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Delivery of Well-Child Care: A Look Inside the Door

  • Chuck Norlin
    Correspondence
    Address correspondence to Chuck Norlin, MD, University of Utah Department of Pediatrics, PO Box 581289, Salt Lake City, Utah 84158.
    Affiliations
    Department of Pediatrics (Drs Norlin and Sheng) and School of Medicine (Dr Crawford and Mr Bell), University of Utah Health Sciences Center, Salt Lake City, Utah; and Department of Pediatrics, University of California–San Diego, San Diego, Calif (Dr Stein)
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  • Morgan A. Crawford
    Affiliations
    Department of Pediatrics (Drs Norlin and Sheng) and School of Medicine (Dr Crawford and Mr Bell), University of Utah Health Sciences Center, Salt Lake City, Utah; and Department of Pediatrics, University of California–San Diego, San Diego, Calif (Dr Stein)
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  • Christopher T. Bell
    Affiliations
    Department of Pediatrics (Drs Norlin and Sheng) and School of Medicine (Dr Crawford and Mr Bell), University of Utah Health Sciences Center, Salt Lake City, Utah; and Department of Pediatrics, University of California–San Diego, San Diego, Calif (Dr Stein)
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  • Xiaoming Sheng
    Affiliations
    Department of Pediatrics (Drs Norlin and Sheng) and School of Medicine (Dr Crawford and Mr Bell), University of Utah Health Sciences Center, Salt Lake City, Utah; and Department of Pediatrics, University of California–San Diego, San Diego, Calif (Dr Stein)
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  • Martin T. Stein
    Affiliations
    Department of Pediatrics (Drs Norlin and Sheng) and School of Medicine (Dr Crawford and Mr Bell), University of Utah Health Sciences Center, Salt Lake City, Utah; and Department of Pediatrics, University of California–San Diego, San Diego, Calif (Dr Stein)
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      Abstract

      Objective

      To describe the delivery of well-child care and its components; to compare that delivery with recommendations in Bright Futures; and to compare delivery of well-child care for children with special health care needs with that for children without special needs.

      Methods

      Over a 10-week period, 2 medical students observed and documented characteristics of well-child care visits by general pediatricians and midlevel pediatric providers. Parents completed a demographic questionnaire and a screener for children with special health care needs.

      Results

      A total of 483 visits by 43 pediatricians and 9 midlevel providers with patients from 0 to 19 years of age were observed. Adjusted mean visit duration was 20.3 minutes; 38.9% of visits began with an open-ended question about parent/child concerns. A mean of 7.2 health supervision/anticipatory guidance topics were addressed per visit. Clinicians addressed a mean of 42% of Bright Futures–recommended age-specific health supervision/anticipatory guidance topics. Topics addressed less frequently than recommended included family support, parental well-being, behavior/discipline, physical activity, media screen time, risk reduction/substance use, puberty/sex, social-peer interactions, and violence. Shorter visits were associated with asking about parent/child concerns and with addressing greater proportions of recommended health supervision/anticipatory guidance topics. Well-child care visits with children with special health care needs were 36% longer than those with children without special needs and addressed similar numbers of age-specific health supervision/anticipatory guidance topics. More time was spent with children with special health care needs addressing health supervision/anticipatory guidance topics, other conditions (usually their chronic condition), and testing, prescriptions, and referrals.

      Conclusions

      Utilizing direct observation of visits with pediatric clinicians, we found that solicitation of parent/child concerns occurred less frequently than recommended. Fewer than half of recommended visit-specific health supervision/anticipatory guidance topics were addressed, and there was little congruence with some Bright Futures age group–specific recommendations. Notably, both solicitation of patient/parent concerns and greater adherence to health supervision/anticipatory guidance recommendations were associated with shorter visits. Well-child care visits with children with special health care needs were longer than those with children without special needs; more time was spent addressing similar numbers of health supervision/anticipatory guidance topics as well as their chronic conditions.

      Keywords

      What’s New
      Through direct observation of well-child care, we found that pediatric clinicians begin fewer visits with open-ended questions and address fewer health supervision/anticipatory guidance topics than Bright Futures recommends. However, greater compliance with these recommendations was associated with shorter visits.
      Well-child care visits with a focus on prevention comprise 30%–36% of pediatric office visits.

      American Academy of Pediatrics Division of Health Services Research. Socioeconomic Survey of Pediatricians: Part 1—Pediatricians’ Practice and Personal Characteristics—Comparison of Findings From: PS#43—Part 1(2000), PS#33 (1996), PS#21 (1993). Elk Grove Village, Ill: American Academy of Pediatrics; 2000. Available at: http://www.aap.org/research/periodicsurvey/ps43soci.htm. Accessed August 4, 2009.

