title: Delivery of well-child care: a look inside the door.
abstract: OBJECTIVE
  To describe the delivery of well-child care and its components; to compare that delivery with recommendations in Bright Futures; and to compare delivery of well-child care for children with special health care needs with that for children without special needs.
  
  
  METHODS
  Over a 10-week period, 2 medical students observed and documented characteristics of well-child care visits by general pediatricians and midlevel pediatric providers. Parents completed a demographic questionnaire and a screener for children with special health care needs.
  
  
  RESULTS
  A total of 483 visits by 43 pediatricians and 9 midlevel providers with patients from 0 to 19 years of age were observed. Adjusted mean visit duration was 20.3 minutes; 38.9% of visits began with an open-ended question about parent/child concerns. A mean of 7.2 health supervision/anticipatory guidance topics were addressed per visit. Clinicians addressed a mean of 42% of Bright Futures-recommended age-specific health supervision/anticipatory guidance topics. Topics addressed less frequently than recommended included family support, parental well-being, behavior/discipline, physical activity, media screen time, risk reduction/substance use, puberty/sex, social-peer interactions, and violence. Shorter visits were associated with asking about parent/child concerns and with addressing greater proportions of recommended health supervision/anticipatory guidance topics. Well-child care visits with children with special health care needs were 36% longer than those with children without special needs and addressed similar numbers of age-specific health supervision/anticipatory guidance topics. More time was spent with children with special health care needs addressing health supervision/anticipatory guidance topics, other conditions (usually their chronic condition), and testing, prescriptions, and referrals.
  
  
  CONCLUSIONS
  Utilizing direct observation of visits with pediatric clinicians, we found that solicitation of parent/child concerns occurred less frequently than recommended. Fewer than half of recommended visit-specific health supervision/anticipatory guidance topics were addressed, and there was little congruence with some Bright Futures age group-specific recommendations. Notably, both solicitation of patient/parent concerns and greater adherence to health supervision/anticipatory guidance recommendations were associated with shorter visits. Well-child care visits with children with special health care needs were longer than those with children without special needs; more time was spent addressing similar numbers of health supervision/anticipatory guidance topics as well as their chronic conditions.
authors.affiliation: Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City, Utah 84158, USA. chuck.norlin@hsc.utah.edu
authors.forename: Chuck
authors.initials: C
authors.lastname: Norlin
authors.forename: Morgan A
authors.initials: MA
authors.lastname: Crawford
authors.forename: Christopher T
authors.initials: CT
authors.lastname: Bell
authors.forename: Xiaoming
authors.initials: X
authors.lastname: Sheng
authors.forename: Martin T
authors.initials: MT
authors.lastname: Stein
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D019988:Children with Disabilities / Q000706:statistics & numerical data; D018479:Early Intervention, Educational / Q000379:methods; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D015999:Multivariate Analysis; D010287:Parent-Child Relations; D010372:Pediatrics / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data*; D010808:Physical Examination / Q000706:statistics & numerical data*; D010817:Physician-Patient Relations; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000592:standards / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D013997:Time Factors; D014589:Utah; D055815:Young Adult