"The time is right to reconsider the goals, content, and processes of preventive pediatric care," argues Edward L. Schor, M.D., in "The Future Pediatrician: Promoting Children's Health and Development"(The Journal of Pediatrics, Nov. 2007).
The past several decades have seen vast changes in children's health and in the social patterns of family life, Schor notes. These changes, combined with the recognition that social and physical environments play an important role in lifelong health and social competence, has brought increasing focus on the preventive care available to children and their families.
Schor believes that the content of preventive care, as well as the training of practitioners, should be guided by a predetermined set of measurable outcomes for well-child care. Strategies to improve preventive care could include individualized care plans; greater use of practice management tools, such as flow sheets and e-mail; team-based care; and standardized data collection through structured screening and other means.
Signs of Inadequate Preventive Care
Studies have found that many children reach kindergarten without ever being screened for vision or hearing problems. Others have language delays that are identified too late for early intervention. Parents concerned about their children's learning, behavior, or development often report that their pediatrician did not adequately address their concerns. "There is accumulating evidence that, similar to sick care, the quality of well-child care is quite variable," Schor says. "Despite a growing body of evidence demonstrating the efficacy of many elements of preventive care, much of the care as currently provided in busy practices is no doubt ineffective."
As an example, Schor says that "routine care" is often too routine—that is, it responds insufficiently to families' specific circumstances. Higher-need families, including those with low incomes and low levels of education, may receive less information or shorter visits, or may not receive referrals to potentially helpful community resources. At-risk children, moreover, have been found to be less likely to receive preventive and developmental services during well-child visits.
Dissonance Between Needs and Capacity
Pediatricians report concerns about their ability to address the changing health problems of children, given their training and a reimbursement system that values procedures over cognitive services. "The dissonance between the needs of patients and the capacity of the health care system is even more pronounced for preventive pediatric care and developmental services," the author writes.
The failure to individualize care is likely a function of physicians' habits, the time pressures of running a financially viable practice, and the failure to adopt practice systems that have proven effective and efficient, says Schor. For example, standardized screening tools, which can be used in the office waiting room to identify children and adolescents at risk for health problems with minimal use of practitioner time, tend to not be used routinely.
Steps to Improve Care
To improve the quality of preventive care, Schor recommends regularly measuring a number of child health outcomes, including: physical goals, like treating vision and hearing problems; emotional, social, and cognitive goals, like recognizing and treating developmental delays; and family functioning goals, like detecting the warning signs of child abuse or neglect. But achieving these outcomes—especially those that require an integrated effort by families, child care providers, early childhood educators, and others—will require significant changes in pediatric education and practice.
Schor says that to address some of the inefficiencies in the care system, pediatric practices should con-sider the following operating changes:
- Have ancillary staff handle some aspects of well-child care, like anticipatory guidance or development screening.
- Develop the capacity to create patient registries based on immunization status, biopsychosocial risks, or disease conditions.
- Offer group well-child care.
- Collect information from parents before face-to-face visits.
- Tailor the content and duration of preventive care visits to meet children and families' unique needs.
- Adopt more patient- and family-centered approaches.
Practicing pediatricians will need to strengthen their skills and continuously improve the care they provide, Schor says. At the same time, training programs will have to be modified to ensure that future pediatricians enter practice with appropriate skills and knowledge. Greater use of information technology, altered reimbursement procedures, as well as other systemic changes will also be necessary. Making these changes will be an important but manageable challenge, the author concludes. "Many pediatric practices have already demonstrated that the quality of care, including the quality of preventive care, can be dramatically improved when modest changes are accompanied by a firm commitment to 'do the right thing' for their patients."
Facts and Figures
- Preventive care is the most common reason for pediatric office visits, which aver-age 18 to 22 minutes.
- Well-child care now constitutes 20% to 25% of pediatric office visits overall, and a much greater proportion of visits for children under age 2.
- The proportion of parents who reported they were asked whether they had concerns about their children's learning, behavior, or development during a pediatric visit ranged from 29% to 56%, according to the National Survey of Child Health.
- On average, families have only about half the number of preventive care visits recommended by the American Academy of Pediatrics.
