure to thrive). (5) For day of care criteria, appli-
cable to any day during a hospital stay other thanthe days of admission and discharge, additions weremade to allow inpatient performance of gastroin-testinal endoscopy and traction for major orthope-
dics problems.
Two nurse reviewers who were already trained in
AEP application then used the new criteria andinstructions to assess a set of 1200 pediatrics rec-ords at New England Medical Center Hospital,Boston. They provided documentation regardingapplicability of the criteria and adequacy of thewording of the criteria and the instruction manual.Where indicated, additional wording changes to the
criteria and instructions for their application weremade by Health Care Review Unit researchers with
the assistance of clinical consultants.The third step in the development process in-
volved field trials. A small trial addressed the ques-
tion: Does the Pediatric AEP work as well forcommunity hospitals as it does in academic centers
and teaching hospitals. For this preliminary trial,50 records from each of two community hospitals
were reviewed independently by a physician and a
nurse reviewer. No additional problems were foundinvolving the instrument or the instructions. How-
ever, a much larger trial was necessary both toensure the generalizability of this finding and to
establish a baseline appropriateness level with
which to compare subsequent pediatric applica-
tions.To that end, the Eastern Massachusetts Profes-
sional Services Review Organization (EMPSRO)
agreed to assist us, after review of the Pediatric
AEP criteria by EMPSRO member pediatriciansindicated that the criteria had sufficient validity to
warrant a large field trial. EMPSRO then helpedorganize field testing in 24 hospitals in the greater
Boston area and 2 hospitals in western Massachu-
setts. In each hospital, 100% of all Medicaid pa-
tients aged 2 to 15 years discharged during a 6-month period in 1983 (February to July or March
to August) were sampled, a total of 793 patients.After receiving training in use of the pediatric AEPfrom Health Care Review Unit staff, EMPSRO
nurse reviewers applied the pediatric AEP to thetime of admission and to the day before discharge.For admissions lasting only 1 day, no day of care
criteria were applicable. When an admission or daywas found to be inappropriate at the acute hospitallevel, the reviewer identified the probable cause of
inappropriateness with the assistance of the AEPReasons List (see Appendix 2). To assess reliability,143 patients from 3 of the study hospitals wererereviewed by a second nurse reviewer.
RESULTS
In the reliability study, 93.7 and 88.4% agreement
was found among reviewers in terms of appropri-
ateness decisions regarding admissions and days ofcare, respectively. The K statistic was applied todetermine the extent to which this agreement dif-fered from the agreement occurring by randomchance.’2 A K of 0.68 (P < .0001) for admissions and0.46 (P < .0001) for days indicated that agreementwas not due to chance alone and was sufficiently
great for the pediatric AEP to be used as either a
screening instrument in use review of individual
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244 HOSPITALIZATION EVALUATION
patients or as an instrument to assess accuratelyrates of appropriateness among groups of patients,as was the case in this study.
Of the 26 hospitals in the field trial, 14 had fewerthan 25 sample patients during the 6-month period
reviewed. The total study sample consisted of 793patient admissions and 648 days of care (ie, there
were 145 one-day stays). Mean length of stay was
4.6 days, with a range of 1 to 49 days. Mean age
was 7.5 years; 55% were male.By objective criteria, 10.5% ofpatient admissions
were judged inappropriate, with a range of 2.4% to24.1% among the 12 hospitals at which there had
been at least 25 admissions. For day of care, theobjective inappropriateness rate was 13.3% among
the same hospitals, ranging from 3.5% to 24.7%.The application of override options resulted in re-
duction of these rates to 5.8% (0% to 17.1%) foradmissions and 9.4% (0% to 22.5%) for days of
care. As had been the case in the development ofthe Adult Medical/Surgical AEP, when we analyzedthe use of overrides, we found only a few situations
that were considered suitable to warrant additionsto objective criteria. These additions were accom-plished by expanding definitions of existing admis-sion criteria in posttrial versions of the Pediatric
AEP rather than creating totally new ones. In themain, though, the differences between objective
conclusions and those made through the use of
overrides reflected incorrect use of the override
option. The misuse often occurred because of theconfusion of relatively inexperienced reviewers be-tween reasons for inappropriate hospitalization andmedical need for hospitalization: for example, usingan override to conclude that a patient requiring
outpatient services that could not be scheduledconveniently was appropriately hospitalized ratherthan using the reason, “Patient admitted for diag-nosis and/or treatment because it was not possible
to be scheduled on an outpatient basis” to indicatewhy the patient was hospitalized despite not havinga need for acute hospitalization. It was therefore
judged that the data from the use of objective
criteria alone provide the most accurate picture ofpatterns of inappropriateness.
