Rethinking Well-Child Care

Rethinking Well-Child Care

Edward L. Schor, MD*

* From the Commonwealth Fund, New York, New York

Top
Background
The Periodicity Schedule
Parents' Expectations
Experience In Practice
Barriers To High-Quality...
The Right Thing For...
Changing Well-Child Care: A...
Changing The Periodicity...
Low-Cost Changes To Office...
Standards For Preventive Care...
The Community Of Child...
Conclusions
References

Abbreviations: AAP, AmericanAcademy of Pediatrics

Well-child care is a core service of pediatrics, but it receiveslittle emphasis in pediatric training, reluctant considerationby insurers, and rare attention from researchers. Although itencompasses a variety of health-promoting and disease-preventingservices, the desired outcomes of well-child care and qualitystandards for its provision have not been specified. It is notsurprising, then, that preventive care services, as they arebeing provided currently, are not meeting the needs of manyfamilies, especially families with the most vulnerable children.The quality of child health supervision varies greatly amongphysician practices, and parents are signaling their dissatisfactionby failing to obtain approximately one-half of recommended preventivecare services. In addition, evidence of effectiveness is lackingfor much of the content of well-child care, which may jeopardizeboth its place as a covered insurance benefit and its reimbursement.It is time for major revision of well-child care, taking intoaccount the varying needs of individual children and families,the operation of child health care practices, and the broadissues of access to primary care and payment for services withinthe US health care system. Because preventive health care forchildren, at least as it occurs within well-child visits, isauthoritatively guided by the AmericanAcademy of Pediatrics(AAP) Recommendations for Preventive Pediatric Health Care,1otherwise known as the periodicity schedule, review and revisionof well-child care must begin with that document.

/ BACKGROUND

Historically, the field of pediatrics has been as concernedwith promoting children’s health and development as withtreating children’s diseases.2 The current need to returnto this holistic approach is evident in the trends in children’shealth status. Children’s physical health is better thanit ever has been.3 Scientific progress has led to substantialreductions in many of the acute morbidities of the early 20thcentury and increasing survival from acute illness and prematurebirth. However, increasing survival has led to a higher prevalenceof "new morbidities" such as obesity, attention-deficit/hyperactivitydisorder, behavior disorders, depression, and adolescent riskbehaviors has become more obvious, and the incidence is increasing.4Applying a broad definition of health would lead to the conclusionthat there are many unmet needs among children and familiesand the term "well-child care" is applicable to fewer children.

Other changes within the profession have significantly alteredhow general pediatricians spend their time. Although pediatrictraining has emphasized the care of seriously ill children,current trends are increasingly putting the care of such childrenin the hands of hospitalists, emergency care physicians, andpediatric subspecialists. Unfortunately, the remaining and emergingfunctions of general pediatricians have been relatively neglectedin their professional education. This neglect is not based ona lack of knowledge. During the period in which these changeshave occurred, the amount of information about how to promotechildren’s health and development has been dramaticallyincreasing.

The quality of preventive care for children varies greatly.Among a Medicaid population, only approximately one-fifth ofchildren received preventive and developmental services thatmet a basic threshold of quality for each aspect of care assessed.5A national survey of parents found that >94% of parents reported1 unmet need for parenting guidance, education, or screeningby pediatric clinicians in 1 of the content of care areas.6In general, substantially less than one-half of children andadolescents receive developmental and psychosocial surveillance,disease screening, and anticipatory guidance (P. J. Chung, MD,et al, unpublished data, 2003). More than deficiencies in theeducation of pediatricians account for these findings. Lackof standards of care and sometimes-unrealistic expectationsabout the content of well-child care contribute to this variability.Also prompting a reexamination of well-child care is the nationalattention being placed on reducing medical errors of commissionand omission and improving quality by relying on evidence-basedmedical care approaches. The need to be able to justify or atleast rationalize preventive health care for children is rapidlyincreasing. That rationale must be apparent in the documentsguiding the provision of preventive child health care. Therefore,it is time for a serious review of the process of well-childcare and the periodicity schedule that guides it.

