Well-Child Care Clinical Practice Redesign for Young ... · of accepted articles. Thirty-three arti-cles were accepted; these included 13 articles primarily on alternative for-matsforWCC,16,25–36

Well-Child Care Clinical Practice Redesign for YoungChildren: A Systematic Review of Strategies and Tools

abstractBACKGROUND AND OBJECTIVE: Various proposals have been made toredesign well-child care (WCC) for young children, yet no peer-reviewed publication has examined the evidence for these. The objec-tive of this study was to conduct a systematic review on WCC clinicalpractice redesign for children aged 0 to 5 years.

METHODS: PubMed was searched using criteria to identify relevantEnglish-language articles published from January 1981 through Febru-ary 2012. Observational studies, controlled trials, and systematicreviews evaluating efficiency and effectiveness of WCC for childrenaged 0 to 5 were selected. Interventions were organized into 3 cate-gories: providers, formats (how care is provided; eg, non–face-to-faceformats), and locations for care. Data were extracted by independentarticle review, including study quality, of 3 investigators with consen-sus resolution of discrepancies.

RESULTS: Of 275 articles screened, 33 met inclusion criteria. Seventeenarticles focused on providers, 13 on formats, 2 on locations, and 1miscellaneous. We found evidence that WCC provided in groups isat least as effective in providing WCC as 1-on-1 visits. There was limitedevidence regarding other formats, although evidence suggested thatnon-face-to-face formats, particularly web-based tools, could enhanceanticipatory guidance and possibly reduce parents’ need for clinicalcontacts for minor concerns between well-child visits. The addition ofa non–medical professional trained as a developmental specialistmay improve receipt of WCC services and enhance parenting practi-ces. There was insufficient evidence on nonclinical locations for WCC.

CONCLUSIONS: Evidence suggests that there are promising WCC rede-sign tools and strategies that may be ready for larger-scale testing andmay have important implications for preventive care delivery to youngchildren in the United States. Pediatrics 2013;131:S5–S25

AUTHORS: Tumaini R. Coker, MD, MBA,a,b,c Annika Windon,AB,d Candice Moreno, MD, MPH,a,b Mark A. Schuster, MD,PhD,e,f and Paul J. Chung, MD, MSa,b,c,g

aDepartment of Pediatrics, Mattel Children’s Hospital, DavidGeffen School of Medicine, University of California at Los Angeles,Los Angeles, California; bUCLA/RAND Prevention Research Center,Los Angeles, California; cRAND, Santa Monica, California;dMeharry Medical College, Nashville, Tennessee; eDivision ofGeneral Pediatrics, Children’s Hospital Boston, Boston,Massachusetts; fDepartment of Pediatrics, Harvard MedicalSchool, Cambridge, Massachusetts; and gDepartment of HealthServices, UCLA School of Public Health, Los Angeles, California

KEY WORDSwell-child care, practice redesign, patient-centered medical home

ABBREVIATIONSAOR—adjusted odds ratioCI—confidence intervalED—emergency departmentGWCC—group well-child careHS—Healthy Steps for Young Children ProgramHSS—Healthy Steps specialistIRR—incidence rate ratioIWCC—individual well-child careNP—nurse practitionerRCT—randomized controlled trialsWCC—well-child care

Drs Coker, Schuster, and Chung are former Robert WoodsJohnson Foundation Clinical Scholars.

Dr Moreno is currently affiliated with University of IllinoisCollege of Medicine, Chicago, Illinois.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-1427c

doi:10.1542/peds.2012-1427c

Accepted for publication Dec 20, 2012

Address correspondence to Tumaini Coker, MD, MBA, David GeffenSchool of Medicine at UCLA, UCLA/RAND Center for AdolescentHealth Promotion, 10960 Wilshire Blvd, Suite 1550, Los Angeles, CA90024. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

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Well-child care (WCC) during infancyand early childhood provides a criticalopportunity to address important so-cial, developmental, behavioral, andhealth issues for children. Ideally, WCCprovides parents with the knowledgeand confidence necessary to ensurethat their children meet their full de-velopmental potential and optimalhealth status. In our current WCC sys-tem, this opportunity is often missed;many children either do not receivethese important services or receivelow-quality services.1,2 Many parentsleave visits with unaddressed psycho-social, developmental, and behavioralconcerns,3–5 and many children do notreceive recommended screening fordevelopmental delay.6,7

WCC in the United States is structuredso that the clinician (pediatrician,family physician, or nurse practitioner[NP]) is expected to provide nearly allrecommended services in 13 face-to-face visits during the first 5 years of life.The number of recommended serviceshas expanded beyond what can be ac-complished in the typical visit, perhapscontributing to the wide variation inthe quantity and quality of servicesreceived.8–10 Pediatric practices in-terested in changing how they provideWCC can turn to the pediatric literaturefor a variety of clinical practice redesignoptions. Researchers and clinicianshave described options for improvingthe delivery of care by focusing on

changes to structural elements of care(eg, personnel and organization usedfor care provision). These changes in-clude using nonphysicians to providemore WCC services, providing someservices in non–face-to-face visits, andoffering some services outside theclinical setting.11–18 A comprehensive re-view of these proposed tools and strate-gies is needed to help providers makeevidence-based decisions regarding WCCclinical practice redesign. To our knowl-edge, this article provides the first suchpublished systematic review.

The objective of this systematic reviewis to examine tools and strategies forWCC clinical practice redesign for USchildren aged 0 to 5, focusing onchanges to the structure of care (non-physician providers [eg, nurses, layhealth educators], nonmedical loca-tions [eg, day-care centers, home vis-its], and alternative formats [eg, groupvisits, Internet]) that may affect receiptof WCC services, child health and de-velopmental outcomes, and overallquality of WCC.

The conceptual model for this review isbased on Donabedian’s model forassessing the quality of care based onstructure, process, and outcome.19,20

Structures of care (eg, facilities,equipment, personnel, and organiza-tion used for the provision of care)directly influence processes of care (ie,how care is provided and received),ultimately leading to health outcomes

(eg, health status),21 as detailed byStarfield (Fig 1).

METHODS

Data Sources and Article Selection

WesearchedPubMed forpeer-reviewedEnglish-language articles publishedJanuary 1, 1981, through February 1,2012 using keywords for WCC (WCC,well-baby care, health supervision) andMeSH terms (primary care, preventivecare). We also searched the referencesof accepted articles. We looked forarticles that evaluatedapractice-basedintervention to change WCC delivery forchildren aged 0 to 5.

This review focused on interventions tochange WCC delivery in primary caresettings in the United States. To fulfillthis objective, interventions had to bepractice-based, applicable to WCC de-livery, and based in the United Statesor other developed country. We didnot include articles that (1) evaluateda quality improvement process withoutidentifying a specific change to caredelivery, (2) addressed only 1 topicwithinWCC (eg, car-seat safety) and notWCC services more generally (eg, an-ticipatory guidance), (3) focused onchanges to WCC content or screeningwithout addressing changes in the de-livery of services, or (4) evaluatedinterventions designed solely to in-creasecompliancewithoruseof typicalWCC.

FIGURE 1Conceptual model: dynamics of health outcome (adapted from Starfield21).

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Accepted articles were systematic re-views,randomizedcontrolledtrials(RCTs),nonrandomized trials, or observationalstudies of interventions that includedchildrenaged0to5andreportedfindingsrelated to receipt of WCC services, childhealthanddevelopmental outcomes, andquality of care.

