BACKGROUND: Studies of pediatric primary care suggest that time is an important limitation to the delivery of recommended preventive services. Given the increasingly frenetic pace of pediatric practice, there is an increased need to monitor the length of pediatric visits and the association of visit length with content, family-centered care, and parent satisfaction with care.
OBJECTIVE: To examine the length of well-child visits and the associations of visit length with content, family-centered care, and parent satisfaction among a national sample of children.
METHODS: We conducted a cross-sectional telephone survey of parents of children aged 4 to 35 months from the 2000 National Survey of Early Childhood Health (n = 2068).
RESULTS: One-third (33.6%) of parents reported spending ≤10 minutes with the clinician at their last well-child visit, nearly half (47.1%) spent 11 to 20 minutes, and 20.3% spent >20 minutes. Longer visits were associated with more anticipatory guidance, more psychosocial risk assessment, and higher family-centered care ratings. A visit of >20 minutes was associated with 2.4 (confidence interval [CI]: 1.5–3.7) higher odds of receiving a developmental assessment, 3.2 (CI: 1.7–6.1) higher odds of recommending the clinician, and 9.7 (CI: 3.5–26.5) higher odds of having enough time to ask questions.
CONCLUSIONS: Many well-child visits are of short duration, and shorter visits are associated with reductions in content and quality of care and parent satisfaction with care. Efforts to improve preventive services will require strategies that address the time devoted to well-child care. The results of this study should be interpreted in light of changes in practice standards, reimbursement, and outcome measurement that have taken place since 2000 and the limitations of the measurement of utilization solely on the basis of parent report.
WHAT'S KNOWN ON THIS SUBJECT:
Pediatricians are being asked to do more in less time. The dilemma is what to provide in the time available. What is not known is the impact of time limitations on the content of and satisfaction with care.
WHAT THIS STUDY ADDS:
Parents report that time spent in well-child visits varies from <10 minutes to >20 minutes. Longer visits are associated with more developmental screening, discussions of more psychosocial risks, and greater parent satisfaction.
Pediatric well-child care is designed to prevent health problems and injuries, and to promote the well-being of children.1 Since the Standards of Child Health Care was published by the American Academy of Pediatrics (AAP) in 1967,2 pediatricians, through the AAP, have debated and created recommendations for the content and periodicity of preventive visits. As knowledge has grown about how to prevent illness and injury and promote positive development, the demands on pediatricians who perform well-child visits have expanded. An analysis of AAP statements revealed that 53 new verbal advice directives that focused on infants and toddlers were issued between 1987 and 2002; this finding raises questions about how much anticipatory guidance can be fit into 1 well-child visit.3,–,7 Studies of physicians' views on primary care indicate that time constraints and lack of reimbursement are among the main limitations to the delivery of preventive services.8,–,14 In recognition of these increased demands and limited visit time, the new edition of Bright Futures: Guidelines for Health Supervision for Infants, Children, and Adolescents published by the AAP sets content priorities for each age group and gives priority to addressing parent concerns.15 The dilemma of pediatricians as to what issues to address within limited visit time and how to balance parent concerns with expanding preventive health directives requires a better understanding of the impact of the length of well-child visits on content and quality of care, as well as parent satisfaction.16,17
Results of previous studies have shown that the provision of more anticipatory guidance is associated with longer well-child visits.18,–,21 In most studies, however, only the question of whether any anticipatory guidance was provided was addressed. A content-specific assessment of what services are provided within different time frames could suggest what can realistically be done within the current time constraints of pediatric care. Although many strategies are available to increase the efficiency of preventive care delivery,22,–,25 methods are scarce for the evaluation of how time allocated to visits influences what services are delivered, what services receive priority during visits of different lengths, and how these factors influence the quality of the pediatrician's relationship with the family and ultimately the parent's satisfaction with care.
In this study we assessed the length of well-child visits for young children (aged 4–35 months) and associations of visit length with parent-reported content of care, family-centered care, and satisfaction. We examined the relationship of visit length to 4 aspects of preventive care, including the receipt of (1) specific anticipatory guidance content, (2) psychosocial assessment of risks, (3) developmental assessment, and (4) family-centered care. We also examined the relationship between visit length and 4 measures of parent satisfaction.
