Spending for epoetin is Medicare's single largest drug expenditure. We chronicle the evolution of epoetin policy based on a lack of well-designed post-Food and Drug Administration approval studies demonstrating clinical benefit; congressional/federal agency reliance on clinical practice guidelines that might have misinterpreted evidence supporting causality; and the premature translation of research into practice and policy. Were the right choices made? Epoetin showcases the risk and benefit conundrum created when evidentiary standards are relaxed. Our review concludes with broad-based policy recommendations for the newly implemented Medicare Part D program. [Health Affairs 25, no. 5 (2006):

High-quality pediatric emergency care can be provided only through the collaborative efforts of many health care professionals and child advocates working together throughout a continuum of care that extends from prevention and the medical home to prehospital care, to emergency department stabilization, to critical care and rehabilitation, and finally to a return to care in the medical home. At times, the office of the pediatric primary care provider will serve as the entry site into the emergency care system, which comprises out-of-hospital emergency medical services personnel, emergency department nurses and physicians, and other emergency and critical care providers. Recognizing the important role of pediatric primary care providers in the emergency care system for children and understanding the capabilities and limitations of that system are essential if pediatric primary care providers are to offer the best chance at intact survival for every child who is brought to the office with an emergency. Optimizing pediatric primary care provider office readiness for emergencies requires consideration of the unique aspects of each office practice, the types of patients and emergencies that might be seen, the resources on site, and the resources of the larger emergency care system of which the pediatric primary care provider's office is a part. Parent education regarding prevention, recognition, and response to emergencies, patient triage, early recognition and stabilization of pediatric emergencies in the office, and timely transfer to an appropriate facility for definitive care are important responsibilities of every pediatric primary care provider. In addition, pediatric primary care providers can collaborate with out-of-hospital and hospital-based providers and advocate for the best-quality emergency care for their patients. INTRODUCTIONPediatricians and pediatric primary care providers (PPCPs) are vitally important members of the emergency care system for children. Children with potentially life-threatening illnesses and injuries are sometimes taken to primary care offices, which often serve as the child's medical home, by parents or caregivers seeking help from health care professionals they know and trust. The office site then serves as an entry into the emergency care system, and it is there that vital, perhaps even life-saving, care is provided.Studies have shown that emergencies are common in primary care practices that provide care to children. In 1 study, the authors surveyed 52 pediatric offices and found that these practices saw a median of 24 emergencies per year. 1 Most of the offices (82%) reported that they encountered, on average, at least 1 emer-

Pediatric observation units (OUs) are hospital areas used to provide medical evaluation and/or management for health-related conditions in children, typically for a well-defined, brief period. Pediatric OUs represent an emerging alternative site of care for selected groups of children who historically may have received their treatment in an ambulatory setting, emergency department, or hospital-based inpatient unit. This clinical report provides an overview of pediatric OUs, including the definitions and operating characteristics of different types of OUs, quality considerations and coding for observation services, and the effect of OUs on inpatient hospital utilization.

Emergency departments are vital in the management of pediatric patients with mental health emergencies. Pediatric mental health emergencies are an increasing part of emergency medical practice because emergency departments have become the safety net for a fragmented mental health infrastructure that is experiencing critical shortages in services in all sectors. Emergency departments must safely, humanely, and in a culturally and developmentally appropriate manner manage pediatric patients with undiagnosed and known mental illnesses, including those with mental retardation, autistic spectrum disorders, and attention-deficit/hyperactivity disorder and those experiencing a behavioral crisis. Emergency departments also manage patients with suicidal ideation, depression, escalating aggression, substance abuse, posttraumatic stress disorder, and maltreatment and those exposed to violence and unexpected deaths. Emergency departments must address not only the physical but also the mental health needs of patients during and after mass-casualty incidents and disasters. The American Academy of Pediatrics and the American College of Emergency Physicians support advocacy for increased mental health resources, including improved pediatric mental health tools for the emergency department, increased mental health insurance coverage, and adequate reimbursement at all levels; acknowledgment of the importance of the child’s medical home; and promotion of education and research for mental health emergencies.

Change in medical education through curricular reform has gained momentum in recent years due to multiple external forces. In addition, health access issues have coalesced to require that a broad set of voices be heard and served through the current health-care system. This requires that medical professionals be especially attuned to their communities and the multitude of cultures and voices that reside within them. In an attempt to illustrate how these changes can be practically incorporated into a medical education curriculum, this article highlights one institution's experience with a community-based health solution. The Georgetown University School of Medicine (GUSOM) Service-Learning program provides an example of how a community-based health solution can bridge the gap of social and clinical medicine through the framework of systems thinking principles and focus on teamwork to facilitate collaboration among faculty, community members, and students. This article will briefly explain the history, learning objectives, and context of the program, and in addition, provide a brief case study examining how the program engaged the problem of increasing immunization rates in the Washington, DC area.