well-child care clinical practice redesign for young ... · of accepted articles. thirty-three...
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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.
PEDIATRICS Volume 131, Supplement 1, March 2013 S5
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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.
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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)
20visits/25patients(0.8)
Hospitalizations
0hospitalizations
1hospitalization
Acuteam
bulatory
visits
43visits/11patients(3.9)
110visits/25patients(4.4)
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
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TABLE1
Continued
Firstauthor,year
Design,m
easurement,outcom
esMajor
findings
Dodds,1993
35Observationalstudy
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
Enrolled:N=887families
•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
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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.
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TABLE3
AlternativeLocations
ofCare
Firstauthor,year
StudyDesign
Major
Findings
Gance-Cleveland,2005
38Observationalstudy
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
Enrolled:N=630families
(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.
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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
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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.
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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
9quasi-experimentalsites(n
=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
9quasi-experimentalsites(n
=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
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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)
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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)
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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
Outcom
e:perspectives
onHS
program
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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.
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(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
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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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SUPPLEMENT ARTICLE
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