In this study we used data from the 2000 National Survey of Early Childhood Health (NSECH) conducted by the National Center for Health Statistics. The NSECH is a cross-sectional nationally representative survey of children aged 4 to 35 months, in which parents report about their child's health and health care.26 Sampling weights were developed to adjust for nonresponse, oversampling, and stratification of the survey sample.27 The NSECH was approved by the institutional review boards of the AAP, the University of California at Los Angeles, and the Centers for Disease Control and Prevention.
Structured telephone interviews to obtain information for 2068 children were conducted in English or Spanish with the primary caregivers of 1 sampled household child. According to the Council of American Survey Research Organizations, the response rate was 65.6%. Detailed information about the NSECH is available elsewhere.26,–,28 Ninety-six children had not had a checkup in the previous 12 months, and 18 parents did not report the length of the last visit. The final analytic sample (N = 1691) was further restricted to exclude 263 individuals with missing data on the study covariates. Some variability in sample size occurred across outcome variables because of missing data.
Parents reported the length (in minutes) of their last well-child visit. Parents were asked, “Let's talk about the well-child care [child] has received. Think about the last time you took your child for a checkup. How long was the doctor or health care clinician who examined your child in the room with you?” Responses were grouped into quartiles: 1 to 10 minutes, 11 to 15 minutes, 16 to 20 minutes, and ≥20 minutes.
Content and Quality of Preventive Care
Parents were asked whether in the previous 12 months they had received anticipatory guidance on 9 to 12 topics appropriate to the age of their child. Possible topics included immunizations, food/feeding, breastfeeding, sleeping with a bottle, weaning from a bottle, night waking and fussing, sleeping positions, bedtime routines, use of a car seat, burn prevention, dangerous situations, toilet training, washing/dressing, getting along with others, reading, communication, vocabulary development, discipline, and child care arrangements. Anticipatory guidance was measured with a 100-point scale score that represented the proportion of age-appropriate items discussed.
Parents were asked whether in the previous 12 months the clinician had asked about parent use of alcohol/drugs, community violence, smoking, parent health, emotional support, spousal support, and difficulty paying for basic needs. Psychosocial assessment is measured as a 100-point scale score that represented the proportion of items the parent was asked about by the clinician.
Parents were asked (1) whether the doctor or other clinician told the parent he or she was carrying out a “developmental assessment” and (2) if the doctor or other clinician ever had the child pick up small objects, stack blocks, throw a ball, or recognize different colors. If parents answered yes to either question, the child was coded as having received a developmental assessment.
Parents were asked how often in the previous 12 months the clinician (1) took time to understand the specific needs of the child, (2) respected the parent as the expert on the child, (3) asked how the parent was feeling, and (4) understood the family and how they preferred to raise children. We created a 100-point family centered care scale by averaging responses to the 4 questions with the following metric: always, 100; usually, 67; sometimes, 33; and never, 0. A higher score reflected more family-centered care.
Parents were asked, “How would you rate the child's checkups during the past 12 months?” Parents rated the checkups by using a scale from 0 to 10, where 0 was the worst health care possible and 10 was the best. Responses were converted to a 100-point scale.
Recommendation of the Clinician
Parents were asked, “How likely or unlikely are you to recommend your child's regular provider to your friends or family; would you say very likely, somewhat likely, somewhat unlikely, or not at all likely?” Responses were dichotomized into “very likely” versus all others because the responses were highly positively skewed.
Two questions were asked about visit satisfaction. First, parents were asked, “During the last checkup, did you ask all the questions you wished to ask?” Responses were dichotomous (yes/no). Second, parents were asked whether the length of time the provider spent with them at the last checkup was, “Too much time, about the right amount of time, or not enough time.” Responses were divided into, “Too much time or the right amount of time” versus “not enough time.”