      • Slora E.J.
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      Patient visits to a national practice-based research network: comparing pediatric research in office settings with the National Ambulatory Medical Care Survey.
      Guidelines for well-child care, first published in 1967 by the American Academy of Pediatrics’ Council on Pediatric Practice in its Standards of Child Health Care, recommended 15 well-child care visits in the first 3 years of life, followed by annual visits through adolescence. Each encounter was estimated to require 30 minutes of combined physician and staff time.
      Council on Pediatric Practice, American Academy of Pediatrics
      Standards of Child Health Care.
      Over the ensuing 4 decades, recommendations for what should be accomplished during well-child care visits have grown to include increasing numbers of screening tests, immunizations, and expanded anticipatory guidance addressing a wide variety of topics related to physical and psychosocial health.
      These recommendations are now codified in Bright Futures—Guidelines for Health Supervision of Infants, Children, and Adolescents, first published in 1994 to guide clinicians in responding “to the current and emerging preventive and health promotion needs” of pediatric patients.
      The 2008 third edition of Bright Futures suggests 11 well-child care visits in the first 3 years, followed by annual visits through age 21.
      Its age-specific recommendations include 33 universal and 117 selective screening tests, observation of parent-child interaction, addressing parent concerns through open-ended questions, monitoring of growth, developmental surveillance, physical examinations, and anticipatory guidance on numerous topics.
      Bright Futures and others acknowledge that clinicians face time constraints that make it difficult to accomplish all of the goals proposed for well-child care.
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      Drowning in a sea of advice: pediatricians and American Academy of Pediatrics policy statements.
      The recommendations in Bright Futures are the current standards for well-child care practice. However, the difficulty of meeting these standards, an inadequate evidence base for many recommendations,
      • Wagner J.L.
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      Well-child care: how much is enough?.
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      and evidence that well-child care is not valued by many consumers
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      have led some experts to recommend rethinking well-child care and to suggest alternative approaches to accomplishing the many goals detailed in Bright Futures.
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      Well-child care: how much is enough?.
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      Effectiveness of targeted anticipatory guidance during well-child visits: a pilot trial.
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      Improving pediatric preventive care.
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      The use of Internet-based technology to tailor well-child care encounters.
      Despite these concerns and the importance of prevention,
      • Young P.C.
      Prevention: a new focus for the country but old stuff for pediatricians.
      the substantial time devoted by clinicians to well-child care, and legislative mandates for its provision,
      • Wagner J.L.
      • Herdman R.C.
      • Alberts D.W.
      Well-child care: how much is enough?.

      Health and Human Services Press Office. Administration announces regulations requiring new health insurance plans to provide free preventive care. 2010. US Department of Health and Human Services. Available at: http://www.hhs.gov/news/press/2010pres/07/20100714a.html. Accessed October 22, 2010.

      few studies have examined the quality of well-child care delivery or compared its real-life content with what is recommended. Two recent studies raise concerns about the quality of well-child care compared to published guidelines; one found composite quality measure scores between 13.5% and 59.6%,
      • Bethell C.
      • Reuland C.H.
      • Halfon N.
      • Schor E.L.
      Measuring the quality of preventive and developmental services for young children: national estimates and patterns of clinicians’ performance.
      and the other found a weighted adherence rate of 38.3% across 33 indicators of well-child care quality.
      • Mangione-Smith R.
      • DeCristofaro A.H.
      • Setodji C.M.
      • et al.
      The quality of ambulatory care delivered to children in the United States.
      An accurate understanding of current well-child care delivery is essential to guide efforts to improve its quality or to rethink its content. Determining how the content of well-child care as currently delivered compares with recommendations in Bright Futures—particularly the assessment of parent concerns and addressing health supervision and anticipatory guidance topics—may identify key areas for further research and quality improvement activities.
      Children with special health care needs have issues related to their chronic conditions that could be addressed during well-child care visits, in addition to the usual recommended services.
      • Carey J.C.
      Health supervision and anticipatory guidance for children with genetic disorders (including specific recommendations for trisomy 21, trisomy 18, and neurofibromatosis I).
      • Cooley W.C.
      Providing a primary care medical home for children and youth with cerebral palsy.
      • Carbone P.S.
      • Farley M.
      • Davis T.
      Primary care for children with autism.
      With estimates of the prevalence of children with special health care needs in the United States ranging from 12.8% to 19.3%,
      • Bethell C.D.
      • Read D.
      • Blumberg S.J.
      • Newacheck P.W.
      What is the prevalence of children with special health care needs? Toward an understanding of variations in findings and methods across three national surveys.
      • Blumberg S.J.
      • Welch E.M.
      • Chowdhury S.R.
      • et al.
      Design and operation of the National Survey of Children With Special Health Care Needs, 2005–2006.
      pediatricians frequently face the challenge of addressing both the universal and the specific needs of children with special health care needs in well-child care. How and how well they accomplish this has received little attention. A study using the Medical Expenditure Panel Surveys found children with special health care needs were more likely to receive anticipatory guidance than children without special needs,
      • Houtrow A.J.
      • Kim S.E.
      • Chen A.Y.
      • Newacheck P.W.
      Preventive health care for children with and without special health care needs.
      and a study using pre- and post-visit surveys of parents found that the number of preventive topics addressed during well-child care visits increased as more illness-related topics were discussed.
      • Van Cleave J.
      • Heisler M.
      • Devries J.M.
      • et al.
      Discussion of illness during well-child care visits with parents of children with and without special health care needs.
      Because well-child care occurs largely behind closed doors, it has been difficult to study. Much of what is known is based on surveys of physicians or parents or on interviews after visits.
      • Bethell C.
      • Reuland C.H.
      • Halfon N.
      • Schor E.L.
      Measuring the quality of preventive and developmental services for young children: national estimates and patterns of clinicians’ performance.
      • Van Cleave J.
      • Heisler M.
      • Devries J.M.
      • et al.
      Discussion of illness during well-child care visits with parents of children with and without special health care needs.
      • Bethell C.
      • Peck C.
      • Schor E.
      Assessing health system provision of well-child care: the Promoting Healthy Development Survey.
      • Olson L.M.
      • Inkelas M.
      • Halfon N.
      • et al.
      Overview of the content of health supervision for young children: reports from parents and pediatricians.
      Physicians’ and parents’ reports of services delivered or topics discussed are often discordant.
      • Olson L.M.
      • Inkelas M.
      • Halfon N.
      • et al.
      Overview of the content of health supervision for young children: reports from parents and pediatricians.
      • Morrongiello B.A.
      • Hillier L.
      • Bass M.
      “What I said“ versus ”what you heard”: a comparison of physicians’ and parents’ reporting of anticipatory guidance on child safety issues.
      Studies in family medicine practices have found disagreement between survey findings and data obtained through direct observation of visits.
      • Flocke S.A.
      • Stange K.C.
      Direct observation and patient recall of health behavior advice.
      • Stange K.C.
      • Zyzanski S.J.
      • Jaen C.R.
      • et al.
      Illuminating the “black box”: a description of 4454 patient visits to 138 family physicians.
      Direct observation is likely to provide a more accurate assessment of the content and delivery of outpatient care.
      A detailed evaluation of well-child care visits could include time spent in the visit and its various components, identification of health-related problems and risks, health supervision/anticipatory guidance topics covered and time spent per topic, adherence to guidelines, analysis of the quality of the provider-patient interaction, parent satisfaction, change in parent/child behavior resulting from the visit, and variations in well-child care delivery and outcomes for different types of patients. This study, which is based on direct observation of pediatric clinicians, addressed time spent in well-child care visits, topics covered, adherence to Bright Futures guidelines, and compared visits with children with special health care needs and children without special needs.

