Friday, May 7, 2010

Primary Care Management of Chronic Conditions in Pediatrics

Discussion of Chronic Conditions at Different Types of Pediatric Primary Care Visits

Jeanne Van Cleave, MD1, Dianali Rivera Morales, MS1 and James M Perrin, MD1. 1Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, Boston, MA, United States.

Prevalence of chronic conditions in children are increasing,1 yet the organization of primary care is less oriented toward management of chronic conditions.2 Categorizing visits as preventive, urgent, and chronic care may limit opportunities for management of chronic conditions. Understanding how chronic conditions are managed in this context can guide improvements in primary care.

Previous work demonstrated that parents of children with chronic conditions prioritize discussing their child's chronic condition at preventive care visits, where the main reason for the visit is typically not for the child's chronic condition.

The objective of this study was to characterize physicians' perceptions of the discussion of chronic conditions at well-child visits and urgent visits not related to a child's chronic condition, and to identify barriers and facilitators to this discussion.

Primary care pediatricians from an integrated delivery system were surveyed after well-child and sick visits with patients whose medical records identified them as having a chronic condition. After verifying that the reason for visit was not the chronic condition, physicians were asked if they discussed the patient's chronic condition, and time spent and content of the discussion. Specific content items were a review of recent symptoms related to the chronic condition, medication changes, subspecialty referrals, and parent education and support. We examined associations of chronic condition discussion with potential barriers to discussion, such as time during the visit and reimbursement levels.

From 28 physicians, we collected 127 surveys where the visit was not related to the chronic condition (response rate 76%). The child's chronic condition was discussed at 63% of visits, and more often when the physician who primarily manages the chronic condition saw the patient (74% of visits, versus 7% of visits where the physician did not manage the condition, p<0.001). Discussion was associated with perception of enough time during the visit (p=0.06), perception that the parent wanted to discuss the chronic condition (p<0.001), and belief that discussion would positively impact care (p<0.001). Discussion was not associated with differences in perception of adequate reimbursement (p=0.43) (Table 1).

Table 1.  Physicians' perceptions of barriers and facilitators to discussing chronic conditions at visits where the chronic condition is not the primary reason for the visit.


Chronic condition discussed*

Chronic condition not discussed*

Enough time to discuss chronic condition



Physician is confident in managing condition



Discussion made/would make a difference in child's care



Physician was able to tailor discussion to chronic condition



Parent wanted to discuss chronic condition



Child too sick at the visit to discuss chronic condition



Adequate reimbursement



*Likert type scales; 1=strongly agree; 4=strongly disagree


For visits where the chronic condition was discussed, discussion was usually initiated by the physician (81% of visits), and content included review of recent symptoms (83%), parent/patient education (60%), and medications (63%). Prescriptions were refilled at 26% of these visits, with changes in management (medication changes, new referrals) made at 36% of visits. Mean time spent discussing chronic conditions was 6.0+/-4.0 minutes.

Our findings demonstrate that much management of chronic conditions occurs at visits where the reason for the visit is preventive care or an unrelated problem, and was associated with seeing a familiar physician, ample time for discussion, and physicians' perception that parents desired discussion. Restructuring primary care to align with these facilitating factors may increase quality of care for children with chronic conditions.

1. Van Cleave J, Gortmaker SL, Perrin JM. Dynamics of obesity and chronic health conditions among children and youth. JAMA. Feb 17 2010;303(7):623-630.

2. Bodenheimer T, Wagner EH, Grumbach K, Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA. Oct 16 2002;288(15):1909-1914.

Back to Top