/ THE PERIODICITY SCHEDULE

The structure of well-child care in pediatrics is provided bythe Recommendations for Preventive Pediatric Health Care,1 theperiodicity schedule, produced by the Committee on Practiceand Ambulatory Medicine of the AAP. This document recommendsscheduled well-child visits and is a matrix of potential categoriesof preventive services, organized according to the age of thechild. The matrix is accompanied by a preamble and by a largenumber of footnotes that provide important guidance and caveatsfor its use.

It is difficult to overstate the importance of this documentin shaping the schedule and content of well-child care in theUnited States. The periodicity of the schedule is reflectedin the organization of the 2 leading references on the contentof preventive care for children, ie, Bright Futures7 and Guidelinesfor Health Supervision,8 and in pediatric screening forms andmedical record systems, parent-held records, and numerous bookletsand brochures for parent education. Federal regulations requirestate Medicaid programs to set their own schedules for periodicscreening and to consult with "recognized medical organizationsinvolved in child health care" in developing these standards.9Consequently, state Medicaid program early periodic screening,diagnosis, and treatment services frequently draw directly fromthe recommendations of the AAP. In the past, private insurersbased their well-child care benefits on the AAP periodicityschedule; however, some managed care organizations, such asHealthPartners in Minnesota, have questioned the value of manyof the visits and have decided to cover fewer visits duringthe first 1 year of life.10

Despite its importance, the current periodicity schedule hasbecome anachronistic and, like its predecessors, it is not ascientific document. The first schedule for preventive childhealth care was produced in 1967 by the Council on PediatricPractice of the AAP.11 The council acknowledged its subjectiveorigins and anticipated that revision would be needed. Theywrote, "The Schedule for Preventive Child Health Care representsan amalgamation of schedules used in various clinics and privateoffices and may not prove feasible for all situations. Modificationswill, no doubt, be made in the future."11 The original counciland its successors also designed the schedule to allow preventivecare to be individualized to suit the patient and the practice.The current recommendations commence, "Each child and familyis unique; therefore these Recommendations for Preventive PediatricHealth Care are designed for the care of children who are receivingcompetent parenting, have no manifestations of any importanthealth problems, and are growing and developing in a satisfactoryfashion. Additional visits may be necessary if circumstancessuggest variations from normal."12 A large proportion of childrenand families certainly fall into the latter category, but thereis no evidence that pediatricians often individualize the visitschedule.

It is difficult to ascertain the extent to which promoting children’sdevelopment has guided the structure of well-child care. Theoriginal periodicity schedule seems to have been strongly influencedby the schedule for immunizations recommended in the reportof the Committee on the Control of Infectious Diseases.13 Theimmunization schedule at that time called for 15 visits betweenbirth and 16 years of age, 6 of which were for skin testingfor tuberculosis. The preventive care schedule recommended 28visits during the same period, including annual visits beginningat age 3 years. The influence of the immunization schedule maybe inferred from the concordant recommendations for only alternate-yearimmunizations and tuberculosis testing after age 4 years andthe later recommendations by the council, in 1977,14 for onlyalternate-year preventive care visits after age 6 years. Thesignificant overlap between the immunization and well-childvisit schedules may account for the belief of many parents thatreceiving immunizations is equivalent to receiving well-childcare and for the decrease in attendance at well-child visitswhen no immunizations are scheduled.

The periodicity schedule has been modified by the AAP many timessince its introduction. Each change led to a more extensivedocument and often to more responsibilities for child healthcare professionals. In addition, many of the components of well-childcare that are noted in the schedule can be linked to extensivepolicy statements and other recommendations about the contentof care. Decades of accretion have led to a rich but unwieldydocument and to unreasonable expectations of practicing pediatricians.

