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Changes in the Daily Practice of Primary Care for Children
Timothy G. Ferris, MD, MPhil;
Demet Saglam, MA;
Randall S. Stafford, MD, PhD;
Nancyanne Causino, EdD;
Barbara Starfield, MD, MPH;
Larry Culpepper, MD, MPH;
David Blumenthal, MD, MPP
Arch Pediatr Adolesc Med. 1998;152:227-233.
Background The environment in which medicine is practiced has changed in the past 2 decades, but little information has been available on how the day-to-day practice of primary care for children has changed during this period.
Objective To identify aspects of primary care practices for children that are undergoing substantial changes.
Design Analysis of National Ambulatory Medical Care Surveys from 1979 to 1981, 1985, and 1989 to 1994.
Participants Primary care practitioners recorded data on 58488 child visits.
Main Outcome Measures Characteristics and insurance status of children, physician activities during visits, and disposition after visit.
Results Child visits to primary care physicians increased by 22% between 1979 and 1994. The mean age of children visiting primary care physicians decreased from 6.7 years in 1979 to 5.7 years in 1994 (P for trend, <.001). The ethnic diversity of child visits increased primarily as a result of an increasing proportion of visits by Hispanic (6.0% in 1979 to 12.6% in 1994, P for trend, <.001) and Asian patients (1.6% in 1979 to 4.1% in 1994, P for trend, <.001). Medicaid and managed care increased dramatically as sources of payment. Changes in physician activities included an increase in some preventive services, changes in the most commonly encountered medications, and an increased mean duration of patient visits (11.8 minutes in 1979 to 14.2 minutes in 1994, P for trend, <.001).
Conclusions These data may assist in the development of educational and research initiatives for physicians caring for children. The declining proportion of adolescent visits may present physicians with challenges in the care of adolescents. Physician prescribing practices showed changes without evidence of a benefit to child health. The increased ethnic diversity and provision of preventive services were associated with an increased mean duration of primary care visits. The increased duration of child visits may conflict with the managed care emphasis on physician productivity.
From the Health Policy Research and Development Unit, Divisions of General Medicine (Drs Ferris, Saglam, Stafford, Causino, and Blumenthal) and General Pediatrics (Dr Ferris), Massachusetts General Hospital and Harvard Medical School, Boston; School of Hygiene and Public Health, Johns Hopkins University (Dr Starfield), Baltimore, Md; and the Department of Family Medicine, Boston University School of Medicine (Dr Culpepper).
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