      Methods

      Participants

      All primary care pediatricians and midlevel pediatric providers (nurse practitioners and physician assistants) who provide primary care in Utah were identified through professional societies, phone book and web searches, and hospital provider lists. Clinicians in training were excluded. We invited all identified clinicians by email and/or regular mail (up to 3 attempts by each method) to participate in a study of well-child care.
      From a randomly ordered list, willing pediatricians were contacted sequentially to schedule their participation until all available observation days were filled. All willing midlevel providers were contacted to schedule their participation. Consent was obtained from each participating clinician. Observations were performed between June 19 and August 29, 2008. The study was determined by the University of Utah institutional review board to be exempt from review and was approved by the Intermountain Healthcare institutional review board.

      Study Design

      Two medical student observers recorded time spent on various components of well-child care using an observation form developed by the investigators. The form (available upon request) was based on Bright Futures
      recommendations and was refined with suggestions from experts in well-child care and representatives of pediatric and midlevel provider organizations. The categories of health supervision/anticipatory guidance topics included on the observation form were (topics followed by the same symbol were later combined for analysis): behavior,‡ bowels/toileting, community involvement, discipline,‡ emotions,§ family support, feeding, fine motor development,† gross motor development,† growth, hearing, language development, literacy, media, mental health,§ nutrition, oral health, parental well-being, peer interactions/social, physical activity, puberty, risk reduction,¶ safety, school, screen time, sex, sleep, social development, substance use,¶ violence, and vision.
      Both students had substantial prior experience observing outpatient encounters. Training in discriminating visit components and health supervision/anticipatory guidance topics was accomplished through careful review of Bright Futures guidelines with the principal investigator (C.N.), collaborative development of the observation form, and pilot testing in well-child care visits. The observers honed their shared approach to data collection through a day of joint observation of all well-child care visits with one clinician. Further consistency was attained through subsequent comparisons of observation data and review of how topics were discriminated.
      On the day of observation, the parent(s) or guardian(s) of all patients scheduled for well-child care with the participating clinician were offered an explanation of the study and invited to participate. If willing, they completed a brief demographic questionnaire about the child’s age, source of health care funding, number of older siblings, and number of previous visits with the clinician. Each also completed a Children With Special Health Care Needs screener,

      Children With Special Health Care Needs Screener. The Child and Adolescent Health Measurement Initiative. Available at: http://cahmi.org/pages/Sections.aspx?section=10. Accessed February 12, 2010.

      • Bethell C.D.
      • Read D.
      • Stein R.E.
      • et al.
      Identifying children with special health care needs: development and evaluation of a short screening instrument.
      used to identify children with special health care needs in the National Survey of Children With Special Health Care Needs (NS-CSHCN),
      • Blumberg S.J.
      • Welch E.M.
      • Chowdhury S.R.
      • et al.
      Design and operation of the National Survey of Children With Special Health Care Needs, 2005–2006.
      • Strickland B.B.
      • Singh G.K.
      • Kogan M.D.
      • et al.
      Access to the medical home: new findings from the 2005–2006 National Survey of Children With Special Health Care Needs.
      the National Survey of Children’s Health,
      • Newacheck P.W.
      • Kim S.E.
      • Blumberg S.J.
      • Rising J.P.
      Who is at risk for special health care needs: findings from the National Survey of Children’s Health.
      and numerous other studies. The screening instrument asks about issues that have lasted, or are expected to last, at least 12 months in each of 5 categories: 1) needing or using medicine prescribed by a doctor; 2) needing or using more medical care, mental health, or educational services than is usual for most children of the same age; 3) limited or prevented in ability to do things most children of the same age do; 4) needing or receiving special therapy, such as physical, occupational, or speech therapy; and 5) needing or receiving treatment or counseling for any kind of emotional, developmental, or behavioral problem. All patients 7 years or older were given a simpler explanation of the study and allowed to refuse the observation.
      For each willing patient/parent, the observer accompanied the clinician into the examination room, collected the parent questionnaire, and silently observed the visit. Using a clipboard and timer, the observers recorded total visit duration and time spent on each visit component and in discussion of specific health supervision/anticipatory guidance topics. Time spent discussing health supervision/anticipatory guidance topics during the physical examination was double counted—that is, 1 minute spent during the examination discussing oral health would count toward both that health supervision/anticipatory guidance topic and the physical examination. All open-ended questions asked by the clinician regarding parental or patient concerns were noted. At the visit’s conclusion, the observers clarified any questions they had about their observations with the clinician and entered their data into an electronic spreadsheet.
      Data collected from participating clinicians included years since pediatric training, type of practice organization, number of pediatric clinicians practicing in the same location, number of half-days per week typically worked, and total number of patients seen during the day of observation. From our literature review and discussions among academic and community pediatricians, these characteristics and those requested of parents on their questionnaire were deemed the most likely to affect clinicians’ approach to well-child care.
      • Randolph G.
      • Fried B.
      • Loeding L.
      • et al.
      Organizational characteristics and preventive service delivery in private practices: a peek inside the “black box” of private practices caring for children.
      • Rushton J.L.
      • Fant K.E.
      • Clark S.J.
      Use of practice guidelines in the primary care of children with attention-deficit/hyperactivity disorder.
      We examined the relationships of these characteristics to the outcomes of visit duration, time spent on recommended health supervision/anticipatory guidance topics, and use of open-ended questions.

