Improving Adolescent Preventive Care in an Urban Pediatric Clinic: Capturing Missed Opportunities

Pediatric Preventive Care: Population Health and Individualized Care

Well-child care is a near-universal service for young children toward which a great deal of time and professional resources are devoted but for which there is scant evidence of effectiveness in routine practice. It is composed of many components, the value of which likely varies with the quality of their provision and the needs and priorities of the children and families who receive them. Achieving more efficient and effective preventive care will require that pediatric practices segment the population they serve and design schedules and staffing to match patients' health, well-being, personal and social circumstances, and service needs. Care should be individualized and include essential screening, tests, procedures, and education on the basis of assessment of patients' and families' needs and priorities. The traditional schedule of individual, comprehensive preventive care visits should be reconsidered and replaced with a schedule that allows complete care to be provided over a series of visits, including those for acute and chronic care. Preventive pediatric care should be provided in family-centered, team-based practices with strong linkages to other providers in the community who serve and support children and families. Care should make use of the wide variety of modalities that exist, and face-to-face time should be reserved for those services that are both important and uniquely responsive to in-office intervention. This model of preventive care will require changes in training, responsibilities and reimbursement of health care team members, and enhanced communication and collaboration among all involved, especially with families.

Improving rates of ferrous sulfate prescription for suspected iron deficiency anaemia in infants

BACKGROUND

Iron deficiency anaemia (IDA) in infancy is prevalent and associated with impaired neurodevelopment; however, studies suggest that treatment and follow-up rates are poor.

OBJECTIVES

To improve the rate of ferrous sulfate prescription for suspected IDA among infants aged 8-13 months to 75% or greater within 24 months.

METHODS

We implemented a multidisciplinary process improvement effort aimed at standardising treatment for suspected IDA at two academic paediatric primary care clinics. We developed a clinical pathway with screening and treatment recommendations, followed by multiple plan-do-study-act cycles including provider education, targeted reminders when ferrous sulfate was not prescribed and development of standardised procedures for responding to abnormal lab values. We tracked prescription and screening rates using statistical process control charts. In post hoc analyses, we examined rates of haemoglobin (Hgb) recheck and normalisation for the preintervention versus postintervention groups.

RESULTS

The prescription rate for suspected IDA increased from 41% to 78% following implementation of the intervention. Common reasons for treatment failure included prescription of a multivitamin instead of ferrous sulfate, and Hgb not flagged as low by the electronic medical record. Screening rates remained stable at 89%. Forty-one per cent of patients with anaemia in the preintervention group had their Hgb rechecked within 6 months, compared with 56% in the postintervention group (p<0.001). Furthermore, 30% of patients with anaemia in the postintervention group had normalised their Hgb by 6 months, compared with 20% in the preintervention group (p<0.05).

CONCLUSIONS

A multipronged interdisciplinary quality improvement intervention enabled: (1) development of standardised practices for treating suspected IDA among infants aged 8-13 months, (2) improvement of prescription rates and (3) maintenance of high screening rates. Rates of Hgb recheck and normalisation also increased in the intervention period.​.

Patterns of Primary Care Physician Visits for US Adolescents in 2014: Implications for Vaccination

OBJECTIVE

Because most adolescent vaccinations are delivered in primary care, opportunities to vaccinate depend on the presence of visits and types of visits. We evaluated: 1) national visit patterns (having an annual preventive visit with a physician, provider type seen, visit types) for adolescents across the United States, and 2) the type of physician visits at which vaccines are administered for this age group.

METHODS

We performed a secondary data set analysis of the 2014 Medical Expenditure Panel Survey. Data are collected through interviews of caregivers of a nationally representative sample of the noninstitutionalized US population. We used descriptive analyses to examine use of health care according to age and gender, and visit types at which vaccines were given according to age.

RESULTS

During a 12-month period, almost half of participants had no primary care physician (PCP) visits, and one-third had a preventive visit to a PCP. An additional 19% had only nonpreventive care visits to a PCP. Uninsured participants had the highest rate of no care, and the lowest rate of preventive care. Most preventive care visits by adolescents 11 to 17 years of age were to pediatricians, and most visits among those 18 to 21 years of age were to family/general practitioners. Overall, 67% of non-check-up PCP visits were for acute care, 10% were for follow-up, and 7% for immunization only. Nationally, 61%, 26%, and 12% of vaccines were given at preventive, immunization-only, and acute/follow-up visits, respectively.

CONCLUSIONS

Fewer than half of adolescents receive preventive care, and many have no PCP visits. This reinforces the need to offer outreach to adolescents to improve rates of preventive visits, and to take advantage of all primary care visits for vaccinations. Because pediatricians and family practice/general practice physicians vaccinate most adolescents, these providers should remain the target audience for vaccine education and quality improvement activities.