Threeinvestigatorsindependentlyscreenedthe initial list of titles to exclude thosethat appeared irrelevant to the search.Abstracts for all potentially relevant titleswerescreenedby2 investigators (TC,CM)using a brief structured screening tool todetermine whether the article met theinclusion criteria, including (1) studydesign (systematic review, RCT, non-RCT,observationalstudy), (2)studytopic(WCCclinical practice redesign), (3) targetpopulation (aged 0–5 years), and (e)country (developed nation22). The thirdinvestigator (PC) reviewed abstractscreening results; disagreements wereresolved by consensus. Full-text articleswere obtained for accepted abstracts; 2investigators used a structured form toextract data on design, methods, out-comes, and findings. For RCTs, overallmethodologic quality was assessed us-ing the 5-point Jadad score, which eval-uates the quality of randomization,blinding, and description of withdrawalsand dropouts.23 Double-blinding is partof the criteria and accounts for 2 points;however, because double-blinding is notfeasible in most clinical practice re-design interventions, 3 out of 5 wasour maximum score. For observationalstudies and nonrandomized trials, weused a modified version of the Downsand Black checklist to assess overallmethodologic quality, focusing on exter-nal validity (3 items), bias (5 items),confounding (4 items), and power (1item).24 The maximum possible totalscore was 13 (1 point per item).

RESULTS

Our initial PubMed search yielded 2234titles (Fig 2). After 1959 titles were ex-

cluded because they were not relevantto WCC clinical practice redesign, 275titles remained for abstract screening.Of these, 233 abstracts did not meetinclusion criteria for reasons de-scribed in Fig 2; 42 abstracts went on tofull-text article data extraction. Twentyarticles were rejected because they didnot meet criteria for WCC clinicalpractice redesign. Eleven articles wereidentified through a reference searchof accepted articles. Thirty-three arti-cles were accepted; these included 13articles primarily on alternative for-mats for WCC,16,25–36 2 articles primarilyon nonclinical locations for WCC,37,38 17articles primarily on nonphysicians/non-NPs added to enhance WCC,17,39–54

and 1 miscellaneous article.55

Of 13 WCC format articles, 5 were onnon–face-to-face formats,25–28,36 and 8were on group visit formats.16,29–35 Ofthe 17 WCC provider articles, 13 arti-cles and 1 systematic review reportedon the Healthy Steps for Young Chil-dren Program (HS, which uses a de-velopmental specialist in WCC),17,39–51 2articles reported on a study usinga developmental specialist in anotherintervention,52,53 and 1 reported on useof a parent coach.54 The WCC locationarticles included 1 intervention ofhome WCC37 and 1 for preschool-basedWCC.38 The miscellaneous articlereported findings from an interventionthat included a social worker in visitsand so was placed in the providercategory. The RCT quality scores(Jadad) were 2 to 3 points; the obser-vational and non-RCT quality scores(modified Downs and Black) were 6 to12 points (Tables 1, 2, 3, 4, and 5).

Alternative Formats

Group Visits

We found 8 articles (Table 1) thatevaluated group WCC (GWCC). In GWCC,families are seen for a well-child visit ina group of 4 to 6 families with similarlyaged children. All but 1 study examined

GWCC for children from newbornthrough 12 to 15 months of age; 1 studyexamined GWCC for children up to age12. The group discussion section of theGWCC visit was often conducted by thephysician or NP and was preceded orfollowed by measurement, physicalexamination, and immunization of eachchild. The group visit took 60 to 90minutes, allowed parents to have moreprovider time, and maintained or in-creased the usual provider time perpatient.

Taylor and colleagues31–33 performedan RCT of GWCC among children at highrisk (eg, maternal poverty) and re-ported results in 3 publications. In-vestigators enrolled 220 mothers (111GWCC; 109 individual WCC [IWCC]).There were few statistically significantdifferences between the study arms inhealth care utilization, visit compli-ance, maternal outcomes (eg, stress),and child development. The authorsconcluded that GWCC was at least aseffective as IWCC in providing WCC tochildren aged 4 to 15 months. In acontrolled trial of GWCC with 50 fami-lies,16 investigators found few differ-ences in outcomes between the 2 studyarms, but a chart review showed thatintervention children had fewer illnessvisits between well-child visits thancontrol children (27 visits/10 controlpatients vs 5 visits/12 GWCC patients).These studies do not report an a prioripower analysis for all major outcomesand may not be sufficiently powered. Inanother controlled trial of GWCC (n =78), intervention parents were lesslikely to seek advice concerning theirchild between well-child visits (did notseek advice 89 vs 49 times, P , .05).29

The reason for this decrease in utiliza-tion is unclear; parents could have beenless likely to seek advice between visitsfor a number of reasons, rangingfrom more effective parent educationto weaker doctor-parent relationships.Dodds et al35 conducted an observational

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study comparing GWCC with IWCC andfound that more anticipatory guidancecontent was covered in GWCC comparedwith IWCC (eg, 69% vs 41% of behav-ioral/developmental content, P , .01).

Page et al34 interviewed mothers whoparticipated in GWCC to examine per-ceptions of the visit format. Partici-pating mothers highlighted severalbenefits of GWCC, including (1) supportfrom other women, (2) opportunities tomake developmental comparisonswith other infants, (3) the chance tolearn from other participants’ experi-

ences, (4) enhanced parental involve-ment in the visit, and (5) more timewith the provider. Saysana et al30 con-ducted a study of GWCC in a pediatricresidency continuity clinic, with a pri-mary objective of comparing learningexperiences for pediatric residentsparticipating in GWCC versus IWCC; theinvestigators also assessed visit satis-faction for the 7 families who partici-pated in GWCC. Parents were generallysatisfied with the visits, but no com-parison group was included forparents.

Non–Face-to-Face Formats

Two studies incorporated an Internet-based tool into WCC to deliver antici-patory guidance (Table 2). In Christakiset al,28 parents received a link to a web-based system, MyHealthyChild, beforetheir well-child visit. On the web site,parents could select age-appropriateand personally relevant topics to re-ceive more information on and to dis-cuss with their provider at the nextvisit. Providers could access parents’responses and scores on the previsitassessment to tailor the visit. An RCT

FIGURE 2Article selection.


TABLE1

Articleson

GroupWell-Child

Care

Firstauthor,year

Design,m

easurement,outcom

esMajor

findings

Page,20103

4Controlledtrial

Mothers

reported

thefollowingbenefitsfrom

groupvisits:

Enrolled:N=55

families

(13

intervention;42

comparison)

1.Supportfromotherwom

en

Intervention:GW

CCfacilitated

byphysician

2.Opportunities

tomakedevelopm

entalcom

parisons

with

otherinfants

Child

age:0–12

mo

Qualitativeinterviewsandchartreview

3.Learning

from

otherparticipants’experiences

Outcom

esincluded

4.Enhanced

parentalinvolvem

entinthevisit

•Parent

perspectives

onGW

CC5.Moretim

ewith

theprovider

inthevisit

•Health

care

utilizationandclinic

retentionat12

mo

Downs

&Blackscore(m

odified):8

Healthcare

utilization

GWCC

(n=11)

IWCC

(n=25)

EDvisits

7visits/11patients(0.64)


Hospitalizations

0hospitalizations

1hospitalization

Acuteam

bulatory

visits



Nostatisticaltestingwas

performed

onquantitativedata.

Saysana,2011

30Observationalstudy

Results

ofparent

survey:

N=7families

Twenty-eight

surveyswerecollected

from

the7intervention

families,nearlyalwaysansw

ering“agree”or

“stronglyagree”

for

(7intervention;no

comparisongroup)

Intervention:6scheduledgroup

well-childvisitsforfirstyear

ofinfant’slife

•Satisfactionwith

visits,

Child

age:1–12

mo

•Understandingofinform

ationshared

atvisits,

Six-itemparent

survey

aftereach

groupvisit

•Usefulness

ofinform

ationshared,

Outcom

e:parent

satisfaction

•Having

theirquestions

answ

ered,and

Downs

&Blackscore(m

odified):7

•Having

enough

timetoaskquestions

atvisits

ClusterRCT

Enrolled:N=27residents(9

intervention;18

control)

Resident

survey

Outcom

e:resident

learning

experience

(resultsnot

reported

here)

Downs

&Blackscore:N/A

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TABLE1

Continued

Firstauthor,year

Design,m

easurement,outcom

esMajor

findings

Taylor,1997,Taylor,1997a,

Taylor,19983

1RCT

Outcom

es(Taylor1997

33)

GWCC

(n=106)

IWCC

(n=104)

Pvalue

Enrolled:n=220families

(111

intervention;109control)

