Child/Adolescent Health

Studies reveal variations in preventive care and parental guidance among pediatric and family medicine practices

Private pediatric practices provide the majority of primary care for children, but little is known about the organizational characteristics of these practices and how they affect quality of care for children. Two new studies of 44 private pediatric and family medicine practices in North Carolina reveal tremendous variation in the organization of these practices, as well as low levels of preventive care and parental guidelines. The studies were supported by the Agency for Healthcare Research and Quality (HS08509) and are briefly described here.

Randolph, G., Fried, B., Loeding, L., and others (2005, June). "Organizational characteristics and preventive service delivery in private practices: A peek inside the 'black box' of private practices caring for children." Pediatrics 115(6), pp. 1704-1711.

This study of 44 private pediatric and family practices in North Carolina found low levels of preventive care, with substantial variation among practices. Only 39 percent of children received three of four recommended preventive services: immunizations, testing for anemia, tuberculosis testing, and lead screening by 2 years of age; the range among clinics was 2 to 88 percent. Also, actual preventive service rates were 19 to 42 percent lower than clinicians thought they were.

Few practices demonstrated evidence of a systematic approach to prevention. For instance, only 7 percent used preventive service prompting sheets, 9 percent measured immunization rates in the previous year, 9 percent had a majority of physicians using prompts, and 11 percent used tracking systems.

Furthermore, practice organizational characteristics varied greatly, some of which could cause problems that might impede delivery of high quality primary care for children. For example, turnover of clinicians and staff members was high, with practices losing an average of 27 percent of their clinicians every 4 years and 39 percent of their office staff members every 2 years.

Rosenthal, M.S., Lannon, C.M., Stuart, J.M., and others (2005, May). "A randomized trial of practice-based education to improve delivery systems for anticipatory guidance." Archives of Pediatric and Adolescent Medicine 159, pp. 456-463.

Pediatricians are supposed to provide parents with anticipatory guidance, that is, counsel them about child development, injury prevention, nutrition, and other topics that will help them to become more effective caregivers. Yet, physicians typically spend less than 2.5 minutes of the well-child visit on anticipatory guidance. Coaching the staff of private pediatric practices to implement new care processes can improve the rate at which physicians provide anticipatory guidance, according to this study.

The researchers randomly assigned 22 pediatric practices in North Carolina to an intervention and 22 practices to usual care. In the intervention practices, project staff coached practice staff in auditing performance and identifying, testing, and implementing new care processes to improve delivery of anticipatory guidance. These processes ranged from assigning an office prevention coordinator and creating a prompting system to establishing a tracking/recall system (for example, reminder postcards) for preventive care.

The researchers surveyed parents of 1- and 6-month-old infants about their recollection of this guidance and their behaviors as a result of the guidance to determine the effects of the intervention. The proportion of parents of 1-month-old infants who reported that they received all age-appropriate anticipatory guidance decreased from 15.9 percent to 10 percent in control practices and increased from 7.3 to 24 percent in intervention practices. The proportion of parents of 6-month-old infants who reported that they received all age-appropriate anticipatory guidance decreased from 8.2 percent to 5.4 percent in control practices and increased from 2.2 percent to 18.1 percent in the intervention practices. However, there were no differences in self-reported parent knowledge or behavior.

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