      Statistical Analysis

      We used univariate analysis to determine associations between visit duration and child, parent, and clinician characteristics. Multivariable analysis was used to determine associations of those characteristics with visit duration, time spent on visit components and on individual health supervision/anticipatory guidance topics, and the number and proportion of recommended health supervision/anticipatory guidance topics addressed. For some analyses, patients were grouped by age as in Bright Futures: infant, less than 1 year of age; early childhood, 1–4 years; middle childhood, 5–10 years; and adolescence, 11 years and older. A linear mixed effect model was used to analyze total visit time and time spent on visit components and to incorporate dependencies among visits to the same provider, treating each provider as a cluster. Tukey’s multiple comparison adjustment was used for all post-hoc comparisons. Analysis was performed using SAS software 9.1.3 (SAS Institute, Cary, NC).
      Outcomes of interest included the frequency of and time spent in discussions of health supervision/anticipatory guidance topics. Our first analysis of the frequency of health supervision/anticipatory guidance discussions compared all the topics recommended by Bright Futures for each visit, including those that might be addressed at a different visit within an age group, with the topics recorded by the observers. The times spent addressing 5 pairs of topics were combined because their discussions often overlapped.
      The second analysis compared age group-specific frequencies of topic discussions with Bright Future’s recommendations, as follows. For each health supervision/anticipatory guidance topic, we determined the proportion of visits within each age group in which addressing the topic is recommended—for example, addressing sleep is recommended during 4 (80%) of the 5 infant visits. We then divided the proportions of visits in each age group during which addressing each topic was observed by those recommended proportions. The resultant proportions were considered congruence—eg, for discussions of sleep during infant visits, 50% congruence would mean that sleep was addressed during 40% of observed infant visits (50% of the recommended 80%), while 100% congruence would reflect its discussion at ≥80% of those visits.

      Results

      Clinicians

      Of the 245 primary care pediatricians identified, 172 (70.2%) responded. Of the respondents, 91 (52.9%) were willing to participate and 43 (25.0%) were scheduled and observed. Of the 47 midlevel providers identified (22 nurse practitioners and 25 physician assistants), 28 (59.6%) responded. Of those, 13 (46.4%) were willing to participate and 9 (32.1%, 6 nurse practitioners and 3 physician assistants) were scheduled and observed. All available observation days were filled. Of the 52 observed clinicians, 63.5% were male and 78.9% practiced in urban or suburban areas. They worked a mean of 7.6 half-days per week and their practices reflected a range of organizational structures (Table 1).
      Table 1Characteristics of Participating Clinicians
      Data are presented as n (%) or mean (range).
      CharacteristicValue
      Type of clinician
       All clinicians52 (100)
       Pediatricians43 (82.7)
       Midlevel providers9 (17.3)
      Nurse practitioners6 (11.5)
      Physician assistants3 (5.8)
      Sex
       Male33 (63.5)
       Female19 (36.5)
      Practice organization type
       Private small group (1–4 clinicians)16 (30.8)
       Large single specialty group (≥5 clinicians)14 (26.9)
       Multispecialty group7 (13.5)
       Vertically integrated health system13 (25.0)
       Academic faculty practice2 (3.8)
      Practice locale
      Urban indicates within Salt Lake City (SLC) or immediate surrounds, <15 miles to children’s hospital; suburban, outside SLC but within 4 contiguous metropolitan counties, 15–40 miles from children’s hospital; small urban, distant, cities of 40–50 000 population, limited local pediatric specialty care, 80–290 miles from children’s hospital; rural, cities <30 000 population, 40–240 miles from children’s hospital.
       Urban20 (38.5)
       Suburban21 (40.4)
       Small urban, distant7 (13.5)
       Rural4 (7.7)
      Other characteristics
       No. of years since training14.1 (0–39)
       No. of half-days worked per week7.6 (2–10)
       No. of patients seen during day of observation
      Numbers from half-day observations were doubled for this calculation.
      17.8 (8–31)
      Data are presented as n (%) or mean (range).
      Urban indicates within Salt Lake City (SLC) or immediate surrounds, <15 miles to children’s hospital; suburban, outside SLC but within 4 contiguous metropolitan counties, 15–40 miles from children’s hospital; small urban, distant, cities of 40–50 000 population, limited local pediatric specialty care, 80–290 miles from children’s hospital; rural, cities <30 000 population, 40–240 miles from children’s hospital.
      Numbers from half-day observations were doubled for this calculation.