Visitcom

pliance

47%

54%

NSProvider

timeperpatient,m

inute,mean(SD)

19(7.1)

20(8.6)

NSIntervention:GW

CCvisits

Immunizations

up-to-dateat1y

67%

73%

NSED

visits,m

ean(SD)

1.12(1.98)

1.18(1.62)

NSChild

age:4–15

mo

Child

health

status

score,mean(SD)

92.4(1.4)

92.5(1.1)

NS

Parent

questionnaires,standardized

inventories,andchartreview

Outcom

es(Taylor1998)

GWCC

IWCC

Pvalue

Outcom

esincluded

thefollowing:

Maternalcom

petence(%

with

low-riskscore)

41/72(57%

)35/69(51%)

NS•Health

care

utilization

Maternalsocialisolation(%

with

low-riskscore)

48/71(68%

)61/80(76%

)NS

•Child

health

status

Maternalsocialsupport(%

with

low-riskscore)

56/75(75%

)66/83(80%

)NS

•Maternalcom

petence

Child

ProtectiveServices

referral

7/80

(9%)

7/84

(8%)

NS

•Maternalisolation

•Maternalsupport

Outcom

es(Taylor1997

32)

GWCC

(n=50)

IWCC

(n=50)

Pvalue

•CPSreferral

Bayley

motor

index,mean(SD)

103.6(11.5)

100.0(12.4)

NS•Infant

developm

ent(Bayley)

Bayley

mentalindex,m

ean(SD)

99.3(14.8)

100.4(14.3)

NS•Maternal-childinteractions

(NCATS)

NCATS,high

risk

(%)

10%

10%

NS•Homeenvironm

ent(HOM

E)HO

MEassessment,high

risk

(%)

4%16%

NSJadadscore:2

Rice,19971

6Controlledtrial(sequential

assignmenttointervention

versus

control)

Outcom

esGW

CC(n

=25)

IWCC

(n=25)

Pvalue

Know

ledgeofchild

health

anddevelopm

ent,

meanscore(SD)

5.08

(3.58)

3.24

(3.39)

NS

Enrolled:n=50

families

(25intervention;

25control)

Maternalsocialsupport,m

eanscore(SD)

0.28

(3.96)

0.48

(5.56)

NS

Intervention:GW

CCMaternaldepression,meanscore(SD)

2.00

(6.65)

4.38

(10.45)

NSChild

age:2–10

mo

Parent

questionnaires,standardized

instruments,and

chartreview

Outcom

esGW

CC(n

=12)

IWCC

(n=10)

Pvalue

Illness-related

office

visitsup

to4moofage

NRNR

NSOutcom

esincluded:

Illness-related

office

visitsfrom

4–6moofage

5visitsin12

patients

27visitsin10

patients

NR•Parent

know

ledgeofchild

health

and

developm

ent

•Maternalsocialsupport

•Depression

recovery

•Illness-related

visits

Downs

&Blackscore(m

odified):9


TABLE1

Continued

Firstauthor,year

Design,m

easurement,outcom

esMajor

findings

Dodds,1993


FormostAAP-recom

mendcategories,m

orecontentw

ascoveredinGW

CCversus

IWCC

visits

N=76

health

supervisionvisits(14

intervention;62

comparisongroup)

Percentofcontent

covered

GWCC

IWCC

Pvalue

Intervention:GW

CCSafety

51%

25%

,.01

Child

age:2and12

mo

Nutrition

59%

47%

,.01

14GW

CCvisitsobserved

62IWCC

visits

observed

Behavior

anddevelopm

ent

69%

41%

,.01

Family

andparentingissues

56%

15%

NSCodedvisitcontent

fortopiccategories

Sleep

72%

50%

,.01

Outcom

e:am

ount

ofcontentcovered

during

health

supervisionvisits

Toilet

100%

66%

NS

Downs

&Blackscore(m

odified):10

Osborn,19812

9Controlledstudy

Outcom

esGW

CCN=42

IWCC

N=36

Pvalue

Enrolled:N=78

families

(42intervention;

36control)

Cliniciantim

eperinfant,m

in,m

ean

1516

NSVisitcom

pliance,numberofvisits,m

ean

3.4

2.9

NSIntervention:3GW

CCvisitswithinfirst

6mooflife

Numberoftim

esillness

notreportedininfant

9755

,.001

Numberoftim

esmothers

sought

advice

betweenvisits

5454

NS

Numberoftim

esmothers

didnotseekadvice

betweenvisits

8949

,.05

Child

age:2wk–6mo

Contentanalysisofvisits:

Parent

questionnaires,parent

interviews,

andtape

recordings

Comparing

GWCC

tobaseline,moretim

ewas

spent

discussing

personalconcerns

intheinfant’sdaily

care

(28%

vs11%,P

,.005),andless

timewas

spentd

iscussing

medicalaspectsofcare

(23%

vs57%,P

,.002).Similar

results

werefoundcomparing

GWCC

totheIWCC

studyvisits;

moretim

espentd

iscussingpersonalconcerns

(28%

vs22%,

P,

.002)andless

timespentdiscussing

medicalaspects

(23%

vs43%,P

,.02)

Outcom

esincluded

thefollowing:

Processanalysisofvisits:

•Cliniciantim

espentp

erinfant

Comparedwith

baseline,providersinGW

CCvisitshada

decrease

indirectquestions

(10%

vs29%,P

,.001)and

reassurance(4%vs

10%,P

,.02)

butanincrease

inexplanations

(57%

vs28%,P

,.001).Comparedwith

IWCC

studyvisits,the

interventionvisitshadmoreindirectquestions

(11%

vs7%

,P,

.02),lessreassurance(4%vs

9%,P

,.02),

andfewer

directquestions

(10%

vs22%,P

,.001).

•Patient

visitcom

pliance

•Health

care

utilization

•Contentand

processofvisits

Downs

&Blackscore(m

odified):9

AAP,Am

erican

Academ

yofPediatrics;HOM

E,HomeObservationforMeasurementoftheEnvironm

ent;NCATS,NursingChild

AssessmentTeaching

Scale;NR

,not

reported;NS,notsignificant.

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TABLE2

Non–Face-to-FaceForm

ats

Firstauthor,year

Studydesign

Major

findings

Paradis,2011

27RCT

Enrolled:N=137families

(70intervention;67

control)

Nodifferences

inscores

onscales

forparent

competence,self-efficacy,orknow

ledgeofinfant

developm

ent.

Intervention:15-mineducationalDVD

foranticipatory

guidance

atnewborn

visit

Parentsincontrolgroup

had2.6tim

esgreaterodds

ofhaving

1additionaloffice

visitsbetweenthenewborn

and2-movisits(adjusted

odds

ratio

2.6,95%CI:1.3–5.5)

Child

age:#1–2mo

Parent

survey

andchartreview

Outcom

esincluded:

•Parent

know

ledgeofinfant

developm

ent

•Self-efficacy

with

infant

care

skills

•Problem-solving

competence

Jadadscore:3

Bergman,20092

5Observationalstudy

Outcom

esE-visit

E-visit+in-personvisit

Tailoredvisit

Families:N

=78

Parent

satisfactionwith

WCC

visit

80%

84%

80%

•E-visitonly(n

=10)

Parent

perceptionthatthemodelofcare:

•E-visitwith

briefprovidervisit(n=25)

•Extended

CSHCNvisit(n=15)

Tailoredvisit(n=28)a

Helped

them

toprepareforvisit

N/A

92%

94%

Providers:N=7

Intervention:modelforWCC

thatincludes

3visittypes

Helped

tothem

identifyimportanttopics

70%

84%

80%

Parent

andprovider

phonesurveys

Improved

efficiency

ofWCC

visit

90%

88%

80%

Outcom

esincluded

•Feasibilityofintervention

•Acceptance

ofintervention

Downs

&Blackscore(m

odified):6

Christakis,20062

8RCT

Discussion

ofpreventiontopics


•Allinterventiongroups

vscontrol:IRR(CI)1.07

(1.01–1.14)

Web

content+

provider

notification(n

=210)

