In the Literature
The March 2008 issue of Pediatric Annals includes three articles that focus on the implications of Bright Futures—updated health supervision guidelines for children from the American Academy of Pediatrics (AAP). Bright Futures was created in 1990 by the Maternal and Child Health Bureau to emphasize the psychosocial aspects of health and the social and emotional functioning of child and family.
Improving Quality at the Practice Level
Making small, systematic changes over time in the way care is provided can substantially improve health care quality and, ultimately, health outcomes for children, writes Judith S. Shaw, Ed.D., M.P.H., R.N., of the University of Vermont, in "Practice Improvement: Child Healthcare Quality and Bright Futures."
Although guidelines provide a roadmap for health care professionals, they have not been consistently followed, and studies have shown "dramatic variation in care across providers and communities," writes Shaw. In fact, according to a recent report, only 38 percent of children receive recommended well-child care. Families of children, especially children with chronic illnesses, report their care is largely uncoordinated, and communication and support are inadequate.
Fundamental change, however, will require a systems-based approach—that is, one aimed at "multiple layers" of the health care system. In children's health care, the roles of community agencies and schools are of particular importance, the author notes. At the medical practice level, Bright Futures can help bring about changes and provide tools like anticipatory guidance handouts, visit summary sheets for parents, and risk assessment questionnaires.
While some practices "will undoubtedly struggle with exactly what to implement and when," Shaw notes that implementing the guidelines need not be complex. She includes a list of tips and strategies for practice improvement, like seeking free labor from undergraduate and graduate students and brainstorming among all staff members to encourage collaboration.
Finding Evidence of Effectiveness
There is growing agreement that decisions regarding medical treatments should be based on high-quality evidence of their effectiveness, produced by randomized controlled trials (RCTs). But generating evidence-based primary care for children is a struggle. Key elements of care, including health promotion, are not easily evaluated through RCTs because they depend on long time horizons and rely heavily on the input of family and community.
This can put pediatricians in a bind, write Robert D. Sege, M.D., Ph.D, and Edward De Vos, Ed.D., of Boston University, in "Care for Children and Evidence-based Medicine," which was supported by The Commonwealth Fund. Pediatricians find that many AAP recommendations are not supported by the U.S. Preventive Services Task Force. Bright Futures—which is "evidence-informed," if not "evidence-driven," note the authors—attempts to bridge this gap, although the link between care and outcomes remains indirect. "Someday there will be a new consensus on evidence standards for child health promotion in the health care setting," the authors say.
RCTs provide optimal study designs for interventions aimed at preventing or treating specific diseases in individual children. Interventions in Bright Futures may be directed at the individual child, the family, and may be most easily measured at the community level. Much of the suggested content of Bright Futures office visits is designed as much to optimize the child's development as it is to identify and treat a specific medical condition. The authors propose that a wider variety of rigorous study designs be systematically considered in evaluating the effectiveness of these approaches to children's health care.
Enduring Goals and Challenges
Motivated by the Bright Futures guidelines to revisit the history of preventive care in pediatrics, the authors of "Well-Child Care: Looking Back, Looking Forward" conclude that while much has been accomplished, more must be done to translate best practices across increasingly diverse communities and practice environments.
The article, written by the AAP's Lynn M. Olson, Ph.D., and colleagues, and supported by the Fund, illustrates the impact that the changing demographics of U.S. children have had on the delivery of effective, culturally competent care. Maintaining continuity of care, for example, remains an elusive goal for many children, especially those from disadvantaged families lacking health insurance. Hispanic families, which make up a growing portion of U.S. children, are particularly at risk for being uninsured.
The authors note the numerous challenges in providing well-child care, including: the growing number of topics addressed during well-child visits; the relative lack of evidence for the outcomes of well-child visits; barriers like inadequate time and reimbursement; and substantial variation—often according to race, ethnicity, language, income, and geography—in access, satisfaction, and quality.
In recent years, a new debate has emerged about the future directions for well-child care. Experts are rethinking the priorities for well-child care, considering alternative ways to deliver care (for example, through e-mail or over the phone), and exploring the value of collaborating with families more to set priorities based on their goals, strengths, and needs.
In their conclusion, the authors point out that the Centers for Disease Control and Prevention published a 2000 forecast of the top 10 public health challenges of the 21st century. Four of the 10 relate to the importance of preventive care for children and its impact on their future health and well-being. As has been noted by the AAP for the past 40 years, preventive pediatrics is not a luxury, but a necessity for proper health.