      Visits/Patients

      We observed 483 well-child visits, 56 (11.6%) of which were with children who met children with special health care needs criteria in one or more categories. One parent refused to be observed. No child refused to participate but for a portion of 7 visits with adolescents the observer was asked to leave the room for privacy reasons. Patient ages ranged from a few days to 19 years. A mean of 9.3 well-child care visits were observed per clinician (range 2–17). The number of visits with children without special needs decreased with increasing patient age (Figure 1). However, the number and proportions of visits that were with children with special health care needs increased with increasing patient age group—7 (4.2%) infants, 14 (9.9%) in early childhood, 16 (15.2%) in middle childhood, and 19 (26.8%) adolescents (Cochran-Armitage Trend Test, P < .0001) (Figure 1). The mode and median number of children with special health care needs seen for well-child care on the day of observation was 1 (range 0–4).
      Figure thumbnail gr1
      Figure 1Number of patients observed by age group and special needs status. CSHCN = children with special health care needs, Cw/oSN = children without special needs.
      Of the observed patients, 71.9% were insured by a commercial plan and 17.1% by Medicaid or CHIP. The observed visit was the first to the clinician for 11.6% of patients and 37.1% had no older siblings. Table 2 provides further detail about the patients. Among the patients who met any children with special health care needs criteria, 28 (50%) qualified in only 1 of the 5 categories (Table 3). Of the observed children with special health care needs, 45 (80.4%) met criteria for needing prescribed medicine; fewer met criteria in the other categories (Table 4). The proportions of children meeting children with special health care needs criteria in our study were similar to those for Utah and the United States.

      National Survey of Children With Special Health Care Needs (2005/2006). Child and Adolescent Health Measurement Initiative. Available at: http://cshcndata.org/Content/Default.aspx. Accessed February 12, 2010.

      Table 2Characteristics of Patients in Observed Visits
      Characteristicn (%)
      No. of patients483
      Sex
       Male254/483 (52.6)
       Female229/483 (47.4)
      Completed questionnaire474/483 (98.1)
       Completed by patient’s mother424/474 (89.5)
       Completed by patient’s father34/474 (7.2)
       Completed by guardian, both parents, or the patient16/474 (3.4)
      Insurance
       Commercial339/474 (71.9)
       Medicaid/Children’s Health Insurance Program81/474 (17.1)
       None17/474 (3.6)
       Unknown21/474 (4.4)
      No. of previous visits to clinician
       055/474 (11.6)
       138/474 (8.0)
       2–393/474 (19.6)
       4–590/474 (19.0)
       6–10112/474 (23.6)
       ≥1157/474 (17.9)
      No. of older siblings
       0176/474 (37.1)
       1147/474 (31.0)
       281/474 (17.1)
       ≥360/474 (12.7)
      Table 3Number of Categories in Which Each Child Met Children With Special Health Care Needs Criteria for Observed Patients and From State and National Samples
      No. of CategoriesPatients, n (%) (N = 56)Utah, n (%)
      Data from the National Survey of Children With Special Health Care Needs 2005/2006.37
      (N = 1014)
      United States, %
      Data from the National Survey of Children With Special Health Care Needs 2005/2006.37
      (N = 55 767)
      150.0 (28)54.155.2
      223.2 (13)20.320.8
      314.3 (8)13.212.7
      4 or 512.5 (7)12.411.4
      Data from the National Survey of Children With Special Health Care Needs 2005/2006.

      National Survey of Children With Special Health Care Needs (2005/2006). Child and Adolescent Health Measurement Initiative. Available at: http://cshcndata.org/Content/Default.aspx. Accessed February 12, 2010.

      Table 4Children With Special Health Care Needs Categories in which Observed Patients and State and National Samples Met Criteria
      Category of Special NeedsPatients, (%) n
      Sum is greater than 100% because of children meeting criteria in more than one category.
      (N = 56)
      Utah, %
      Data from the National Survey of Children With Special Health Care Needs 2005/2006.37
      (N = 1014)
      United States, %
      Data from the National Survey of Children With Special Health Care Needs 2005/2006.37
      (N = 55 767)
      Prescribed medicine80.4 (45)76.178.4
      Medical/other services46.4 (26)40.338.5
      Limited abilities23.2 (13)23.421.3
      Therapies16.1 (9)17.617.5
      Counseling etc25.0 (14)31.028.4
      Sum is greater than 100% because of children meeting criteria in more than one category.
      Data from the National Survey of Children With Special Health Care Needs 2005/2006.

      National Survey of Children With Special Health Care Needs (2005/2006). Child and Adolescent Health Measurement Initiative. Available at: http://cshcndata.org/Content/Default.aspx. Accessed February 12, 2010.

      Visit Duration

      The adjusted mean duration of observed visits was 20.3 minutes and range was 4.2–77.2 minutes. Visit duration varied directly with age (P < .0001) and by age group, as shown in Table 5 with adjusted means, medians, 25th and 75th percentiles, and ranges.
      Table 5Visit Durations by Age Group
      Age GroupVisit Duration (Min)
      Adjusted MeanMedian25th–75th PercentileRange
      All ages20.316.011.3–20.54.2–77.2
      Infant (<1 y)19.3
      P = .0001 compared to adjusted mean duration for adolescence.
      14.210.8–17.94.9–77.2
      Early childhood (1–4 y)18.9
      P = .0001 compared to adjusted mean duration for adolescence.
      15.511.5–19.34.2–46.8
      Middle childhood (5–10 y)21.017.812.1–23.44.2–49.9
      Adolescence (≥11 y)22.018.113.3–23.76.0–54.1
      P = .0001 compared to adjusted mean duration for adolescence.
      The mean visit duration was 36% longer for children with special health care needs than for children without special needs (22.3 and 18.2 minutes respectively, P < .0001). Visit duration did not vary significantly by age group for children with special health care needs (trend test P = .248). In the univariate analysis, visit duration was associated both with meeting children with special health care needs criteria in any category (P < .0001) and with the number of categories for which criteria were met (P < .0001). Multivariable analysis found statistically significant associations between visit duration and meeting children with special health care needs criteria for needing more than usual medical care, mental health, or educational services (P < .001) and for needing counseling (P = .048).