•Content+

notificationgroupvs

control:IRR1.09

(1.00–1.20)

Web

contentonly(n

=238)

Implem

entationofpreventiontopics

Provider

notificationonly(n

=211)

•Allinterventiongroups

vscontrol:IRR1.04

(1.01–1.06)

Controlgroup

(n=228)

•Content+

notificationgroupvs

control:IRR1.07

(1.03–1.11)

Intervention:tailored,evidence-based

web

sitefor

preventiontopics

Child

age:0–11

yParent

interviewandhomevisitvalidationofpractices

Outcom

esincluded

•Numberofpreventiontopics

discussed

•Numberofpreventionpractices

adopted

Jadadscore:3


with 887 parents was conducted, dem-onstrating a modest increase in thenumber of topics discussed (8%–9%more topics discussed in interventionvisits; incidence rate ratio [IRR] 1.07,95% confidence interval [CI]: 1.01–1.14)and in the number of prevention-re-lated changes parents made in re-sponse (implemented 5%–7% moretopic suggestions; IRR 1.04, 95% CI:1.01–1.06). A similar tool was studied inSanghavi et al.26 An educational kioskprovided anticipatory guidance toparents in the waiting room before a 6-week and 4-month well-child visit. Thecontrolled trial showed greaterknowledge among intervention versuscontrol parents on prevention-relatedtopics (81% vs 61% of questions an-swered correctly, P = .01).

Bergman et al25 recognized that oneformat may not work for all families.This study examined a tailored WCCmodel in which the provider chose visittype on the basis of the family’s needs.Parents completed web-based de-velopmental and behavioral screeningbefore their visit. Sixty-three familiesreceived WCC in 1 of 3 ways: (1) elec-tronically (e-visit) with no in-personcontact with the provider, (2) as ane-visit paired with a brief in-office en-counter, or (3) as an expanded well-child visit for children with specialhealth care needs. Parents with eachvisit type were satisfied with their visitand reported that it was more efficientthan a usual visit. Parents with an e-visit only did not think that it should beused for all visits.

Two studies examined more “low-tech”formats to enhance anticipatory guid-ance in WCC. Kemp et al36 examineda parent phone advice line that pro-vided pre-recorded messages on 278topics related to preventive care, healthpromotion, behavior and development,and mild acute illness management. Of561 phone-system users, most reportedthat their use of the phone system hadTA

BLE2

Continued

Firstauthor,year

Studydesign

Major

findings

Sanghavi,20052

6Controlledtrial

Parent

know

ledgeofAG

topics

Intervention(N

=49)

Control(N=52)

Pvalue

N=101families

(49intervention;52

control)

Perfectscore

oronly1questionwrong

35%

2%,.001

Intervention:interactive,self-guided

educationalkiosk

for

anticipatoryguidance

Average%ofquestions

correct

81%

61%

.01

Child

age:6wkand4mo

Parent

questionnaire

Outcom

e:parent

know

ledgeofAG

topics

Downs

&Blackscore(m

odified):12

Kempe,19993

6Observationalstudy

Audiotaped

survey

ofusers

N=561audiotaped

survey

users

PALmadeacalltophysicianunnecessary:69%

PALmadeavisittophysicianunnecessary:70%

N=137telephonesurvey

users/nonusers

(44users;93

nonusers)

PALansw

ered

theirquestion:87%

WouldusePALagain:98%

Intervention:Parent

Advice

Line

(PAL),collectionof278health-

relatedmessagesaccessibleby

phone

Telephonesurvey

ofrandom

sampleofusers(n

=44)

Satisfactionwith

PAL:86%

Child

age:,12

yAudiotaped

survey

andtelephonesurvey

Outcom

esincluded

•UtilizationofPAL

•User

satisfaction

•Effecton

health-seeking

behavior

Downs

&Blackscore(m

odified):8

aAllparticipantscompleted

theweb-based

preassessm

enttool;participantsinthetailoredvisitgrouphadaregularvisittailoredtotheirresponses.AG,anticipatoryguidance.

SUPPLEMENT ARTICLE


TABLE3

AlternativeLocations

ofCare

Firstauthor,year

StudyDesign

Major

Findings

Gance-Cleveland,2005


The2groups

ofparentswerenotdem

ographicallysimilarandno

adjustmentsweremadeintheanalysis.Parentswithoutaccesstothe

PBHC

weremorelikelytoreceivepublicassistance,haveachild

onthefree/reduced

lunchprogram,haveasingleparenthousehold,and

have

lower

educationalgoalsfortheirchild.

N=261families

130families

from

preschoolw

ithPBHC

131families

from

preschoolw

ithoutP

BHC

Intervention:PBHC

programthatincluded

WCC,m

inor

acutecare,immunizations,m

entalhealth

services,

andassistance

with

enrolling

inlow-costinsurance

Thestudyfound

nosignificantdifferencesinparent-reportedhealthproblemsb

etweenthe2groups,butdidfind

thatthePBHC

childrenhad

fewer

parent-reportedbehavioralproblemsinschool.

Child

age:3–5y

Othersignificant

findings

(PBH

Cvs

comparisongroup):

Parent

survey

•Access

tocare

(97%

vs89%,P

,.001)

Outcom

esincluded

thefollowing:

•No

problemsgettingcare

forchild

(64%

vs50%,P

=.019)

•Obtaininghealthcare

services

•No

problemsgettingimmunizations

(92%

vs82%,P

=.005)

•Satisfactionwith

care

(resultsnotreportedhere)

•No

problemsgettingphysicalhealth

services

(84%

vs79%,P

=.045)

•Parent-perceived

child

health

problems

Downs

&Blackscore(m

odified):6

Christ,20073

7Controlledtriala

Outcom

esIntervention%

Control%

Pvalue

Maternalsatisfactionwith


(150

intervention;480control)

•Convenienceofvisit

9161

,.05

•Caring

attitudeofprovider

9375

,.05

Intervention:homevisitfor

2-wkwell-babyvisit

•Timespentw

ithprovider

8664

,.05

•Skills/abilitiesofprovider

9073

,.05

Child

age:2wk;assessmentat4–6wk

•Preventiveadvice

given

8565

,.05

•Overallcaresincebirth

8673

NSParent

telephonequestionnaire

Preference

forclinicover

homevisit

648

,.05

Anticipatoryguidance

givenon

Outcom

esincluded

thefollowing:

•Sleepposition

9669

,.05

•Maternalsatisfaction

•Comfortingbaby

8555

,.05

•Quality

ofanticipatoryguidance

•Howto

geth

elpforthebaby

9772

,.05

•Health

care

utilization

•Baby’sweight

9995

NSExclusivebreastfeeding

4738

NS

Utilizationoutcom

esInterventionno.

Controlno.

Pvalue

Downs

&Blackscore(m

odified):9

Contactedadvice

lines

00

NSAcutecare

visitstoED

orclinic

11

NS

NS,not

significant;PBH

C,preschool-based

health

center.

aThestudywas

likelyunderpow

ered

todetectdifferences

betweenthe2groups;the

authorsprovided

apower

analysisestim

ationof500patientsperstudyarm.


made a subsequent call (69%) or re-lated visit (70%) to their doctor un-necessary. Paradis et al27 conducted anRCT of an anticipatory guidance DVDshown to 70 parents at the newbornvisit. Scores on parent knowledge, self-efficacy, and competency measured af-ter 2 weeks were similar between the 2

groups; however, intervention parentswere less likely to have a sick visit orother problem-related visit outside ofscheduled WCC visits (39% vs 63%, P =.01). It is not clear whether this de-creased utilization was related to a re-duced need (eg, improved parentknowledge) or unmet need.

