584943
research-article2015
CPJXXX10.1177/0009922815584943Clinical PediatricsHammig and Jozkowski
Article
Health Education Counseling During Pediatric Well-Child Visits in Physicians’ Office Settings
Clinical Pediatrics 2015, Vol. 54(8) 752–758 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815584943 cpj.sagepub.com
Bart Hammig, PhD, MPH1 and Kristen Jozkowski, PhD1
Abstract Objective. The current study assessed factors associated with health education counseling during well-child visits. Methods. Data from the 2007-2010 National Ambulatory Medical Care Survey (NAMCS) were used to examine well-child visits made to physicians’ offices in the United States. Logistic regression models examined the relationship between the provision of health education counseling and selected covariates. Health education provisions measured included injury prevention, nutrition, exercise, tobacco use, and weight reduction. Results. A total of 4837 well-child visits were identified during the study period, which is equivalent to a weighted estimate of 43.4 million well-child visits annually. Multivariate analyses indicated that the length of the well-child visit was the predominant factor associated with delivery of health education counseling. Conclusions. Provider education and counseling of patients concerning health behaviors were implemented at a low level. Time spent with the patient was associated with the majority of health education counseling. Implications for pediatric practice are discussed. Keywords prevention, primary care, pediatrics
Introduction Pediatric well-child visits are designed to provide an opportunity for parents to receive information from physicians regarding various aspects of a child’s health and preventative health practice. Well-child visits also provide an opportunity for parents to ask questions of physicians regarding the health and care of their children. In the United States, nearly one-third of all visits to the pediatrician are well-child visits.1 Formal recommendations regarding age-related topics for health care providers to address as part of the well-child visit have been developed by the American Academy of Pediatrics in their Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents.2 These guidelines provide specific recommendations for what should be accomplished during the well-child visit and include recommendations for physicians to follow regarding preventative health practices such as screening tests, immunizations, and anticipatory guidance. Specifically, Bright Futures recommends “33 universal and 117 selective screening tests, observation of parent-child interaction, addressing parent concerns through open-ended questions, monitoring of growth, developmental surveillance, physical examinations and anticipatory guidance on
numerous health topics.”2,3 Given these specific guidelines aimed at prevention, the goal of well-child visits are to promote health and prevent the onset of leading public health problems in children and youth including illness and injury.4 Previous research has examined various aspects of well-child visits. For example, Schuster et al5 provided an overview of the topics parents received information about, what topics they would like to receive information about, and the extent to which they received anticipatory guidance during well-child visits. Not surprisingly, they found that parents who received information about a greater variety of topics from their physicians were more likely to indicate excellent care from the physician.5 However, time constraints greatly limit the extent to which physicians can provide information and anticipatory guidance to parents.3,6
1
University of Arkansas, Fayetteville, AR, USA
Corresponding Author: Bart Hammig, University of Arkansas, 306 HPER, Fayetteville, AR 72701, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at UNIV OF WISCONSIN OSHKOSH on November 15, 2015
753
Hammig and Jozkowski Norlin et al7 found that pediatricians were not adequately following age-specific guidelines as they noted that an average of 42% of the well-child visit recommendations were being met in their assessment of wellchild visits because of time constraints. This is unfortunate given that higher quality of care has been associated with greater anticipatory guidance8 and shorter well-child visits have been associated with a lower quality of care and less parental satisfaction regarding quality of care.3 When specifically examining physicians’ discussions with parents related to obesity, Leventer-Roberts et al9 found that only parents of “extremely obese” children seemed to be receiving any health education related to nutrition and exercise and that even these rates were insufficient as providers seemed to be relying on visual cues to drive their discussion with parents about obesity prevention. Although formalized discussion with parents regarding leading public health issues as part of well-child visits have been recommended,2 little research has specifically examined the extent to which physicians provide targeted education to parents and children regarding health topics related to leading public health issues facing youth such as unintentional injury, tobacco, and overweight/obesity. Considering unintentional injuries are the leading cause of death among children and youth younger than 18 years, 18.1% of high school students reported smoking cigarettes in the past month,10 and childhood obesity has more than doubled in the past 30 years,11 research in this area is needed. It is likely the case that parents may be looking for guidance and advice from physicians during well-child visits regarding how to address such topics with their children and what strategies would be best to implement in order to maximize child health. As such, the current study aimed to assess the factors associated with delivery of health education related to leading causes of morbidity and mortality among youth during well-child visits, including (a) unintentional injury, (b) nutrition, (c) exercise, (d) tobacco prevention, and (e) weight loss.