      Time Spent on Components of Well-Child Care

      A mean of 8.6 minutes were spent addressing health supervision/anticipatory guidance topics, 4.2 minutes on physical examination, 1.1 minutes on discussion of immunizations, 1.2 minutes on other health-related conditions, 0.8 minutes addressing prescriptions, tests, and referrals, and 4.2 minutes on other topics, including minor complaints, siblings’ issues, family history questions, and social conversation (Figure 2).
      Figure thumbnail gr2
      Figure 2Mean proportions of total visit time spent in visit components. HS/AG = health supervision/anticipatory guidance.
      The time spent in physical examination, in discussing and arranging immunizations, and in discussing other topics was similar for children with special health care needs and children without special needs (Figure 3). Clinicians spent more time with children with special health care needs than with children without special needs in addressing health supervision/anticipatory guidance topics (adjusted mean times were 9.1 and 8.0 minutes, respectively, P = .044). More time also was spent with children with special health care needs than with children without special needs in providing, arranging, and discussing prescriptions, testing, and referrals (mean times over all visits were 1.2 and 0.4 minutes, respectively, P < .0001).
      Figure thumbnail gr3
      Figure 3Mean times spent in various components of the visit, children without special needs (Cw/oSN) vs children with special health care needs (CSHCN). HS/AG = health supervision/anticipatory guidance.

      Open-Ended Questions

      In 371 (76.8%) of the 483 observed visits, clinicians asked at least one open-ended question about parent or patient concerns. An open-ended question was asked at the beginning of 183 visits (37.9% of the total) and sometime later in 188 (38.9%) visits. Among the 112 visits during which clinicians did not ask an open-ended question, the parent or child spontaneously raised at least one issue of concern in 53 (47.3%).

      Health Supervision/Anticipatory Guidance Topics

      Clinicians addressed a mean of 7.2 (range 0–15) health supervision/anticipatory guidance topics per visit. Table 6 lists the mean and median times spent addressing each topic by age group. The number of topics addressed increased with increasing age group (P = .016)—a mean of 6.8 topics were discussed during infant visits; 7.3 during early childhood, 7.7 during middle childhood, and 7.3 during visits with adolescents. More topics were discussed with female (7.5) than with male patients (7.0, P = .009). The number of topics addressed was inversely associated with the number of older siblings at home (P = .032).
      Table 6Time Spent Addressing Health Supervision/Anticipatory Guidance Topics by Age Group
      TopicMean, Median Time (Min)
      InfantEarly ChildhoodMiddle ChildhoodAdolescent
      Nutrition/feeding
      Time spent in topics separated by slashes were combined because of difficulty consistently distinguishing and separating their discussions.
      2.22, 1.901.68, 1.221.21, 0.781.47, 1.05
      Growth0.85, 0.670.94, 0.751.01, 0.801.05, 0.85
      Safety0.57, 0.330.78, 0.501.25, 0.570.60, 0.07
      School
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      0.18, 01.02, 0.670.94, 0.68
      Sleep0.65, 0.230.39, 0.130.46, 0.020.35, 0
      Bowels, toileting0.45, 0.130.69, 0.170.52, 00.11, 0
      Development—gross/fine motor
      Time spent in topics separated by slashes were combined because of difficulty consistently distinguishing and separating their discussions.
      0.51, 0.370.43, 0.230.21, 0
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      Behavior/discipline
      Time spent in topics separated by slashes were combined because of difficulty consistently distinguishing and separating their discussions.
      0.09, 00.56, 00.31, 00.11, 0
      Puberty, sex
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      0.08, 00.95, 0.42
      Development—social0.35, 0.070.43, 00.22, 0
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      Emotions/mental health
      Time spent in topics separated by slashes were combined because of difficulty consistently distinguishing and separating their discussions.
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      0.03, 00.33, 00.59, 0
      Development—language0.09, 00.67, 0.350.15, 0
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      Physical activity0.00, 00.02, 00.21, 00.65, 0.45
      Oral health0.14, 00.31, 0.130.29, 0.080.10, 0
      Media, screen time
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      0.06, 00.26, 00.34, 0
      Social, peer interactions
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      0.05, 00.11, 00.37, 0
      Risk reduction/substance use
      Time spent in topics separated by slashes were combined because of difficulty consistently distinguishing and separating their discussions.
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      0.03, 00.41, 0
      Vision0.02, 00.02, 00.22, 00.08, 0
      Literacy0.04, 00.10, 00.13, 00.04, 0
      Family support0.01, 00.01, 00.01, 00.12, 0
      Hearing0.02, 00.02, 00.03, 00.03, 0
      Parental well-being0.05, 00.01, 00.03, 0
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      Community involvement
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      0.00, 0
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      0.04, 0
      Violence0.00, 00.00, 0
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      0.00, 0
      Time spent in topics separated by slashes were combined because of difficulty consistently distinguishing and separating their discussions.
      Topics for which no discussions were recorded and Bright Futures did not recommend discussion.
      Overall, the number of health supervision/anticipatory guidance topics addressed was not significantly different for children with special health care needs and children without special needs, with means of 7.5 topics per visit with children with special health care needs and 7.2 with children without special needs. We recorded time spent on health topics that were not among those recommended in Bright Futures under the label “other conditions.” These discussions occurred in 45% of visits with children with special health care needs and 12% of visits with children without special needs (P < .0001) and their mean duration over all visits with children with special health care needs was 2.1 minutes and 0.3 minutes with children without special needs (P < .0001) (Figure 3). For children with special health care needs these discussions usually addressed the child’s chronic health condition(s) whereas for children without special needs they addressed a variety of health and related issues. When evaluating only the visits in which other conditions were addressed, those discussions averaged 3.8 minutes with children with special health care needs and 1.8 minutes with children without special needs (P < .006).