Nonclinical Locations

Two studies examined WCC redesign intermsof locationof care (Table 3). Otherstudies that we reviewed incorporatedhome visits into their WCC model (ie,HS); however, only 1 study used homevisits as its primary location for WCC.There is a large literature on home

TABLE 4 Other Providers Added to the Well-Child Visit

First author, year Study Design Major Findings

Farber, 200954 Observational study Parent outcomes Interventionmean (SD)

Comparisonmean (SD)

P value

N = 80 families Total basic needs score (n = 65) 52.4 (7.8) 44.9 (9.0) .001(50 intervention; 30 comparison) 28.0 (3.4) 20.2 (7.2) ,.001

28.8 (5.0) 25.5 (5.8) .025Intervention: parent mentoring witha parent coach to strengthenanticipatory guidance

Total needs and resources scorea 117.8 (15.9) 96.1 (20.3) ,.001Total knowledge of nurturing practices

and childrearing beliefsa (n = 65)0.63 (0.76) 1.50 (1.10) .001

Total resilience score (n = 58) 108.5 (11.0) 101.2 (11.2) .026

Child age: newborn–18 moStandardized inventories and instruments,and chart review

Child Outcomes Interventionmean (SD)

Comparisonmean (SD)

P value

Expressive vocabulary, mean (n = 40) 83 (9.6) 73 (12.2) .01Receptive vocabulary, mean (n = 40) 89 (11.6) 79 (12.5) .02

Parent outcomes:• Adequacy of family needs and

resources• Parent knowledge of nurturingpractices and childrearing beliefs

• Personal resilienceChild outcomes:• Immunizations• Developmental milestones• Emerging language competency

Downs & Black score (modified): 6

Mendelsohn, 2005,52

200753RCT Outcomes at 21 mo (Mendelsohn 2005) ANOVA, F statistic P value

Enrolled: n = 150 families (77 intervention;73 control)

Cognitive development (MDI) F = 5.4 (n = 93) .02

Intervention: an approach to WCC thatadds a child developmental specialistto the regular well visit from age2 wk to 3 y

Language development (expressive) F = 2.0 (n = 91) .16Language development (receptive) F = 1.2 (n = 91) .27

Child age: 2 wk–33 mo; assessmentsat 6, 9, 21, 33 mo

Outcomes at 33 mo (Mendelsohn 2007) Intervention(N = 51)

Control (N = 46) P value

Standardized inventories and instruments,and video recording

Parenting stress (PSI), % in clinicalrange

39 59 .09

Parent-child dysfunction subscale, % inclinical range

37 48 .40

Outcomes included: Difficult child subscale, % in clinicalrange

29 28 1.0

• Maternal depression (CES-D) Maternal depression, % in clinical range 19 26 .61• Parenting stress (PSI) and subscales Cognitive MDI score, % normal 64 44 .048• Child cognitive development (MDI) Language PLS-3 score, % normal 31 36 .69• Language development (PLS-3) Behavior CBCL score, % in clinical range 8 17 .16• Child behavior (CBCL) Jadad score: 2

SUPPLEMENT ARTICLE


visitation to improve health and well-being for families with young children;this literature is reviewed elsewhere.56–60

We focus on studies that examined homevisits explicitly to deliver WCC.

Christ et al37 conducted a controlledtrial of home WCC among militaryfamilies for the 2-week well-child visit.Home visits lasted 60 to 90 minutes,were provided by an NP, and includedall typical WCC services. The inves-tigators compared 480 usual careclinic visits to 150 home visits andfound that maternal perceptions ofvisit quality was higher for home visits(satisfaction with preventive advicegiven was 85% vs 65%, P , .05), butthey found no differences in acute careutilization.

Gance-Cleveland et al38 compared par-ent-reported child health status, ac-cess to care, perceptions of care, andhealth care utilization for 261 childrenaged 3 to 5 years at 2 preschools, 1 withand 1 without access to a preschool-based health center that provided WCC.The preschoolers with health centeraccess were less likely to have behav-ioral problems in school (P = .01, esti-mates not reported), problems getting

care (64% vs 50%, P = .02), and un-necessary emergency department (ED)visits (12% vs 22%, P, .001) reportedby parents. However, there were sig-nificant differences in respondents’demographics, suggesting that the 2schools were not adequately matchedon socioeconomics. Parents of childrenfrom the preschool without healthcenter access were more likely to re-ceive public assistance (P = .003, pointestimates not reported), to use the freeor reduced lunch program (P , .001),to have a single-parent household(P value not reported), and to reportlower educational goals for their chil-dren (P value not reported).

Nonphysician Providers

Studies of 3 interventions examined theuse of additional providers to enhanceWCC. Thefirst of these interventions, HS,is a program in which a physician andchild developmental specialist (typi-cally a nurse, social worker, or earlychildhood educator61) provide WCC inpartnership. The program includeswell-child visits conducted jointly orconsecutively by the physician and HSspecialist (HSS), as well as other

services offered by the HSS, including 6home visits during the first 3 years oflife, a child development telephone in-formation line, written information onprevention, and monthly parent groupsessions. In 2009, Piotrowski et alpublished a systematic review of theliterature evaluating HS.51 There were13 articles included in this review, from1999 to 2007; we have summarizedthem in Table 5. Among the 13 articles,8 analyzed data from a large, national3-year prospective, randomized con-trolled and quasi-experimental trial at15 US sites that evaluated the programwith 5565 newborns.17,39,40,45–49 Threearticles report data from an extensionstudy at a large integrated healthmaintenance organization,41–43 and 2report findings from residency conti-nuity clinics that implemented HS aspart of the national program.44,50

Chart review and parent interview atchild age 30 to 33 months revealed thatintervention children were more likelyto have timely well-child visits (eg, 12-month visit 90% vs 81%, P , .001), beup-to-date on vaccinations at 24months (83% vs 75%, P, .001), remainat the practice for$20 months (70% vs

TABLE 4 Continued

First author, year Study Design Major Findings

O’Sullivan, 199255 RCT Outcomes at 18 mo Intervention % Control % P value

N = 243 teen mothers (120 intervention;123 control)

Visit attendance for well-baby visits 40 18 .002

Intervention: physician/nurse practitioneralternating WCC visits; social workerat 2-wk visit; waiting-room healtheducation by NP and trained volunteers usingvideo and slides

Repeat pregnancies 12 27 .003Return to school 56 55 NSInfant fully immunized 33 18 .011At least 1 ED visit for infant care 76 85 NS

Child age: newborn to 18 moParent interview, chart review, and school

attendanceOutcomes:

• Repeat pregnancy rate• Mother returning to school• Immunization status• ED visits

Jadad score: 2

ANOVA, analysis of variance; CBCL, Child Behavior Checklist, CBCL, Child Behavior Checklist; CES-D, Center for Epidemiological Studies-Depression Scale; MDI, Bayley Scales of InfantDevelopment, 2nd Edition, Mental Development Index; PLS-3, Preschool Language Scale -3; PSI, Parenting Stress Index.a Higher scores on this scale indicate parenting difficulties.


TABLE5

HealthyStepsArticlesIncluded

inPiotrowskiet

alReview

FirstAuthor,Year

Design,Outcomes

Findings

Minkovitz,20014

7 ;Minkovitz,20031

7 ;Minkovitz,20074

9

Controlledtrial

Adjusted

odds

ratio

(95%

CI)

Child

age

Articlefirst

author,yr

6RCTsites(n

=1987)

9quasi-experimentalsites(n

=2909)

Quality

ofcare

outcom

esParent

questionnaire

atenrollm

ent

Patient-centeredness

•Providers’helpfulness

2.09

(1.80–2.43)

30mo

Minkovitz,03

Phoneinterviewatinfant

age2–4mo

•Dissatisfied

with

provider

support

0.37

(0.30–0.46)

30mo

Minkovitz,03

•Dissatisfied

with

provider

listening

0.67

(0.53–0.84)

30mo

Minkovitz,03

Phoneinterviewatchild

age30–33

mo

•Dissatisfied

with

provider

respect

0.79

(0.63–1.00)

30mo

Minkovitz,03

6RCTsites(n

=1593)

Uptodatewith

immunizations

at24

mo

1.59

(1.27–1.98)

30mo

Minkovitz,03


=2144)

Had24

moWCV

1.68

(1.35–2.09)

30mo

Minkovitz,03

Haddevelopm

entalassessm

ent

8.00

(6.69–9.56)