The inappropriate admission rate was 9.8% for
boys and 10.8% for girls. It was smallest for ages 6to 11 compared with 2 to 5 and 12 to 15 (8.6% vs11.2% and 12.3%). None of these differences was
statistically significant at the P < .05 level. Among
the 10 most frequent discharge diagnoses, the rangeof inappropriateness was 0% to 19.2%, with pneu-monia, gastroenteritis, and cellulitis and abscess
associated with the largest rates of inappropriate-
ness. If the hospital stay included a procedure, the
child’s admission was significantly less likely to be
considered inappropriate (6.6% vs 12.8%, P =
.0055).
For day of care, objective inappropriateness rateswere less for girls than for boys (11.4% vs 14.5%)and least for ages 6 to 11 years compared with 2 to
5 years and 12 to 15 years (11.3% vs 12.2% and
16.8%). The 10 most common diagnoses had 0% to
19% inappropriate penultimate inpatient days, with
pneumonia, acute appendicitis, concussion, and
fracture of radius and ulna all greater than 14%. Atthe end of a child’s hospital stay, those who had a
procedure were more likely to be inappropriatelythere (15.2% vs 10.2%), but not significantly so.
Finally, the reason cited most frequently for in-
appropriate admission was that the patient requiredno institutional care and could be treated as an
outpatient. Similarly, inappropriate days of carewere most commonly attributed to the lack of needfor continuing institutional care.
COMMENT
The extensive experience gained in the designand implementation of the Adult Medical/SurgicalAEP tended to facilitate the development of thepediatric version. The process was made especiallyeasy because of the success some AEP users had
had evaluating pediatrics hospitalizations using theadult criteria. Thus, the pediatric AEP grew out of
an already validated and reliable instrument to
which necessary and appropriate adjustments weremade.
The trial application of this version proceededalong lines similar to those involved in the original
adult version and encountered similar problems.Namely, the EMPSRO reviewers, who were rela-
tively inexperienced in using the AEP in general,made reviewing errors mainly by misuse of the
override option, wherein a reason for inappropriate-ness was used as a justification for hospitalization
instead of an explanation of the reason for the
hospitalization despite its being medically inappro-priate. With sufficient further training, AEP users
both in the United States and abroad have found
that this most common of errors in applicationgradually disappears, although not always totally.Thus, it is best to prohibit use of the override option
unless the reviewer has demonstrated proper use
through formal reliability tests or is required toconsult a physician advisor to obtain approval for
use of the override.
It was not surprising to find inappropriatenessrates for children’s hospitalizations appreciably less
than those for adults. The difference probably re-sults from the presence of built-in care givers at
home for almost all children, whereas many adults,
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ARTICLES 245
especially the elderly, are inconveniently solitary in
this regard. Yet, at least in this initial trial, the
reasons for inappropriate admissions and days of
care seem to echo those chosen to explain inappro-priate hospitalization of adults. Children, too, are
admitted to receive diagnostic and/or therapeuticattention at a level easily achieved as outpatients;
and children ready medically for discharge arenevertheless kept in the hospital.