Study covariates included child age (4–9, 10–18, or 19–35 months); maternal race/ethnicity (black, Hispanic–English speaking, Hispanic–Spanish speaking, white, other), family income (less than $17 500, $17 501–$35 000, $35 001–$60 000, $60 000, or more); maternal education (less than high school, high school graduate, college education); child health status (excellent/very good versus good/fair/poor); health insurance (private, public, other, uninsured); usual practice setting (private office, community health center, hospital clinic/emergency department/urgent care, walk-in clinic); and single clinician for well-child care/clinician gender (no single clinician, female clinician, male clinician). Covariates were selected from previous models of access and quality of care.29,30
To account for the complex survey design, we made adjustments to the SEs using Stata 9.2 (Stata Corp, College Station, TX). First, we presented estimates of visit length according to demographic and health care factors using Pearson χ2 to test significance. Second, we examined the relationship between visit length and content, quality, and satisfaction with care. Linear and logistic regressions (with respective β coefficients and odds ratios) are presented for each visit length category (reference group of ≤10 minutes) with models adjusted for study covariates.
Table 1 presents the overall distribution of visit lengths and associations with demographics and health care factors. Approximately one-third (33.6%) of parents reported that the time with the clinician at their last well-child visit lasted ≤10 minutes. Nearly half (47.1%) of parents said the visit lasted between 11 and 20 minutes, and 20.3% said ≥21 minutes.
There were few differences in visit lengths according to family demographics and health care factors. Both blacks and Hispanics interviewed in Spanish were more likely to have a visit of ≥21 minutes (29.9% and 29.3%). Mothers with less than a high school education were more likely than mothers with a college education to have long visits (28.3% vs 15.9%). Care from a community health center was associated with more visit lengths of ≥21 minutes (27.0% vs 23.4% in a hospital clinic/emergency department/urgent care or walk-in clinic and 18.5% in a physician office). Female health care clinicians seemed less likely than male clinicians to have short visits of ≤10 minutes (23.2% vs 38.1%).
Table 2 shows bivariate and adjusted multivariable associations between visit length and health care measures. Parents who reported longer visit lengths also reported greater content of care, higher levels of family-centered care, and more satisfaction. For example, compared with visits of ≤10 minutes, a visit of ≥21 minutes was associated with 17.9 higher points on the anticipatory guidance scale, 16.9 higher points on the psychosocial risk assessment scale, and 19.5 higher points on the family-centered care scale (all P < .05). Ninety-nine percent of parents reported adequate time with their doctors for visits of ≥21 minutes compared with 76% for the shortest visits. Longer visits were also associated with 2.4 (95% confidence interval [CI]: 1.5–3.7) higher odds of receiving a developmental assessment; 3.2 (CI: 1.7–6.1) of recommending the clinician; and 9.7 (CI: 3.5–26.5) of reporting having enough time to ask questions (all P < .05). Analyses (not shown) indicated that associations between visit length and family-centered care and satisfaction were reduced, but remained significant with controls added for the content-of-care items.
Figure 1 shows how preventive care services were prioritized according to well-child visit length. Regardless of visit length, >80% of parents reported receiving anticipatory guidance on immunizations and breastfeeding. As well-child visit lengths increased, a greater number of services were received by parents. For example, at visit lengths of 11 to 15 minutes, >80% of parents additionally reported receiving information about infant sleeping positions, feeding, and how their child communicated needs. At 16 to 20 minutes, >80% of parents reported guidance about parent smoking; and at ≥21 minutes, >80% of parents additionally received guidance on use of child car seats. Overall, many anticipatory guidance topics were provided more frequently than a developmental assessment (which ranged between 50% and 68% depending on visit length). Even for the longest visits, fewer than 50% of parents received guidance about emotional support, child care, toilet training, finances, and violence, and this list expanded to 10 additional topics for short visits.
In this study we found that one-third of parents reported that their well-child visit time with the clinician lasted ≤10 minutes, whereas 20% of parents reported visit time of ≥21 minutes. Shorter visits were significantly associated with reductions in the content of preventive care and parent reports of family-centered care. Shorter visits were also associated with lower satisfaction; however, even with the shortest visits parent-reported satisfaction generally was high.
