Improving the Delivery of Preventive Services to Children
Am Fam Physician. 2011 Mar 15;83(6):659-665.
See related articles: Health Maintenance in School-aged Children: Part I. History, Physical Examination, and Immunizations and Health Maintenance in School-aged Children: Part II. Counseling Recommendations
As noted by Dr. Riley and colleagues in this issue of American Family Physician, the well-child visit is an opportunity for the family physician to detect diseases and provide counseling to prevent future health problems.1,2 However, multiple barriers, including lack of time, lack of continuity with a physician, financial barriers, cultural barriers, and lack of physician skill or awareness, contribute to children not receiving recommended preventive services.3
How should a busy family physician approach well-child visits and the delivery of preventive services to children? Although there is a lack of robust patient-oriented evidence that addresses this question, several interventions improve the delivery of preventive services to children. The use of electronic health records (EHRs) has been shown to improve rates of developmental screening, risk assessment, and anticipatory guidance, likely because of the combination of structured data elements, decision support tools, longitudinal view of patient data, and improved access to laboratory and health care summary data.4
Immunization rates can be improved with use of reminder or recall systems, which can be delivered via a telephone autodialer system, via letters or postcards, or in person during other types of clinic visits.5 Many EHRs have a built-in function that can alert the physician about delinquent services, such as immunizations. Physicians who do not have an EHR system can track patients who need immunizations or identify system issues in the practice that need to be addressed by developing a database (computerized or paper-based) from chart reviews or practice billing information that contains patients' immunizations.
The use of standardized developmental screening tools, such as the Denver Developmental Screening Test, and parent-response developmental tools, such as the Parents' Evaluation of Developmental Status questionnaire, has been shown to improve rates of developmental screening. These tools can be integrated into standardized forms (paper-or EHR-based) so that a nursing assistant or the physician can review the questions with the parents during the office visit itself, or the forms can be given to the patient's parents at check-in so that they can be completed in the waiting room and reviewed by the physician before the visit. When these tools were integrated with improved coordination between physician offices and community programs (e.g., state-run, early childhood intervention programs; school-based programs) to promote early identification and treatment of developmental problems, referral rates to these programs also improved.6 Family physicians should be knowledgeable about the referral resources available in their communities, including contacts and eligibility criteria. By assisting patients and families in contacting these programs, physicians can ensure that their patients receive appropriate, prompt therapy for developmental issues.
Because of the complexity and fragmentation found in the current U.S. health care system, improving the delivery of preventive services is challenging without implementing system-wide changes. Several studies have shown that rates of well-child services and preventive care improve with collaborative efforts among government and community agencies and physician offices.6–8 Interventions in these studies have included improved physician and office staff education; changes in financing structure; reduction of service duplication; and use of community resources, such as public health nurses and community health centers, to deliver some preventive services. For example, physicians should strive to include their entire staff in the process of providing preventive services (e.g., training nurses and front office staff to be responsible for reviewing immunization status for patients, implementing standing orders for routine immunizations). Also, in many communities, local health departments provide immunizations to many school-aged children, albeit in a fragmented manner. Physicians in these communities are often able to access local health departments' immunization registries, and in some cases integrate that registry information with their EHRs, avoiding duplication of services and allowing for better tracking of immunization status. Improving the delivery of preventive services can also take place outside of the physician's office. Family physicians can take time to talk about prevention at local schools, churches, and other places with group activities for children and become involved in local and national professional organizations that advocate for changes to the health care financing and payment systems to promote prevention and wellness services.
Although achieving widespread adoption of system-wide changes is a daunting task, family physicians can begin by taking small steps to improve the preventive and well-child care services they provide to their patients. By using chart review or abstraction and identifying key measures to improve (e.g., immunization rates, anticipatory guidance on select topics), family physicians and their staff can assess how well they currently deliver these services, then set improvement goals.7,9 Family physicians and their staff can also work together to use well-studied quality improvement techniques, such as the PDSA (plan, do, study, act) cycle, to identify and develop practice-specific ways to improve well-child services.10 The PDSA cycle tests a process change by developing a plan to test the change, doing the test, analyzing the data, and determining if additional changes to the process are needed. By starting with their own practices, using a team-based approach, reaching out to and coordinating with community-based agencies, and continuing to advocate for system-wide reforms at the local and national levels, family physicians can continue to improve the health of the children they serve.
1. Riley M, Locke AB, Skye EP. Health maintenance in school-aged children. Part I: history, physical examination, screening, and immunizations. Am Fam Physician. 2011;83(6):683–688.
2. Riley M, Locke AB, Skye EP. Health maintenance in school-aged children. Part II: counseling recommendations. Am Fam Physician. 2011;83(6):689–694.
3. Chung PJ, Lee TC, Morrison JL, Schuster MA. Preventive care for children in the United States: quality and barriers. Annu Rev Public Health. 2006;27:491–515.
4. Adams WG, Mann AM, Bauchner H. Use of an electronic medical record improves the quality of urban pediatric primary care. Pediatrics. 2003;111(3):626–632.
5. Szilagyi PG, Bordley C, Vann JC, et al. Effect of patient reminder/recall interventions on immunization rates: a review. JAMA. 2000;284(14):1820–1827.
6. Pinto-Martin JA, Dunkle M, Earls M, Fliedner D, Landes C. Developmental stages of developmental screening: steps to implementation of a successful program. Am J Public Health. 2005;95(11):1928–1932.
7. Shaw JS, Wasserman RC, Barry S, et al. Statewide quality improvement outreach improves preventive services for young children. Pediatrics. 2006;118(4):e1039–e1047.
8. Margolis PA, Stevens R, Bordley WC, et al. From concept to application: the impact of a community-wide intervention to improve the delivery of preventive services to children. Pediatrics. 2001;108(3):e42.
9. Chin MH, Alexander-Young M, Burnet DL. Health care quality-improvement approaches to reducing child health disparities. Pediatrics. 2009;124(suppl 3):S224–S236.
10. Margolis P, Lannon CM, Stuart JM, Fried BJ, Keyes-Elstein L, Moore DE Jr. Practice based education to improve delivery systems for prevention in primary care: randomised trial. BMJ. 2004;328(7436):388.
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