30mo

Minkovitz,03

Phoneinterviewatchild

age5.5y

Discussed5of6AG

topics

at2mo,.7of10

AGtopics

at30

mo,or

.4of6

AGtopics

at5y

2.41

(2.10–2.75)

2mo

Minkovitz,01

10.36(8.5–12.6)

30mo

Minkovitz,03

1.33

(1.13–1.56)

5y

Minkovitz,07

6RCTsites(n

=1724)

Compositemeasure

-clinicianprovides

supportfor

parent

2.33

(1.82–3.03)

2mo

Minkovitz,01


=1441)

2.70

(2.17–3.45)

30mo

Minkovitz,03

1.25

(1.02–1.53)

5y

Minkovitz,07

Outcom

es:

•Remainedatpractice

1.82

(1.57–2.12)

30mo

Minkovitz,03

•Receiptofinterventionservices

(results

notreportedhere)

1.19

(1.01–1.39)

5y

Minkovitz,07

•Hospitalizations

inpastyear

1.14

(0.84–1.54)

30mo

Minkovitz,03

•Parentingpractices

0.90

(0.57–1.42)

5y

Minkovitz,07

•Perceptions

ofcare

•ED

useinpastyear

1.03

(0.89–1.20)

30mo

Minkovitz,03

•Quality

ofcare

•ED

useinpastyear,injury-related

0.77

(0.61–0.97)

30mo

Minkovitz,03

•Child

behavior

1.00

(0.83–1.20)

5y

Minkovitz,07

Downs

&Blackscore(m

odified):12

Discipline

•Ever

slap

face

orspankwith

object

0.73

(0.55–0.97)

30mo

Minkovitz,03

0.68

(0.54–0.86)

5y

Minkovitz,07

•Useharshdiscipline

0.78

(0.62–0.99)

30mo

Minkovitz,03

0.98

(0.74–1.30)

5y

Minkovitz,08

•Usenegotiation

1.16

(1.01–1.34)

30mo

Minkovitz,03

1.20

(1.03–1.39)

5y

Minkovitz,07

•Ignore

misbehavior

1.38

(1.10–1.73)

30mo

Minkovitz,03

1.24

(0.97–1.59)

5y

Minkovitz.07

Parent

perceptionofchild

behavior

and

developm

ent

•Parent

concernforbehavior

1.26

(1.01–1.57)

30mo

Minkovitz,03

1.35

(1.10–1.64)

5y

Minkovitz.07

Aggressive

behavior

0.40

(0.06–0.75)

30mo

Minkovitz,03

Anxiousor

depressed

0.19

(–0.004–0.38)

30mo

Minkovitz,03

Problemssleeping

0.20

(0.03–0.36)

30mo

Minkovitz,03

Parentingpractices

•Followsroutines

1.00

(0.88–1.13

2mo

Minkovitz,01

1.03

(0.88–1.20)

30mo

Minkovitz,03

1.02

(0.82–1.26)

5y

Minkovitz,07

SUPPLEMENT ARTICLE


TABLE5

Continued

FirstAuthor,Year

Design,Outcomes

Findings

•Depressedparent

discussedsadness

with

someone

inpractice

1.60

(1.09–2.36)

30mo

Minkovitz,03

•Parent

andchild

book

sharing

1.22

(1.07–1.40)

2mo

Minkovitz,01

0.96

(0.82–1.12)

30mo

Minkovitz,03

1.16

(1.00–1.35)

5y

Minkovitz,07

•Lowered

water

tempon

water

heater

1.03

(0.89–1.20)

30mo

Minkovitz,03

•Uses

covers

onoutlets

1.17

(0.92–1.48)

30mo

Minkovitz,03

•Uses

safetylatcheson

cabinets

1.09

(0.86–1.39)

30mo

Minkovitz,03

Caughy,2003;40Caughy,20043

9Observationalstudy

of2HS

random

ized

sites

Caughv

2003

Parent

discipline

N=378families

at16-to17-mohome

observation(217

intervention,161control)

•Interventionparentsweremorelikelytouseinductive/authoritativedisciplinestrategies

comparedwith

control

groupparentsat16

mo;at34

mo,therewas

nodifferencebetweenthe2groups.There

was

nodifferencebetween

groups

ateither

16or

34moon

theuseofpunitivestrategies.

N=233families

at34-to37-mohome

observation(34intervention,99

control)

•Interventionvs

controlm

eanscores

(SD)

forinductive/authoritative:0.10

(0.07)

vs–0.12

(0.08)

at16

mo,P,

.05

Child

age:birthto37

mo

Caughv

2004

Parent

outcom

esIn-hom

eobservationandparent

interview

•Nodifferences

inparentoutcom

esbetweeninterventionandcontrolat16mo.At34

mo,interventiongroupparents

weremorelikelyto

interactsensitivelyandappropriatelywith

theirchild

comparedwith

controlparents.

Parentingoutcom

esChild

outcom

es•S

ensitiveparent-childinteraction-NursingChild

Assessment

bySatelliteTraining

Nodifferences

inchild

outcom

eat16

or34

mobetweeninterventionandcontrol.

•AppropriateParent

Interaction-Parent/Caregiver

Involvem

entS

cale(P/CIS)

•Optim

alhomeenvironm

ent—

Home

ObservationforMeasurementofthe

Environm

entInventory

Child

outcom

es•Child

attachment—

AttachmentQ-Sort

•Problembehaviors—

Child

Behavior

Checklist

•Self-regulation—

ToyCleanUp

Task

Disciplineoutcom

es•Inductive/authoritativedisciplinestrategies

(eg,tim

eouts)vs

punitivediscipline

strategies

(eg,spanking)—

Parental

ResponsestoChild

Misbehavior

Downs

&Blackscore(m

odified):11

Huebner,2004,41;Johnston,

2004

43;Johnston,2006

42Quasi-experimentalcom

parison

Outcom

eAdjusted

rateratio

(95%

CI)

Enrolled:N=439wom

en(301

intervention;

136comparison)

Child

Health

andDevelopm

ent(Johnston

2006)

Integrated

deliverysystem

24-mowell-visitattendance

1.09(0.97–1.22)

Threeinterventionclinics

Immunizationup

todateat24

mo

1.06

(1.02–1.09)

Twocomparisonclinics

Language

developm

ent

Intervention:HS

+prenatalcomponent

orHS

alone

•Combines2words

at24

mo

1.02

(0.94–1.12)


TABLE5

Continued

FirstAuthor,Year

Design,Outcomes

Findings

Child

age:0–30

mo

•Two-wordendings,$3vs

,3

1.10

(0.82–1.50)

Parent

survey

at3moand30

mo

MaternalD

epression

Outcom

es•Clinicallysignificant

symptom

s1.21

(0.80–1.82)

•At3mo-

•Discussedsadnesswith

provider

1.45

(0.95–2.21)

•Parentalknow

ledgeofdevelopm

ent

Breastfeedingduration.6mo

1.18

(1.11–1.26)

•Parentingpractices

ParentingPractices

•Parentalsatisfactionwith

quality

ofprovider

Readswith

child

1.03

(0.96–1.10)

•At30

mo-

Playswith

child

1.01

(0.99–1.02)

•Child

health

anddevelopm

ent

TVview

ing.1h/d

0.75

(0.62–0.90)

Child

behavioralproblems

Follows3routines

1.12

(1.03–1.22)

•Nurturingparentingstyle

Injury

preventionindex(5

vs,5score)

1.19

(1.09–1.28)

•Parentingself-efficacy

Spanking

with

object/slappinginface

0.46

(0.29–0.73)

•Health

care

self-efficacy

Continuous

outcom

es(Johnston2006)

Adjusted

linear

coefficient(95%

CI)

Maternaldepressivesymptom

sChild

behavior

problems

ParentingPractices

•Aggressive

behavior

score,continuous

0.83

(0.37to1.30)

Downs

&Blackscore(m

odified):12

•Sleepproblemsscore,continuous

0.09

(20.29

to0.48)

•Anxiousor

depressedmoodscore,

continuous

0.03

(20.44

to0.50)

Parentingcompetencescore,continuous

20.92

(21.40

to20.44)