There were few differences in visit length across family demographic and health care factors. Black and Hispanic families, and those with lower maternal education, were somewhat more likely to report longer visits, as were those who received care from community health centers. One explanation for this finding is that children in minority31,–,34 and low-income families35,–,38 generally have poorer health status and may require greater attention during well-child visits. Minority and low-income children are also more likely to receive care in community health centers and public clinics, where Medicaid reimbursements for well-child visits are greater and fiscal pressures for more efficient visits may be less acute.39,40 Although these results suggest that somewhat more time is given to provide preventive care to children at greater risk of poor health, how longer visits and visit content are targeted in relation to risk must be better understood.41
Although the connection between longer visits and greater content of care seems intuitively obvious, the relationship between visit length and parent reports of family-centered care and satisfaction was less straightforward. Parents are more likely to be satisfied when more services are provided and more health care needs are met. But in our study, even after we controlled for the content of care received, the positive relationship between visit length and high ratings of family-centered care and satisfaction remained significant. Clinicians who spend more time in visits likely are addressing additional content not covered by this survey, and their patients may perceive they are receiving more family-centered care when they spend more time with the clinician.42 As other research has revealed, both pediatricians and parents have reported that a trusting relationship and good communication between parents and their child's pediatrician is a key component of optimal well-child care.43,–,47
This study also revealed what services were most likely to be provided within the time limitations of well-child visits. Regardless of visit length, >80% of parents reported receiving anticipatory guidance on immunizations and breastfeeding. As visit length increased, this expanded to include sleeping positions, feeding issues, how children communicate, car seats, and parent smoking. The pattern indicated that traditional topics that have been part of anticipatory guidance for decades are most likely to be addressed, whereas topics added more recently are less likely to get mentioned when time is short. Parent smoking was typically addressed during even the shortest visits, which suggests that emphasis on the impacts of second hand smoke has been persuasive. Developmental assessments were provided approximately half the time in the shortest visits, and ∼70% of the time in the longest visits. Even in the longest visits, fewer than 50% of parents received guidance about emotional support, child care, toilet training, finances, and violence, and this list expanded for shorter visits.
This study had several limitations. One limitation was that the data were cross-sectional and did not demonstrate causality. A second limitation was that all information was reported by parents and may have been subject to recall bias. Although parents were asked to recall visit characteristics up to 1 year later, studies in which parent-reported measures from the NSECH were compared with those of a national survey of pediatricians in 2000 showed good overlap, which included similar average well-child visit length reported by pediatricians (18.3 minutes) and parents (17.7 minutes).17 We could not assess the extent to which parent recollection of content or quality may have influenced their perception of visit length. A third limitation was that the data available did not enable us to assess the effectiveness and efficiency of services rendered. Although a common assumption is that the more guidance a parent receives the greater the benefit, study results have indicated that there are limits to the amount of information a parent can absorb and retain in any 1 visit.48
Another limitation was that the data presented were collected in 2000, and since then a national survey with comparable data has not been performed to address this set of issues. During this period a number of incremental changes in practice recommendations have been made, such as additional anticipatory guidance topics and greater focus on some issues. For example, in 2006, the AAP issued a revised policy statement that included additional emphasis on the value of developmental screening and provided guidance on the use of standardized developmental screening tools during well-child visits for children aged 9 months, 18 months, and 30 months.49 Recent evidence has indicated that between 2002 and 2009 the reported rate of pediatrician use of standardized developmental screening tools has doubled.50 As the focus on developmental screening increases, the overall mix of services provided in well-child care may also change. The new Bright Futures guidelines, released by the AAP in 2008, also included anticipatory guidance priorities for each visit, which may be influencing the length and content of care provided in well-child visits.15
The results of this study raise a number of questions that require additional research. From a patient perspective, it is important to know if there were topics that parents would have rather discussed during their 10 minutes. Some studies suggest that visit efficiency may be enhanced and more anticipatory guidance content covered even in shorter visits when clinicians initiate discussion of parent-identified priorities and concerns.51 In addition, it is important to better understand how practice type, practice style, and reimbursement structures influence how much time is routinely allocated. In this study we found that short visits are common, and in future research that uses different study designs investigators might also seek to determine if the time allotted to well-child visits has an impact on prevention and health promotion behaviors within families.
