Paul J. Chung, M.D., M.S., Tim C. Lee, Janina L. Morrison, and Mark A. Schuster, M.D., Ph.D.
P. J. Chung, T. C. Lee, J. L. Morrison, and M. A. Schuster, Preventive Care for Children in the United States: Quality and Barriers, Annual Review of Public Health, April 2006 27:491515
The importance of childhood preventive care has long been emphasized at the federal level, through such programs as the Maternal and Child Health Services Block Grant, Medicaid's Early and Periodic Screening, Diagnostic, and Treatment Program, and the State Children's Health Insurance Program. Still, less than half of all children and adolescents in the United States receive the preventive care recommended by professional guidelines.
To provide a snapshot of childhood preventive care, researchers from the University of California, Los Angeles, led by Paul J. Chung, M.D., M.S., reviewed articles related to primary health care for children and well-child care published between 1994 and 2003. "What is most evident from the literature," they say, "is how little we know about the quality of preventive care that children receive."
In their study, "Preventive Care for Children in the United States: Quality and Barriers" (Annual Review of Public Health, Apr. 2006), the researchers focused on 58 large observational studies and interventions that addressed child care on four counts: frequency of visits, developmental and psychosocial surveillance, screening for diseases, and anticipatory guidance.
Attending Well-Child Visits
Both the American Academy of Pediatrics and the federal Maternal and Child Health Bureau recommend six well-child visits in the first year, three in the second, and 17 from ages 2 through 21. Estimates of the number of children who attend all their recommended visits vary widely by study (37%–81%), depending on whether the data were obtained from patient surveys or administrative records; whether children were enrolled in public health plans or private plans; and whether the subjects were children or adolescents. "The true percentage of children who receive timely preventive care," say the authors, "is probably between the upper and lower bounds of these studies."
Few Children Receive Adequate Care
Regardless of whether they make it to their appointments, less than half of all children in the United States appear to be receiving adequate developmental and psychological surveillance, screening for health risks like lead exposure, or anticipatory guidance.
For instance, according to regional studies, less than half of all sexually active teenagers are being tested for Chlamydia. In the 1990s, less than one-quarter of children were being screened for lead exposure. And many children, especially those from low-income families, are not being screened for anemia.
Well-child visits generally include at least some anticipatory guidance, but delivery of all or even most recommended age-appropriate guidance is rare. While one study found that more than 80 percent of pediatricians said they always counseled on at least one of nine preventive health topics, such as car restraints, firearms, physical activity, and sexual health, most topics were discussed by less than half of pediatricians. The one notable exception was nutrition—according to the study, most pediatricians discussed nutrition with their patients at all ages. Parents surveyed on their receipt of anticipatory guidance indicate substantial unmet needs across most topics, with about half of parents reporting at least one unmet need.
Breaking Down Barriers
Several identifiable barriers to quality preventive care emerge from this study: insurance coverage; lack of continuity with a clinician or institution; deficient privacy for adolescents in clinical settings; clinician skill; race, language, and gender barriers; and shortage of time.
Insurance is one of the most powerful indicators of whether or not a child will receive all recommended well-child care. One survey showed that 76 percent of privately insured and 85 percent of publicly insured children satisfied well-child visit recommendations, compared with 68 percent of uninsured children. Continuity of care—defined as a long-term relationship between patient and provider—also increased the likelihood of well-child visits. Families in managed care plans had more continuity than publicly insured, Hispanic, and non-English-speaking families.
Time is also a major factor in the provision of recommended care. Survey findings suggest that longer visit times with both young children and adolescents are associated with increased developmental and anticipatory guidance, as well as parent satisfaction. However, one national survey found 47 percent of primary care pediatricians reported concerns over having adequate time.
Improving Children's Health Care
The authors provide several suggestions for relatively simple ways to help improve the quality of child preventive care, given the known barriers. Language services, self-administered patient questionnaires, privacy for adolescents, and office efficiency strategies, such as written reminders, are small steps that health care providers may employ to improve care. In addition, research on barriers and quality improvement will be important. Finally, the authors acknowledge that changes in reimbursement for preventive care relative to therapeutic care—or even radical workforce changes—may be necessary to increase the time that health care providers are willing to devote to preventive care. "Most clinicians have little financial incentive to increase the time they devote to preventive care, which is traditionally less well compensated than is acute care," they say.
Facts and Figures