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Delivery of well-child care: a look inside the door
Chuck Norlin1, Morgan A Crawford, Christopher T Bell
1Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City, Utah 84158, USA. chuck.norlin@hsc.utah.edu
Insights
Pediatric well-child care often falls short of Bright Futures recommendations, with shorter visits addressing more topics. Children with special health care needs receive longer visits but similar guidance content.
Area of Science:
- Pediatric primary care
- Health services research
- Child health supervision
Background:
- Well-child care is crucial for monitoring child development and addressing health concerns.
- Bright Futures provides evidence-based guidelines for well-child care delivery.
- Understanding current practices and identifying gaps is essential for improving pediatric care.
Purpose of the Study:
- To describe the delivery of pediatric well-child care.
- To compare current practices with Bright Futures recommendations.
- To compare well-child care for children with and without special health care needs.
Main Methods:
- Direct observation of 483 well-child care visits by pediatric clinicians over 10 weeks.
- Documentation of visit characteristics, including duration and topics addressed.
- Parental questionnaires to identify children with special health care needs.
Main Results:
- Mean visit duration was 20.3 minutes; only 38.9% started with open-ended parent/child concerns.
- Clinicians addressed a mean of 42% of Bright Futures-recommended topics, with significant omissions.
- Shorter visits were linked to more parent concerns and greater adherence to guidance; visits for children with special needs were longer but covered similar guidance topics.
Conclusions:
- Pediatric well-child care delivery frequently deviates from Bright Futures guidelines.
- Soliciting parent/child concerns and addressing recommended topics were associated with shorter visit durations.
- Well-child visits for children with special health care needs were longer, accommodating their complex needs alongside standard guidance.
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.
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