Finally, in an interesting report, Kemper, of the
University of Wisconsin Hospitals and Clinics, de-
scribed a pediatrics adaptation of the adult AEP
that included several of the changes we made.’3 The
proportion ofinappropriate days found, 21.4%, can-not be compared directly with our results for anumber of reasons: the age range of Kemper’s pop-
ulation extended beyond that in our patient samplein both directions (2 days to 18 years of age);
Kemper reviewed the day of discharge, whereas that
day was omitted from analysis in the AEP; for 1-
day stays, Kemper seemed to have applied day ofcare criteria to the time of admission, again, a
deviation from AEP procedure; and patients insome special units that were evaluated in our study
were not considered in hers. It would be useful to
apply our pediatric AEP to the 6-month to 15-year-
old population described by Kemper, with both
admission and day of care criteria, to see what rate
of inappropriate use would result. Our expectationwould be to find inappropriateness rates closer towhat we described in our trials.
IMPLICATIONS
With children as with adults, medical resources
can be put to better, more effective use withoutsacrificing health. Indeed, the extremely technical
facilities of today’s acute care hospitals should be
more successfully used when they and their person-
nel can concentrate on the care of those who reallyneed them, undiluted by the presence of even 10%
or 15% of patients who are inappropriately there.The pediatric AEP should help identify areas forimprovement not only for individual institutionsbut for the pediatric hospital system as a whole.
APPENDIX 1: PEDIATRIC APPROPRIATENESSEVALUATION PROTOCOL (AEP) ADMISSIONCRITERIA
A. Severity of Illness Criteria1. Sudden onset of unconsciousness (coma or unre-
sponsiveness) or disorientation
2. Acute or progressive sensory, motor, circulatory,
or respiratory embarrassment sufficient to inca-pacitate the patient (inability to move, feed,breathe, urinate, etc)
3. Acute loss of sight or hearing4. Acute loss of ability to move body part
5. Persistent fever (�37.8#{176}C [100#{176}F] orally or�38.3#{176}C [�101#{176}F] rectally) for more than 10 days
6. Active bleeding7. Wound dehiscence or evisceration
8. Severe electrolyte/acid base abnormality (any ofthe following values):a. Na <123 mEqjL,
Na >156 mEqJL
b. K <2.5 mEqJL,K >5.6 mEqjL
c. CO2 combining power (unless chronically ab-
normal) <20 mEciJL,CO2 combining power (unless chronically ab-normal) >36 mEqjL
d. Arterial pH <7.30, arterial pH >7.45
9. Hematocrit <30%10. Pulse rate greater or less than the following ranges
(optimally a sleeping pulse for <12 years old):
6 months-2 years minus 1 day of age, 80-100/mm;2-6 years of age 70-200/mm;7-11 years of age, 60-180/mm;
�12 years of age, 50-140/mm
11. BP values outside following ranges:
6 months-2 years minus 1 day of age, 70-100/40-
85 mm Hg;2-6 years of age, 75-125/40-90 mm Hg7-11 years of age, 80-130/45-90 mm Hg-�
�12 years of age, 90-200/60-120 mmHg
12. Need for lumbar puncture, where this procedure is
not done routinely on an outpatient basis
13. Any of the following conditions not responding to
outpatient (including emergency room) manage-ment:
a. Seizuresb. Cardiac arrhythmiac. Bronchial asthma or croupd. Dehydratione. Encopresis (for cleanout)f. Other physiologic problem
14. Special pediatric problems
a. Child abuseb. Noncompliance with necessary therapeutic reg-
imen
c. Need for special observation or close monitoring
of behavior, including calorie intake in cases offailure to thrive
B. Intensity of Service1. Surgery or procedure scheduled within 24 hours
necessitatinga. General or regional anesthesia orb. Use of equipment, facilities, or procedure avail-
able only in a hospital2. Treatment in an intensive care unit3. Vital sign monitoring every 2 hours or more often
(may include telemetry or bedside cardiac monitor)4. IV medications and/or fluid replacement (does not