      Comparison With Bright Futures Guidelines

      Of the topics recommended by Bright Futures to be addressed at each visit, a mean of 42% (range 0%–92%) were discussed during the observed visits. There were no differences in the proportions of recommended topics discussed in the different age groups nor between children with special health care needs and children without special needs.
      Congruence between the health supervision/anticipatory guidance topics addressed by clinicians and those recommended by Bright Futures (as defined in Methods) ranged from <1% for the topic of violence, which Bright Futures recommends discussing at two-thirds of adolescent visits (and was observed only once), to 205% for nutrition/feeding, which was discussed during 88% of middle childhood visits and recommended in 43%. Table 7 displays the 3 topics with the least congruence between observed and recommended for each age group.
      Table 7Least Congruence Between Recommended and Observed Topics by Age Group
      Age GroupTopicCongruence
      InfantFamily support3%
      Parental well-being7%
      Behavior/discipline15%
      Early childhoodParental well-being5%
      Physical activity31%
      Media, screen time38%
      Middle childhoodRisk reduction/substance use4%
      Puberty, sex13%
      Social, peer interactions15%
      AdolescenceViolence<1%
      Behavior/discipline25%
      Emotions/mental health27%
      Some topics were discussed more frequently than recommended, including nutrition-diet (discussed in 90% of all visits and recommended in 86%), growth (91% and 69%), sleep (61% and 31%), and bowels-toileting (56% and 14%). These were also the topics most frequently raised by parents, with each being raised during 5%–10% of visits, compared to 0%–2% for other topics.

      Variability Related to Clinician or Visit Characteristics

      In multivariable analysis, visits were 1.68 minutes shorter when the clinician asked an open-ended question about parent or child concerns (P = .0152). Greater time spent addressing health supervision/anticipatory guidance topics was associated with a child having fewer older siblings (P = .003).
      Multivariable analysis also found that addressing more health supervision/anticipatory guidance topics was associated with beginning the visit with an open-ended question (P = .037), the frequency of asking about the child’s concerns (P = .020), and fewer years since completion of pediatric training (P = .015). Addressing greater proportions of recommended topics was associated with the clinician seeing more patients on the day of observation (P = .011) and with the frequency of asking about the child’s concerns (P = .014).
      No statistically significant associations were found between visit-related measures and any other of the patient or clinician characteristics listed in Table 1, Table 2. We were unable to analyze congruence by clinician characteristics because of small numbers of visits per clinician within each age group.

      Discussion

      This study describes key aspects of the current delivery of well-child care based on direct observation of 483 visits with pediatric clinicians, and is the first such study to detail differences in the delivery of well-child care for children with special health care needs and children without special needs. Mean well-child care visit duration was 20.3 minutes. A mean of 42% of visit time was devoted to addressing health supervision/anticipatory guidance and 24% to physical examination. Discussion of minor complaints, topics not directly related to well-child care, and social conversation comprised 22% of the visit.
      Overall, clinicians in our study addressed 42% of the health supervision/anticipatory guidance topics recommended by Bright Futures. However, this may underestimate clinician performance because, as suggested by Bright Futures, some topics not addressed at one visit might be discussed at another visit. Addressing greater proportions of recommended topics was associated with more visits on the day of observation. Both shorter visits and addressing greater proportions of recommended topics were associated with asking open-ended questions about patient/parent concerns. Some topics, including those more commonly raised by parents, were addressed more often than recommended in Bright Futures. These findings suggest that visit efficiency is enhanced by asking open-ended questions and that clinicians have learned to address issues that are often of concern to parents. However, open-ended questions were not asked in 23.2% of the visits, suggesting that key concerns may not have been addressed for nearly a quarter of patients.
      Bright Futures acknowledges the difficulty of addressing all recommended health supervision/anticipatory guidance topics at each visit and encourages clinicians to focus on priority topics and those of concern to parents and children. Reisinger and Bires lamented in 1980 that “pediatricians are allotting an insufficient amount of their time to discussion of some of the most significant problems that children and their parents face in today’s society.”
      • Reisinger K.S.
      • Bires J.A.
      Anticipatory guidance in pediatric practice.
      Our study also found that important topics, such as obesity, sexuality, and risk-taking, received less attention than recommended.
      Our findings indicate that both the duration and the composition of well-child care visits were affected when the patient had a special health care need. Well-child care visits with children with special health care needs were 36% longer than those with children without special needs. Discussions of other conditions were more common and longer in visits with children with special health care needs and more time was spent discussing testing, referrals, and prescriptions. Similar numbers and proportions of recommended health supervision/anticipatory guidance topics were addressed per visit with both groups and 14% more time was spent on standard health supervision/anticipatory guidance topics with children with special health care needs. Van Cleave and colleagues observed that 81% of parents reported discussing their child’s chronic condition during well-child care visits,
      • Van Cleave J.
      • Heisler M.
      • Devries J.M.
      • et al.
      Discussion of illness during well-child care visits with parents of children with and without special health care needs.
      compared to the 45% of visits with children with special health care needs in our study in which “other conditions” were discussed. Our observers recorded discussion of health supervision/anticipatory guidance topics under “other conditions” only when explicitly part of a discussion of a chronic diagnosis, whereas parents in the study by Van Cleave and colleagues may have thought that many health supervision/anticipatory guidance topics related directly to their child’s chronic condition. Whether children with special health care needs chronic conditions were adequately addressed during well-child care visits could not be evaluated with our data.
      Comparisons of our study with previous studies of well-child care, though limited by substantial differences in study design, can be found in the online appendix. These studies reflect an upward trend in the mean duration of well-child care visits, from 10.2–13 minutes in the 1960s
      • Bergman A.B.
      • Dassel S.W.
      • Wedgwood R.J.
      Time-motion study of practicing pediatricians.
      • Bergman A.B.
      • Probstfield J.L.
      • Wedgwood R.J.
      Performance analysis in pediatric practice: preliminary report.
      to 20.3 minutes in our study. A 1977 study
      • Foye H.
      • Chamberlin R.
      • Charney E.
      Content and emphasis of well-child visits. Experienced nurse practitioners vs pediatricians.
      found that physicians spent a mean of 8.3 minutes (47.2% of the visit) on behavior and development, similar to the 8.6 minutes (42.8% of the visit) spent on all health supervision/anticipatory guidance topics in our study. Among the 3 studies (including ours) that provided detail on the time spent addressing individual health supervision/anticipatory guidance topics,
      • Reisinger K.S.
      • Bires J.A.
      Anticipatory guidance in pediatric practice.
      • Bergman A.B.
      • Dassel S.W.
      • Wedgwood R.J.
      Time-motion study of practicing pediatricians.
      similarities were found in the relatively large proportions of visit time spent addressing diet, feeding, development, and immunizations.
      This study confirms that much of what is recommended is not accomplished in well-child care visits and that certain recommended health supervision/anticipatory guidance topics are more consistently left unaddressed than others. Underperformance compared to recommendations was also found in soliciting patient/parent concerns. However, better compliance with these guidelines was associated with shorter visits, suggesting greater efficiency.
      Parental satisfaction with well-child care and patient outcomes—the best measures of quality of care—were not evaluated in this study. Nevertheless, our findings may inform and provide some focus for efforts to rethink the content and delivery of well-child care and for ongoing improvements in Bright Futures.