Health

care

self-efficacy

score,continuous

0.04

(20.28

to0.36)

Parentingnurturingscale,continuous

20.06

(20.42

to0.31)

Outcom

e(Johnston2004)

Adjusted

rateratio

(95%

CI)or

linearregression

coefficient

(95%

CI)whenindicated

Parentalknow

ledge

•ofinfant

developm

ent,linearregression

0.02

(0.00–

0.03)

•ofsafesleeppositions

1.01

(0.98–1.04)

•ofappropriatediscipline

1.08

(1.04–1.11)

Parentingpractices

•Homesafetyscore,linearregression

0.10

(0.02–

0.17)

•Breastfeedingat

3mo

1.14

(1.09–1.20)

•Tobacco-free

home

0.97

(0.94–0.99)

•Safesleep

1.02

(0.98–1.05)

•Readingwith

child

1.12

(1.04–1.22)

Minkovitz,2003a

Clinicianperspectives

Interventiongroupproviders

odds

ratio

(95%

CI)

30-movs

baseline

Cross-sectionalsurvey

Practicebarriers

N=118clinicians

atbaseline(80intervention

surveys,70

controlsurveys)

•Limitedstafftoaddressneedsoffamilies

0.43

(0.08–2.40)

•Problemswith

reimbursem

ent

1.86

(0.76–4.53)

•Inadequatetim

ewith

families

1.87

(0.76–4.56)

SUPPLEMENT ARTICLE


TABLE5

Continued

FirstAuthor,Year

Design,Outcomes

Findings

N=99

clinicians

at30-mofollow-up(69

interventionsurveys,70

controlsurveys)

Discussedfamily

psychosocialrisk

factors

0.64

(0.33–1.25)

Child

age:birth-3y

Satisfied

with

abilityofclinicalstafftomeetneedsoffamilies

4.05

(1.15–14.2)

Provider

andstaffsurveys

Perceptions

ofHSS

Outcom

esincluded

thefollowing:

•Talkstoparentsaboutchildbehavior/development

7.58

(2.08–27.67)

•Perspectives

onHSS

•Showsparentsactivities

andgivesinform

ationaboutw

hatto

dowith

theirchild

5.85

(1.89–18.09)

•Perspectives

onHS

program

•Provides

parentswith

support,helpswith

stress,

andrefers

forparent

emotionalproblem

s

5.84

(1.80–19.01)

Results

show

nareforquasi-experimentalgroup

only;changes

from

baselineto30

mo

•Discussestemperamentand/orsleepproblems

5.64

(1.40–22.68)

Downs

&Blackscore:N/Aa

Kizner,20044

4Observationalstudy

Resident

perceptions

ofHSS(N

=29

residents)

N=37

residents(37intervention;no

comparison)

•69%:HSS

assisted

with

resident

learning

ofanticipatoryguidance

Child

age:birthto3y

•69%:HSS

facilitated

resident

know

ledgeofcommon

responsesto

behavioralanddevelopm

entalconcerns

Survey

ofresident

physicians

involved

with

JS•69%:HSS

helped

patientsreceiveinform

ationefficiently

Outcom

esincluded:

•62%:HSS

didnotinterferewith

resident-parentrelationship

•Perceptions

ofHSS

•66%:Enjoyed

working

with

theHSS

•PerceptionofHS

program

•76%:W

ouldconsider

usingHSSintheirfuture

practice

Downs

&Blackscore:N/Aa

•35%:HSS

improved

clinicefficiency

Resident

perceptions

ofHealthyStepsProgram(N

=29

residents)

•90%:HSdidnoth

elpimproveresident

know

ledgeoffamily

violence

•97%:HSdidnoth

elpimproveresident

awarenessofmentalillness

•69%:HSdidnoth

elptheresident

establishcommunity

contactsandreferrals

Niederman,20075

0Controlledtrial

Interventionchildrenhadgreatercontinuityofcare

forwell-childvisitscomparedwith

controlchildren(52%

vs28%with

scores

indicatingexcellentcontinuity).Thiswas

measuredforinterventionandcontrolgroup

childrenat1site(n=263)

usingtheContinuityofCare

IndexofBice

andBoxerm

an.The

scoreis0to1,with

0indicatingthatallvisits

weremade

with

different

providersand1indicatingthatallvisits

weremadewith

1provider.

N=363children(71intervention,292control)

Child

age:birthto3y

Chartreview

Outcom

esincluded

thefollowing:

Therewereno

statisticallysignificant

differences

betweeninterventionandcontrolchildrenfor

•Continuityofcare

•longitudinalityofcare

•Longitudinalcare

•quality

ofcare

(immunizations,anemiaandlead

screening)

•Quality

ofcare

•behavioral,developmental,or

psychosocialdiagnoses

•Ratesofdiagnoses

Downs

&Blackscore(m

odified):9

McLearn,20044

5Cross-sectionalsurveyofclinicians

(physiciansandNPs)at20

HSprogramsites

Does

notcom

pareinterventionversus

controlclinicians;com

paresclinicianperceptions

byincomelevelofpatientsserved

N=104clinicians

atbaseline

N=120clinicians

at30

mo

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e:perspectives

onHS

program


57% P , .001), have better parent re-port of 4 family-centeredness of caremeasures (eg, disagreed that clinicianlistened to parent; 10% vs 14%, P ,.001), and have discussed more than 6anticipatory topics during their visits(87% vs 43%, P, .001). There were nostatistically significant differences inhospitalizations or ED use in general,but intervention children did havea slightly decreased odds of an ED visitfor an injury-related cause (9% vs 11%,adjusted odds ratio [AOR] 0.77, 95% CI:0.61–0.97).17

Intervention parents were less likely toreport using harsh discipline (9% vs12%, P = .006) and slapping their childin the face or spanking them with anobject (6% vs 8%, P = .01), and weremore likely to report ignoring mis-behavior (13% vs 9%, P = .003). In-tervention parents scored slightlyhigher than control parents on a scalefor child aggressive behavior andsleeping problems (difference of meanscores, AOR 0.40, 95% CI: 0.06–0.75; AOR0.20, 95% CI: 0.03–0.36). There were nostatistically significant differences inparental practices of reading or play-ing with the child, following daily rou-tines, or child safety practices. Of thoseparents at risk for depression, in-tervention parents were more likely toreport discussing sadness with theirprovider (24% vs 14% P , .001).3

At child age 5.5 years, 2 years afterstudy completion, 57% of parentscompleted another interview, and someof thesepositivefindingsweremodestlysustained. Intervention families wereless likely to slap or spank their childwith an object (10% vs 14%, P , .001)and more likely to use negotiation asa discipline strategy (60% vs 56%, P,.05), book sharing with their child (59%vs 54%, P , .001), and recommendedcar restraints (43% vs 47% did not usea booster seat, P = .01). There were nodifferences between the 2 groups inchild health status, developmental

concerns, perceived social skills, fol-lowing daily routines, hospitalizations,or ED use.49

Studies also reported clinician per-ceptions of HS. Overall, clinicians weresatisfied with the program andwith therole of the HSS with parents.48

Mendelsohn et al52,53 conducted a 3-year RCT of another intervention thatadded a developmental specialist en-counter to each visit. The level oftraining for the specialists is not de-lineated in the article, but the studydoes reference HSS. Children in theintervention group had twelve 30- to 45-minute developmental specialist ses-sions from 2 weeks to 3 years of age.Visits focused on child developmentand included discussion of a video re-cording of the parent and child en-gaging in an activity. Investigatorsenrolled 150 Latina mothers withouta high school degree and found that at33 months, intervention children weremore likely to have normal cognitivedevelopment scores (64% vs 44%, P,.05), but there were no differences at33 months for language development,behavioral problems, or eligibility forearly intervention.

