Continuity of Primary Care Clinician in Early Childhood
Published in: Pediatrics, v. 113, no. 6, June 2004, p. 1917-1925
Posted on RAND.org on December 31, 2003
OBJECTIVES: This study uses the first national data on well-child care for young children to 1) assess how many children have a specific clinician for well-child care; 2) identify the health insurance, health care setting, and child and family determinants of having a specific clinician; and 3) assess how parents choose pediatric clinicians. METHODS: Data from the National Survey of Early Childhood Health (NSECH), a nationally representative survey of health care quality for young children fielded by the National Center for Health Statistics in 2000, were used to describe well-child care settings for children aged 4 to 35 months. Parents reported the child's usual setting of well-child care, whether their child has a specific clinician for well-child care, and selection method for those with a clinician. Bivariate and logistic regression analyses are used to identify determinants of having a specific clinician and of provider selection method, including health care setting, insurance, managed care, and child and family characteristics. RESULTS: Nearly all young children aged 4 to 35 months in the United States (98%) have a regular setting, but only 46% have a specific clinician for well-child care. The proportion of young children who have a single clinician is highest among privately insured children (51%) and lowest among publicly insured children (37%) and uninsured children (28%). In multivariate logistic regression including health care and sociodemographic factors, odds of having a specific clinician vary little by health care setting. Odds are lower for children who are publicly insured (odds ratio [OR]: 0.7; 95% confidence interval [CI]: 0.45-0.97) and for Hispanic children with less acculturated parents (OR: 0.6; 95% CI: 0.39-0.91). Odds are higher for children in a health plan with gatekeeping requirements (OR: 1.4; 95% CI: 1.02-1.88). Approximately 13% of young children with a specific clinician were assigned to that provider. Assignment rather than parent choice is more frequent for children who are publicly insured, in managed care, cared for in a community health center/public clinic, Hispanic, and of lower income and whose mother has lower education. In multivariate logistic regression, only lack of health insurance, care in a community health center, and managed care participation are associated with lack of choice. CONCLUSIONS: Anticipatory guidance is the foundation of health supervision visits and may be most effective when there is a continuous relationship between the pediatric provider and the parent. Only half of young children in the United States are reported to have a specific clinician for well-child care. Low rates of continuity are found across health care settings. Furthermore, not all parents of children with a continuous relationship exercised choice, particularly among children in safety net health care settings. These provisional findings on a new measure of primary care continuity for children raise important questions about the prevalence and determinants of continuity.