Methods Using data from the National Ambulatory Medical Care Survey (NAMCS), we analyzed well-child visits made to physicians’ offices in the United States from 2007 through 2010 using a national sample of physicians. The NAMCS are maintained by the Centers for Disease Control and Prevention’s National Center for Health Statistics. A multistage, national probability sample design was employed for the NAMCS involving 112 geographic primary sampling units, physicians’ practices within the primary sampling units, and patient visits
within the practices. Data collection was completed using a patient record form completed by trained staff. A more detailed explanation of the NAMCS methodology has been published for further reference.12,13
Measurements Well-child visits were identified if the primary ICD9-CM code for the visit was one of the following: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, or V70.9. Health education provisions were measured by responses to a checkbox provided on the patient record form (PRF). The item, under a section titled “Health Education,” stated “Mark (x) all ordered or provided at this visit.” Options for health education provisions that we examined as part of the well-child visit, included “none,” “injury prevention,” “diet/nutrition,” “exercise,” “tobacco use/exposure,” and “weight reduction.” Other variables used in the current analyses included age group, stratified into 4 categories: infant (aged
research-article2015
CPJXXX10.1177/0009922815584943Clinical PediatricsHammig and Jozkowski
Article
Health Education Counseling During Pediatric Well-Child Visits in Physicians’ Office Settings
Clinical Pediatrics 2015, Vol. 54(8) 752–758 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815584943 cpj.sagepub.com
Bart Hammig, PhD, MPH1 and Kristen Jozkowski, PhD1
Abstract Objective. The current study assessed factors associated with health education counseling during well-child visits. Methods. Data from the 2007-2010 National Ambulatory Medical Care Survey (NAMCS) were used to examine well-child visits made to physicians’ offices in the United States. Logistic regression models examined the relationship between the provision of health education counseling and selected covariates. Health education provisions measured included injury prevention, nutrition, exercise, tobacco use, and weight reduction. Results. A total of 4837 well-child visits were identified during the study period, which is equivalent to a weighted estimate of 43.4 million well-child visits annually. Multivariate analyses indicated that the length of the well-child visit was the predominant factor associated with delivery of health education counseling. Conclusions. Provider education and counseling of patients concerning health behaviors were implemented at a low level. Time spent with the patient was associated with the majority of health education counseling. Implications for pediatric practice are discussed. Keywords prevention, primary care, pediatrics
Introduction Pediatric well-child visits are designed to provide an opportunity for parents to receive information from physicians regarding various aspects of a child’s health and preventative health practice. Well-child visits also provide an opportunity for parents to ask questions of physicians regarding the health and care of their children. In the United States, nearly one-third of all visits to the pediatrician are well-child visits.1 Formal recommendations regarding age-related topics for health care providers to address as part of the well-child visit have been developed by the American Academy of Pediatrics in their Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents.2 These guidelines provide specific recommendations for what should be accomplished during the well-child visit and include recommendations for physicians to follow regarding preventative health practices such as screening tests, immunizations, and anticipatory guidance. Specifically, Bright Futures recommends “33 universal and 117 selective screening tests, observation of parent-child interaction, addressing parent concerns through open-ended questions, monitoring of growth, developmental surveillance, physical examinations and anticipatory guidance on
numerous health topics.”2,3 Given these specific guidelines aimed at prevention, the goal of well-child visits are to promote health and prevent the onset of leading public health problems in children and youth including illness and injury.4 Previous research has examined various aspects of well-child visits. For example, Schuster et al5 provided an overview of the topics parents received information about, what topics they would like to receive information about, and the extent to which they received anticipatory guidance during well-child visits. Not surprisingly, they found that parents who received information about a greater variety of topics from their physicians were more likely to indicate excellent care from the physician.5 However, time constraints greatly limit the extent to which physicians can provide information and anticipatory guidance to parents.3,6
1
University of Arkansas, Fayetteville, AR, USA
Corresponding Author: Bart Hammig, University of Arkansas, 306 HPER, Fayetteville, AR 72701, USA. Email: [email protected]
Downloaded from cpj.sagepub.com at UNIV OF WISCONSIN OSHKOSH on November 15, 2015
753
Hammig and Jozkowski Norlin et al7 found that pediatricians were not adequately following age-specific guidelines as they noted that an average of 42% of the well-child visit recommendations were being met in their assessment of wellchild visits because of time constraints. This is unfortunate given that higher quality of care has been associated with greater anticipatory guidance8 and shorter well-child visits have been associated with a lower quality of care and less parental satisfaction regarding quality of care.3 When specifically examining physicians’ discussions with parents related to obesity, Leventer-Roberts et al9 found that only parents of “extremely obese” children seemed to be receiving any health education related to nutrition and exercise and that even these rates were insufficient as providers seemed to be relying on visual cues to drive their discussion with parents about obesity prevention. Although formalized discussion with parents regarding leading public health issues as part of well-child visits have been recommended,2 little research has specifically examined the extent to which physicians provide targeted education to parents and children regarding health topics related to leading public health issues facing youth such as unintentional injury, tobacco, and overweight/obesity. Considering unintentional injuries are the leading cause of death among children and youth younger than 18 years, 18.1% of high school students reported smoking cigarettes in the past month,10 and childhood obesity has more than doubled in the past 30 years,11 research in this area is needed. It is likely the case that parents may be looking for guidance and advice from physicians during well-child visits regarding how to address such topics with their children and what strategies would be best to implement in order to maximize child health. As such, the current study aimed to assess the factors associated with delivery of health education related to leading causes of morbidity and mortality among youth during well-child visits, including (a) unintentional injury, (b) nutrition, (c) exercise, (d) tobacco prevention, and (e) weight loss.
Methods Using data from the National Ambulatory Medical Care Survey (NAMCS), we analyzed well-child visits made to physicians’ offices in the United States from 2007 through 2010 using a national sample of physicians. The NAMCS are maintained by the Centers for Disease Control and Prevention’s National Center for Health Statistics. A multistage, national probability sample design was employed for the NAMCS involving 112 geographic primary sampling units, physicians’ practices within the primary sampling units, and patient visits
within the practices. Data collection was completed using a patient record form completed by trained staff. A more detailed explanation of the NAMCS methodology has been published for further reference.12,13
Measurements Well-child visits were identified if the primary ICD9-CM code for the visit was one of the following: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, or V70.9. Health education provisions were measured by responses to a checkbox provided on the patient record form (PRF). The item, under a section titled “Health Education,” stated “Mark (x) all ordered or provided at this visit.” Options for health education provisions that we examined as part of the well-child visit, included “none,” “injury prevention,” “diet/nutrition,” “exercise,” “tobacco use/exposure,” and “weight reduction.” Other variables used in the current analyses included age group, stratified into 4 categories: infant (aged