include tube feedings)5. Chemotherapeutic agents that require continuous
observation for life-threatening toxic reaction
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246 HOSPITALIZATION EVALUATION
6. IM antibiotics at least every 8 hours7. Intermittent or continuous respirator use at least
every 8 hours
PEDIATRIC AEP DAY OF CARE CRITERIA
B. Medical Services1. Procedure in operating room that day
2. Procedure scheduled in operating room the next
day, necessitating preoperative consultation or
evaluation3. Cardiac catheterization that day4. Angiography that day5. Biopsy of internal organ that day6. Thoracentesis or paracentesis that day7. Invasive CNS diagnostic procedure that day (eg,
lumbar puncture, cysternal tap, ventricular tap,
pneumoencephalography)8. Gastrointestinal endoscopy that day9. Any test requiring strict dietary control for the
duration of the diet10. New or experimental treatment requiring frequent
dose adjustments with direct medical supervision11. Close medical monitoring by a doctor at least three
times daily (observations must be documented in
record)12. Postoperative day for any procedure described in
numbers 1 or 3 to 8 aboveB. Nursing/Life Support Services
1. Respiratory care-intermittent or continuous res-
pirator use and/or inhalation therapy (with chestphysical therapy, intermittent positive pressure
breathing) at least three times daily, isoetharinehydrochloride (Bronkosol) with oxygen, Oxyhoods,oxygen tents
2. Parenteral therapy-intermittent or continuousIV fluid with any supplementation (electrolytes,protein, medications)
3. Continuous vital sign monitoring, at least every 30
minutes for at least 4 hours4. IM and/or subcutaneous injections at least twice
daily
5. Intake and/or output measurement6. Major surgical wound and drainage care (eg, chest
tubes, t tubes, Hemovacs, Penrose drains)7. Traction for fractures, dislocations, or congenital
deformities8. Close medical monitoring by nurse at least three
times daily with doctor’s ordersC. Patient Condition
A. (Being reviewed the day before for the day of care)
1. Inability to void or move bowels, not attributable
to neurologic disorder-usually a postoperative
problemBeing reviewed within 2 days before the day of
care2. Transfusion due to blood loss3. Ventricular fibrillation or ECG evidence of acute
ischemia, as stated in progress note or in ECG
report
4. Fever at least 38.30C (1010F) rectally (at least
37.8#{176}C[100#{176}F]orally), if patient was admitted for
reason other than fever
5. Coma-unresponsiveness for at least 1 hour
6. Acute confusional state, including withdrawal from
drugs and alcohol
7. Acute hematologic disorders-significant neutro-
penia, anemia, thrombocytopenia, leukocytosis, er-
ythrocytosis, or thrombocytosis-yielding signs or
symptoms
8. Progressive acute neurologic difficulties
APPENDIX 2: REASONS LIST
For Inappropriate Admission1. Any needed diagnosis and/or treatment that can
be done on an outpatient basis2. Patient admitted for diagnostic testing and/or
treatment because patient lives too great a distancefrom a hospital for it to be done on an outpatient
basis
3. Patient admitted for diagnosis and/or treatmentbecause it was not possible to be scheduled on anoutpatient basis (although, aside from scheduling,testing and treatment could have been done on an
outpatient basis)4. Patient needs institutional care, but at a level less
than an acute care hospital-general (unspecified)5. Patient needs care in a chronic disease hospital6. Patient needs care in a skilled nursing facility
7. Patient needs care in a nonskilled nursing facility
8. Premature admission (eg, on Friday for a proce-dure scheduled for the following Monday)
9. Other-specifyFor Inappropriate Day of CareA. For patients who need continued hospital stay for
medical reasons20. Problem in hospital scheduling of operative pro-
cedure
21. Problem in hospital scheduling of tests or nonop-
erative procedure22. Premature admission
23. Patient “bumped” because of operating room prob-lems
