Family physicians have long touted -- indeed, cherished -- the cradle-to-grave continuum of care they provide to patients. In fact, FPs often say the broad scope of practice is what drew them to the specialty.
Family physician Drew Miller, M.D., of Lakin, Kan., shown here with 9-month-old Bria Oroso, offers obstetrical care in his practice. Many of the babies he delivers become patients as children.
However, new research(www.annfammed.org) published in the September/October issue of Annals of Family Medicine suggests an alarming downward trend in the number of children cared for by family physicians.
Authors of the study, titled "Change in Site of Children's Primary Care: A Longitudinal Population-Based Analysis," conducted their research in Vermont using that state's all-payer claims database.
That's an important distinction given that previous research in this area has focused on cross-sectional surveys of patient visits and physician-reported data from American Board of Family Medicine recertification surveys.
The authors said their study added "substantially to our understanding of the state of FP vs. pediatrician practice for child health care."
- New longitudinal research conducted in Vermont shows that fewer family physicians are taking care of children.
- Using the state's all-payer claims database, researchers verified previous research findings that showed a temporal trend of child visits moving from family medicine to pediatric practices.
- Researchers suggested the shift in practice settings could be attributed to various factors, including a decline in the number of family physicians offering obstetrical services.
Specifically, the researchers found 5% overall lower odds of children receiving care from a family medicine practice over time after controlling for confounders, which "verifies previous findings of a temporal trend of child visits moving from FP to pediatrician practices."
They said their analysis also "suggested a new finding related to an enhanced trend toward pediatrician practices among children living in rural areas" that needs to be confirmed by research in other settings.
Corresponding author Richard Wasserman, M.D., M.P.H, has served as a professor of pediatrics at the Larner College of Medicine at the University of Vermont in Burlington since 1983 and, throughout his career, has blended patient care with teaching and primary care research.
He told AAFP News that the research team's findings validated previous lines of research on the topic.
"I'm not a family physician, but I'm very much aware of what's going on with family medicine in my state.
"There's an increasing demand for adult primary care and a shortage of adult primary care physicians here," said Wasserman. Those competing demands on family medicine practices could leave fewer appointments available for children, he said.
Study Methods, Objectives
The study sample included 184,794 patients ranging in age from birth to 21 years. Each patient was matched to at least two medical claims during the eight-year period that spanned Jan. 1, 2009, to Dec. 31, 2016.
Patients could be enrolled in any health plan in the state, including commercial plans and Medicaid.
Stated objectives were to
- test whether the proportion of children at the population level cared for at family medicine and pediatric practices was changing over time,
- show how any change was influenced by patient demographics (i.e., age, sex, rurality and insurance), and
- investigate whether any associations varied by the rurality of the child's residence.
Researchers accessed data from the Vermont Health Care Uniform Reporting & Evaluation System operated by the Green Mountain Care Board; the Board had no input into the study design or implementation and had no role in interpreting the findings.
The researchers found the average distribution of children was 39% in urban settings, 20% in large towns, 16% in small towns and 25% in isolated rural areas. Their results were reported as percentages of all children with claims to either a family medicine or pediatric primary care practice.
In any given year, children had a 5% lower chance of being seen in a family medicine practice than a pediatric practice compared with the previous year, after controlling for child demographics.
The authors noted that child demographic variables independently predicted whether the child was seen by a family physician. For instance,
- females had 5% greater odds than males of going to a family medicine practice,
- children with Medicaid had 9% greater odds than children with other insurance of seeing a family physician and
- each year of increase in age was associated with 11% greater odds of receiving care from a family physician.
Additionally, children living in nonurban areas (compared to urban areas) were more likely to be seen in a family medicine practice when they lived in a large town, small town or isolated rural area.
However, when travel distances between the child's home and the medical practice were taken into account using stratification by the child Rural Urban Commuting Area category, children had
- 3% lower odds of being seen in a family medicine practice in urban areas and
- 8% lower odds in isolated or small rural towns.
Researchers suggested that the shift in practice settings for children's primary care visits could be attributed to various factors, including a decline in the number of family physicians who offer obstetrical services (and the accompanying stream of future pediatric patients that obstetrics provides) and increased appointment availability in pediatric practice schedules due to the relatively large number of pediatricians in the state.
"Projected shortfalls in the primary care workforce to address more complex, chronic ambulatory care needs of older individuals may divert resources from children's primary care and is worthy of further study," wrote the authors.
As a potential limitation of their study, authors noted the low population of Vermont, which has about 626,000 residents and is the second-least populated state, ahead only of Wyoming.
They wrote that it is "possible that what happens in a rural New England state with a small population is not generalizable to the rest of the nation."
Additional Author Comments
Wasserman said the research findings have long-term implications for health care delivery to children in the United States "unless something is done specifically to change it."
"Family medicine as a discipline is completely aware of this challenge; this is not new," he noted.
If the downward trend of fewer family physicians caring for children continues, it will mean less choice for families, said Wasserman. "And choice is something we treasure in our health care system."
He said family physicians often see entire families as patients, and that's a big advantage when caring for children.
"So many problems that children have are very rooted in the families into which they have been born -- parents with illnesses, mental health problems and substance abuse challenges, and families living in poverty.
"You name it, and those things affect the child."
Wasserman noted the experience pediatricians gain from being able to devote all their time to the health challenges of children. "But we don't have the family perspective without seriously going out and finding it -- and usually we end up doing that when there is a problem, rather than anticipating the problem.
"I would prefer a healthy balance, but it looks like the balance is swinging more toward pediatricians," he added.
Wasserman said he'd like to see a practice model where family physicians and pediatricians work side by side -- with each specialty tapping the expertise of the other -- to provide the best possible patient outcomes.
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