The third study, by Farber et al,54 ex-amined an intervention of parentcoaches to strengthen anticipatoryguidance for 50 Latino and AfricanAmerican families in Washington, DC.Parent coaches were not medical pro-fessionals but had a college degreein early child development. Parentcoaches met with families at clinicvisits from the newborn through 18-month visit. Compared with the 30comparison parents, 35 interventionparents had better scores on scales forparenting practices and adequacy offamily resources, but no differenceswere detected in child immunization ordevelopmental status. Interventionchildren performed better than thecomparison group on vocabularyachievement scores for receptiveTA

BLE5

Continued

FirstAuthor,Year

Design,Outcomes

Findings

Downs

&Blackscore:N/A

McLearn,20044

6Observationalstudy

Does

notcom

pareinterventionversus

controlfam

ilies;com

paresoutcom

esforinterventiongroupfamilies

byincomelevel

N=1910

families

(1910families;nocomparison)

Child

age:1–33

mo;assessmentsat2–3and30–33

mo

Parent

survey

Outcom

es:

•Quality

ofcare

•Parent

experiencesandsatisfactionwith

care

Downs

&Blackscore:N/Aa

AG,anticipatoryguidance;W

CV,w

ell-childvisit.

aDowns

andBlackchecklistwas

onlyused

forstudiesthat

reported

parent

orchild

outcom

esandincluded

aninterventionandcomparisongroup.

SUPPLEMENT ARTICLE


(mean score 89 [SD 11.6] vs 79 [12.5],P = .02) and expressive language (83[9.6] vs 73[12.2]).

O’Sullivan et al55 reported findingsfrom an RCT of an intervention of en-hanced WCC for adolescent mothers.Although the study did not fit well intoour 3 WCC clinical practice redesigncategories, it used social workers asan additional provider forWCC (Table 4).A social worker was included at the2-week visit to discuss baby care andfamily planning; at each well-child visitthrough 18 months, mothers receivedteaching on infant care and mild acuteillness management in the waitingroom. At the end of the study, in-tervention mothers (n = 120) weremore likely to still be attending well-child visits compared with controlmothers (n = 123; 40% vs 18%, P, .05),but the dropout rate in both groupswas high. Using an intention-to-treatanalysis, intervention group childrenwere more likely to be fully immunizedat 18 months (33% vs 18%, P = .01);there was no statistically significantdifference in the proportion of childrenin each group with $1 ED visit.

DISCUSSION

This is the first published, peer-reviewed systematic review of WCCclinical practice redesign. We foundevidence suggesting improved effec-tiveness and efficiency for WCC deliveryusing group formats for visits, non–face-to-face formats for anticipatoryguidance, and non–medical profes-sional providers for anticipatory guid-ance and developmental and behavioralservices. Studies suggest that thesestrategies may potentially have an im-pact on parents’ experiences with care,parenting skills and knowledge, andhealth care utilization.

Evidence for GWCC suggests that it maybe at least as effective in providing careas IWCC. Studies demonstrated effi-ciency for GWCC; parents had longer

visits with more content, but providertime per patient was not increased.LongerWCC visits have been associatedwith more anticipatory guidance, fam-ily-centered care, and parent satisfac-tion.62 Group visits may be led by non–medical professionals, allowing foreven more efficient use of physiciantime.63 In the GWCC studies, a physicianor NP moderated the group discussion.More studies may be necessary to de-termine whether these findings arereplicated in GWCC when the facilitatoris not a medical professional.

Evidence for web-based tools for an-ticipatory guidancewas limited; 2 trialsdemonstrated improvements in parentknowledge, discussion, and action onanticipatory guidance topics. Lack ofInternet access may be a barrier insome populations; however, the digitaldivide may be narrowing as more low-income families are gaining access tothe Internet.64

The large HS trial demonstrated im-portant, although somewhat modest,improvements in receipt of WCC serv-ices, positive parenting practices, andparent experiences with care. Despitethis, its adoption has been limited. In2010, only 50 sites nationwide wereusing HS. The median annual programcost of $65 500 has proved to be thegreatest barrier to adopting and sus-taining the program in communitypractices.65

Another consideration is whether thestudies’ findings justify the costs ofimplementing these clinical practiceredesign tools and strategies. Theseinclude financial costs as well the op-portunity costs of time, personnel, andeffort in implementing these changescompared with other practice im-provements that do not alter thestructure of care. Break-even analysesand cost-effectiveness analyses mayhelp practices with these decisions.

Most interventions, except for GWCC,were designed as an enhancement,

rather than a replacement, for whattakes place in usual care. Web-basedtools provided additional anticipatoryguidance and a way to tailor anticipa-tory guidance during the visit but didnot replace anticipatory guidance in thevisit. In HS, parents spend between 15and 30 minutes with an HSS at eachvisit,61 with physician time being re-duced from 18 to 12 minutes.65 For WCCclinical practice redesign to be sus-tainable, interventions may need todemonstrate greater efficiencies inphysician/NP time per patient.

Parent knowledge of mild acute illnessmanagement is a desirable outcome ofanticipatory guidance and can reduceunnecessary clinical contacts betweenscheduled well-child visits. Reducedutilization for acute care was noted inseveral studies; however, other reasonsfor decreased utilization (eg, poor pa-tient-doctor relationship; perceivedpoor access) cannot be excluded insome of these studies.

There are several limitations to con-sider. We limited our review to peer-reviewed publications on WCC clinicalpractice redesign for children aged0 to 5; however, there are redesigntools that are not in the peer-reviewedliterature or that have been describedbut not implemented or evaluated.14,18

Some have been used outside of WCCthat might be applicable to child pre-ventive care,66–74 and some that arenot practice-based could be adaptedfor use in a practice setting.75,76 Weomitted tools that did not alter thedelivery of WCC services (eg, handheldpatient records)77,78 and tools thatfocused on clinical practice redesignfor only 1 WCC topic; these toolsshould be considered in other re-views. Criteria for defining clinicalpractice redesign were somewhatstringent and limited the number ofarticles included. A review with a dif-ferent set of criteria or fewer criteriafor article inclusion could be helpful


in giving pediatric practices a broaderrange of options for clinical practiceimprovements.

Because of the heterogeneity of inter-ventions and outcomes measured,ameta-analysiswas not possible. Studydesign heterogeneity precluded use ofa single quality assessment tool for allstudies; however, we used the Jadadscale for RCTs and a modified Downsand Black checklist for non-RCTs andobservational studies. There is thepossibility of publication bias in whichstudies of interventions with negativeresults never make it to the peer-reviewed literature.

Despite these limitations, this reviewhas important implications for childpreventive care. First, many WCC clini-cal practice redesign tools examined inthis review are also more broadly partof efforts to transform practices intopatient-centered medical homes.79–81

Group visits, non–face-to-face formats,

and additional providers for WCC canincrease accessibility, comprehensive-ness, and family-centeredness of care(key elements of the medical home).Practices working toward a trans-formation into patient-centered medi-cal homes can consider implementingWCC redesign strategies that havedemonstrated some promising, albeitpreliminary, results for WCC delivery.

Next, there are several provisions of thehealth care reform law that make WCCclinical practice redesign a timelyproposition for primary care practi-ces.82 The Affordable Care Act includesthe Centers for Medicare and MedicaidServices Innovation Center, which willinvestigate new service delivery andpayment models, and the Preventionand Public Health Fund, which providesmandatory funding for prevention andwellness programs.

Finally, despite promising evidence forthese interventions, they have not been

widely adopted. In a recent study ex-amining health plan leaders’ views onWCC clinical practice redesign, partic-ipants reported a lack of incentives forpractices and health plans to invest inWCC clinical practice redesign. Fur-thermore, some states require Medic-aid and Children’s Health InsuranceProgram–contracted plans to reporton a set of quality measures thatreward the number of face-to-facewell-child visits and inadvertently dis-courage the use of non–face-to-facestrategies.83

There are promising tools and strate-gies for WCC clinical practice redesignthat may be ready for larger-scale tri-als. Future directions for research in-clude reporting intervention costs andpotential cost savings and a commonlydefined set of child and parent out-comes to help researchers build ca-pacity for comparative studies acrossinterventions.

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Well-Child Care Clinical Practice Redesign for Young ... · of accepted articles. Thirty-three arti-cles were accepted; these included 13 articles primarily on alternative for-matsforWCC,16,25–36