      Limitations

      Because the observed clinicians practiced in Utah and those serving uninsured and publicly insured patients were underrepresented, the findings may not be generalizable to some regions. Although our participants were randomly selected, we do not know how their practices differed from the 29.8% of clinicians who did not respond or the 47.1% of respondents who were unwilling to participate. Our findings may also have been affected by performance of the observations during a single season (summer).
      Although evidence suggests that direct observation is the most accurate method for determining the content of primary care visits,
      • Stange K.C.
      • Zyzanski S.J.
      • Jaen C.R.
      • et al.
      Illuminating the “black box”: a description of 4454 patient visits to 138 family physicians.
      • Stange K.C.
      • Flocke S.A.
      • Goodwin M.A.
      • et al.
      Direct observation of rates of preventive service delivery in community family practice.
      the presence of observers may have affected how the clinicians delivered care. Because an observation effect would most likely result in more health supervision/anticipatory guidance topics being addressed, our findings may overestimate typical performance.
      Our observers may have missed recording some topics that were addressed, particularly during a rapid series of topics. Discussions of sensitive topics with adolescents may be underrepresented because the observers were excluded for portions of 7 visits (10%). Our participants may have been unfamiliar with the recently published third edition of Bright Futures, which may explain some of the variances between its recommendations and practice. However, those variances reflect opportunities to improve well-child care and could provide focus for efforts at doing so.

      Conclusions

      This study details current delivery of well-child care and the contributions of its components to the mean visit duration of 20.3 minutes. Recommendations in Bright Futures for addressing health supervision/anticipatory guidance topics and soliciting patient/parent concerns with open-ended questions were not followed in many clinical encounters. However, addressing more health supervision/anticipatory guidance topics and soliciting concerns were associated with shorter visits. Certain health supervision/anticipatory guidance topics were addressed more often than recommended, while others were addressed much less often. More time was spent with children with special health care needs, with similar numbers of health supervision/anticipatory guidance topics addressed. Research is needed to better understand how current well-child care affects patient outcomes and how its delivery can be improved to better meet the needs of children, their families, and our society.

      Acknowledgment

      This study was supported by a grant from The Commonwealth Fund . Ed Schor, MD, and Paul Young, MD, provided invaluable counsel and suggestions on early drafts of this article. We acknowledge the generosity of the pediatricians and midlevel providers who participated in this study: Timothy D. Bancroft, MD; Barbara E. Bean, MD; Vicki Berger, PA-C; David R. Boettger, MD; Nordell T. Brown, MD; Ellie Brownstein, MD; Brian N. Burrows, MD; Mary D. Burton, MD; Stacey Bushell, C-PNP; Wayne H. Cannon, MD; Daniel Clayton, MD; William Cosgrove, MD; Joseph G. Cramer, MD; J. Timothy Duffy, MD; Ryan N. Evans, MD; David S. Folland, MD; Claudia Fruin, MD; Cynthia Gellner, MD; R. Ross Hightower, MD; Bryan Hofheins, PA; Galina R. Hornyik, MD; Karen Jackson, PNP; Tanya S. Jackson, MD; Nina Jorgensen, MD; Miguel Knochel, MD; Toan H. Lam, MD; David Larson, MD; Peter C. Lindgren, MD; Pari Mashkuri, MD; Karl McMullin, NP; Louis Melini, PA; Thomas J. Metcalf, MD; Sylvia Morin, PNP; Martin J. Nygaard, MD; Anna G. Orchard, MD; Dallen Ormond, NP; Kathy Ostler, MD; Cynthia Owens, MD; Rod Pollary, MD; Charles Ralston, MD; Julie Shakib, MD; Mary Shapiro, MD; Lisa A. Sharp, FNP; Greg Staker, MD; Daniel R. Stampfl, MD; Robert Terashima, MD; Lena K. Terry, MD; Adrianne R. Walker, MD; John Weipert, MD; Ryan Wilcox, MD; Dustin Wise, MD; and Paul Young, MD.

      Supplementary Data

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