Even the original council expected preventive care visits tobe a challenge to accomplish well. They recognized that thequality of care they outlined would require close to 30 minutesper visit, but they thought that other staff members in thepractice could perform approximately one-half of the examinationand the physician could complete the remainder in 15 minutes.The need to rely on other health care personnel and to omitcertain items of the physical examination during some visitswas acknowledged, but the importance of continuity of care by"the child’s personal physician" was also clear.11

/ PARENTS’ EXPECTATIONS

Most parents acknowledge that they need advice on raising children,15and several recent surveys found that parents expect pediatriciansto provide information on child development and parenting aswell as on physical aspects of health.15–17 There alsois evidence that parents adhere to child-rearing recommendationsthey receive from child health care providers, such as breastfeedingtheir infants, putting infants to sleep on their backs, avoidingthe use of physical discipline, and reading to their children.15,18

Furthermore, when queried, parents seem to be quite satisfiedwith the care they receive. In 1 study, the majority (67%) ofparents whose children had a regular source of care reportedthat their child’s physician did an excellent job of providingoverall pediatric care and listening carefully to and answeringquestions.15 Physicians seem to be meeting the expectationsof white, nonpoor, and insured families better than those ofother families, who are 2 to 4 times more likely to be dissatisfiedwith the care their children receive, especially in the areasof the child’s growth and development and listening toand answering questions.2

Regarding the quality of care, there is evidence that physiciansare not using fully their opportunities to provide preventivedevelopmental and psychosocial services during well-child care.Thirty-six percent of parents of young children who respondedto a national survey reported that they had discussed none of6 important topics that were of strong interest to them andwere recommended for inclusion in preventive care visits bythe AAP.15 Nearly all of the parents had 1 unmet need for childhealth-related parenting guidance, education, or screening bypediatric clinicians in 1 of the 4 areas assessed, ie, anticipatoryguidance and parent education, family psychosocial risks, substanceuse, and family-centered care.6 Another study found that 40%of parents were not asked whether they had concerns about theirchildren’s learning, development, or behavior.5 Opportunitiesto help parents are being missed, because parents are >3times as likely to receive information to address their concernsif the pediatric clinician inquires about their concerns.5 Parentswhose questions are answered report being more confident intheir parenting and less concerned about their children’sdevelopment.19

In addition, it seems that parents have not received sufficientinformation to understand or appreciate well-child care, becausethey are not using preventive services to the extent they arerecommended.20,21 Current recommendations suggest a total of6 well-child visits from birth through 1 year of age. On average,families report attending only 2.2 preventive visits and 1.7other visits during the child’s first year and 0.98 preventivevisits during the following year, when 3 preventive visits arerecommended (E.L.S., data from the Medical Expenditure Panel,2000). Nationally, only 26.9% of young children are up-to-datewith their immunizations (3 doses of diphtheria-pertussis-tetanusvaccine, 3 doses of poliovirus vaccine, and 1 dose of a measles-containingvaccine) by the end of their 12th month; that rate reaches 82.7%by 2 years of age.22

/ EXPERIENCE IN PRACTICE

Well-child care comprises a substantial portion of pediatricpractice, accounting for 22% of an average pediatrician’spatient contacts; for children 0 to 1 year of age, well-childcare comprises 57% of all ambulatory visits (E.L.S., data fromthe Medical Expenditure Panel, 2000). A large portion of therecommended content of preventive pediatric health care is devotedto developmental services, such as obtaining a developmentalhistory and eliciting parental concerns, screening for developmentaland behavioral risks and problems, providing anticipatory guidance,assessing identified risks and problems, counseling about orotherwise treating problems, initiating necessary referrals,and coordinating related and subsequent care. These servicesrepresent the primary opportunity for prevention or early interventionfor the vast array of developmental and behavioral problemsthat are so prevalent in American society and are of great concernto parents. However, pediatricians seem to be ambivalent aboutthese aspects of well-child care. Pediatricians spend 18.3 minutesduring an average preventive care visit for children <36months of age, and 79% think that this amount of time is aboutright; paradoxically, only 46% of pediatricians agree that thereis sufficient time to perform developmental assessments, andonly 16.3% agree that there is enough time to address familypsychosocial problems.16 It can reasonably be concluded thatthe majority of pediatricians are not addressing developmentaland psychosocial issues adequately.