Future studies are needed for evaluation of how the Child Health Insurance Program Reauthorization Act (CHIPRA), enacted in 2009, and the Patient Protection and Affordable Care Act (ACA), enacted in 2010, will affect the content and quality of well-child care and the time allotted to well-child visits. CHIPRA will lead not only to expanded access to health care for children but also to the inclusion of more and better measures of health care quality, including screening for developmental disorders. An important feature of the ACA is the requirement that insurance companies cover, with no cost-sharing requirements, the preventive care and screening services that are recommended in Bright Futures. In addition to these major changes in federal law, a number of national initiatives focused on improvement in the provision of pediatric preventive services are under way, including the national dissemination of Connecticut's “Help Me Grow” program.
The results of this study revealed substantial variation in the length of well-child visits in the United States. Efforts to improve preventive services will require strategies that address the time devoted to well-child care. Medical records systems that integrate previsit questionnaires with guidance for clinicians, and tiered systems whereby higher risk children receive longer or more frequent visits might provide mechanisms to enhance service allocation under time constraints.43 Similarly a team approach, in which some of the preventive services in the office are designated to nonphysician clinicians, may expand the number of services provided. Ultimately, greater reimbursement for preventive and developmental services may best encourage the devotion of time and attention to their provision.
This work was supported by the Commonwealth Fund (grant 20020383) and the Gerber Foundation (grant 02118268).
We thank Ms Amy Graber and Ms Louba Aaronson, who assisted with data analysis and manuscript preparation.
- Accepted June 17, 2011.
- Address correspondence to Neal Halfon, MD, MPH, UCLA Center for Healthier Children, Families, and Communities, 10990 Wilshire Blvd, Suite 900, Los Angeles, CA 90024. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- AAP —
- American Academy of Pediatrics
- NSECH —
- National Survey of Early Childhood Health
- CI —
- confidence interval
- Starfield B
American Academy of Pediatrics, Council on Pediatric Practice. Standards on Child Health Care. Evanston, IL: American Academy of Pediatrics; 1967
American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health. Guidelines for Health Supervision III. Elk Grove Village, IL: American Academy of Pediatrics; 1997
- Green M,
- Palfrey J
- Dinkevich E,
- Ozuah PO
- Belamarich PF,
- Gandica R,
- Stein RE,
- Racine AD
- Horowitz SM,
- Kelleher KJ,
- Stein RE,
- et al
- Hagan JF,
- Shaw JS,
- Duncan PM
- Halfon N,
- Inkelas M,
- Mistry R,
- Olson LM
- Olson LM,
- Inkelas M,
- Halfon N,
- Schuster MA,
- O'Conner KG,
- Mistry R
- Galuska DA,
- Fulton JE,
- Powell KE,
- et al
- Reisinger KS,
- Bires JA
- Goldstein EN,
- Dworkin PH,
- Bernstein B
- Glascoe FP,
- Oberklaid F,
- Dworkin PH,
- Trimm F
- Bartlett EE
- Randolph GD,
- Murray M,
- Swanson JA,
- Margolis PA
- Halfon N,
- Olson L,
- Inkelas M.,
- et al.
- Blumberg SJ,
- Olson L,
- Osborn L,
- Srinath KP,
- Harrison H
- Blumberg SJ,
- Halfon N,
- Olson LM
Federal Interagency Forum on Child and Family Statistics. America's Children: Key National Indicators of Well-being, 2002. Washington, DC: Government Printing Office; 2002
- Weinick RM,
- Weigers ME,
- Cohen JW
- Politzer RM,
- Yoon J,
- Shi L,
- Hughes RG,
- Regan J,
- Gaston MH
- Flores G,
- Olson LM,
- Tomany-Korman SC
- Tanner JL,
- Stein MT,
- Olson LM,
- Frintner MP,
- Radecki L
- Wissow LS,
- Roter DL,
- Wilson ME
- Coker T,
- Casalino LP,
- Alexander GC,
- Lantos J
- Radecki L,
- Olson LM,
- Frintner MP,
- Tanner JL,
- Stein MT
Council on Children With Disabilities Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006;118(1):405–420
- Radecki L,
- Sand-Loud N,
- O'Connor K,
- Sharp S,
- Olson LM
- Copyright © 2011 by the American Academy of Pediatrics