24. Delay due to “40-hour week” problem (ie, proce-
dures not done on weekend)
25. Delay in receiving results of diagnostic test or
consultation needed to direct further evaluation/treatment
29. Other-specifyB. For patients who do not need continued hospital stay
for medical reasons1. Hospital or physician responsibility
a. Failure to write discharge ordersb. Failure to initiate timely hospital discharge
planningc. Overly conservative medical management of pa-
tient by physician
d. No documented plan for active treatment of
evaluation of patient
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ARTICLES 247
e. Other-specify2. Patient or family responsibility
a. Lack of family for home careb. Family unprepared for patient’s home carec. Patient/family rejection of available space at
appropriate alternate facilityd. Other-specify
3. Environmental responsibilities
a. Patient from unhealthy environment-patientkept until environment becomes acceptable or
alternative facility foundb. Patient is convalescing from an illness, and it is
anticipated that his/her stay in an alternativefacility would be less than 72 hours
c. Unavailability of alternative facilityd. Unavailability of alternative nonfacility-based
treatment (eg, home health care)e. Other-specify
REFERENCES
1. Gertman PM, Restuccia JD. The appropriateness evaluationprotocol: a technique for assessing unnecessary days ofhospital care. Med Care. 1981;19:855-870
2. Siu AL, Sonnenberg FA, Manning WG, et al. Inappropriateuse of hospitals in a randomized trial of health plans: N
EngI J Med. 1986;315:1259-12663. Strumwasser I, Paranjpe NV. Estimate of non-acute hospi-
talization: a comparative analysis of the appropriateness
evaluation protocol and the standardized medreview instru-ment. Final Report, Health Care Financing Administrationgrant 18-C-98582/5-01 and 02. Detroit, MI, September 1987
4. Rishpon 5, Lubacsh 5, Epstein LM. Reliability of a methodof determining the necessity for hospital days in Israel. MedCare. 1986;24:279-282
5. Wakefield DG, Pfaller MA, Hammons GT, et al. Use of theappropriateness evaluation protocol for estimating incre-mental costs associated with nosocomial infections. MedCare. 1987;25:481-488
6. Restuccia JD, Payne SMC, Lenhart GM, et al. Assessingthe appropriateness of hospital utilization to improve effi-ciency and competitive position. Health Care Manage Rev.1987;13:17-27
7. Restuccia JD, Kreger BE, Gertman PM, et al. The appro-priateness of hospital use in Massachusetts. Health CareFinan Rev. 1986;8:47-53
8. Restuccia JD, Gertman PM, Dayno SJ, et al. A comparativeanalysis of appropriateness of hospital use. Health Aff.1984;3:130-138
9. Studnicki J, Stevens CE. The impact of a cybernetic controlsystem on inappropriate admissions. Quality Rev Bull.1984;304-311
10. Payne SMC. Identifying and managing inappropriate hos-pital utilization. Health Serv Res. 1987;22:709-769
11. Restuccia JD, Payne SMC, Welge CH, et al. Reducinginappropriate use of inpatient medical/surgical and pediat-nc services. Report on Health Care Financing Administra-tion contract 18-C-98317/1-02. Boston, MA: Health CareResearch Unit, Boston University Medical Center, March1986
12. Cohen JA. A coefficient of agreement for nominal scales.Educ Psychol Measure. 1960;20:37-46
13. Kemper KJ. Medical inappropriate use in a pediatric popu-lation. N Engl J Med. 1988;318:1033-1037
ENDURING FAMILIES AT RISK
A divorce-prone society is producing its first generation of young adults, menand women so anxious about attachment and love that their ability to createenduring families is imperiled.
Submitted by Student
From Wallerstein JS. Children after divorce: wounds that don’t heal. The New York Times; Jan 22,1989.
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1989;84;242PediatricsBernard E. Kreger and Joseph D. Restuccia
ProtocolAssessing the Need to Hospitalize Children: Pediatric Appropriateness Evaluation
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