/ BARRIERS TO HIGH-QUALITY PREVENTIVE CARE

Queries of pediatricians yield a convincing list of barriersto providing the preventive services that are recommended, barriersthat urgently need to be addressed. Time constraints, low levelsof reimbursement for preventive pediatric care, lack of reimbursementfor specific developmental services, lack of training in childdevelopment, lack of trained nonphysician staff members, limitedaccess to community services to support families and children,and few external incentives have all been reported as reasonswhy the needs of children and families for preventive pediatriccare services are not being fully met.16 Most of these barriersare systemic rather than personal. As a group, pediatriciansare committed to providing high-quality care to their patients;it seems there simply is too much to do.

/ THE RIGHT THING FOR EACH CHILD AT THE RIGHT TIME

A recent study suggested that it is not possible, in the timeavailable, to provide even the few preventive services mosthighly recommended by the US Preventive Services Task Force.23Nor is it possible to respond effectively to the myriad recommendationsfor the content of well-child care, such as those in BrightFutures,7 or to the new recommendations that committees of theAAP frequently suggest. However, one can hardly argue with anyof the thoughtfully proposed recommendations, and practicingpediatricians are left having to decide what not to do. A nationalreport made the point quite succinctly, "The current care systemcannot do the job. Trying harder will not work. Changing systemsof care will."24 Pediatricians cannot squeeze more into thelimited time they have available for each well-child visit.The approach to preventive care, including the timing and contentcodified by the current periodicity schedule and the processesby which care is provided, needs to be changed.

/ CHANGING WELL-CHILD CARE: A ROAD MAP TO QUALITY

Many experts in the field of preventive care balk at the ideaof tampering with the current periodicity schedule and relatedrecommendations for care. They know that the current systemof preventive care for children is not very scientific, andthey also know that only a few of the recommendations for thecontent and processes of well-child care are supported by evidenceof effectiveness.25 Some fear that opening the system to scrutinymay promote its demise. However, few would argue that the principlesof prevention on which well-child care is based are ill foundedor that a lack of evidence is equivalent to evidence of inefficacy.To a large extent, the evidence does not exist because the researchhas not been performed. There is a pressing need for better,more rational, scientific guidance regarding preventive carefor children, especially as it affects their development. However,much can be done to justify well-child care and to improve itsquality while awaiting the generation of evidence.

/ CHANGING THE PERIODICITY SCHEDULE

BasingPeriodicity on Child Development.

It is time to rethink the content and processes of well-childcare, to improve both efficiency and effectiveness. To begin,although there has been little research on the effectivenessof preventive pediatric care, there is a rich scientific baseavailable to guide practice.26 Much of that guidance comes fromthe field of child and family development and is readily applicableto the structure and content of well-child care.27 Those findingsand the changing lives of children and families in the UnitedStates should be used as the basis for a complete revision ofthe AAP Recommendations for Preventive Pediatric Health Care,the periodicity schedule. The revised visit schedule shouldinclude visits whose timing reflects or coincides with key transitionpoints in the development and adaptation of children and theirparents. An approximation of such a system, based on personalobservations, has been advocated by T. Berry Brazelton28 formany years. As with the current schedule, additional visitsmay be necessary for some children and families who are havingor are likely to have greater difficulty achieving a normaldevelopmental trajectory. Some families may need fewer visits.Therefore, it should be possible to justify each visit on thebasis of scientific findings while evidence of effectivenessis accumulating. Such a schedule should readily accommodaterecommended immunizations, which are likely to change substantiallyduring the coming decade, but the schedule for immunizationswould no longer drive the timing of well-child care.