Primary care physicians caring for children are spending more time with their young patients than they did 15 years ago and providing increased preventive service and counseling, according to a study by researchers from the Massachusetts General Hospital (MGH). The report appearing in the March Archives of Pediatrics and Adolescent Medicine also noted that primary care physicians are prescribing antibiotics and the stimulant drug Ritalin more frequently today than 15 years ago, without clear evidence that wider usage of these medications is appropriate.
"We know that there have been significant changes in the pediatric-care environment over the past two decades," says Timothy Ferris, MD, MPhil, of the MGH Health Policy Research and Development Unit, the study's first author. "These changes -- including a more diverse population, changes in health care financing and insurance coverage, the availability of more medications, and the development of guidelines for preventive and counseling services -- are well characterized. But no one previously has looked at how such developments are actually affecting the way physicians care for children."
"In most instances, the changes in physician practice we observed are not the result of planned policy changes. Therefore we think our results suggest areas for future research and physician educational efforts," he adds.
The study examined results from the National Ambulatory Care Surveys from 1979 to 94. In the survey conducted by the National Center for Health Statistics, physicians complete a form after outpatient visits during a randomly selected week, answering questions about patients' diagnoses and the treatments provided. This study analyzed more than 58,000 visits by patients under the age of 18 to about 2,000 physicians specializing in general practice, family medicine, pediatrics or adolescent medicine.
Among the most significant changes seen over the period studied was an increase in the average length of the patient visit from 11.8 minutes in 1979 to 14.2 minutes in 1994. Longer visits also were associated with Hispanic patients and the provision of counseling and preventive services like vaccination, but the increase was less dramatic in patients belonging to HMOs.
Ferris says, "It seems clear that the increased amount of time physicians are spending with their young patients -- a result we did not expect -- is related to increases in counseling services and in meeting the needs of our more diverse population. While this trend is very positive, we are concerned that it may conflict with demands of managed care organizations for increased physician productivity."
Physicians reported providing counseling services, including dietary and smoking counseling, in 71 percent of 1994 well-child visits, compared with about 40 percent of 1979 visits. Vaccinations were administered in 48 percent of 1994 well-child visits, compared with 33 percent of such visits in 1980; and blood pressure screenings for children over the age of 3 increased to almost 26 percent in 1994 from about 15 percent in 1979.
Although the antibiotic amoxicillin was the most frequently prescribed medication throughout the period of the study, its use increased from 7 percent of visits in 1980 to almost 16 percent of visits in 1994. Overall prescription of antibiotics increased from 26.2 percent of 1978 visits to 31 percent of 1994 visits. Prescriptions for methylphenidate (Ritalin) to treat attention deficit disorder increased from .01 percent of 1980 visits to 1.4 percent of 1994 visits. The other significant increase in medication was seen in the beta-agonist albuterol to treat asthma, which was very rarely used in 1980 but was prescribed in 5 percent of 1994 visits, making it the second most frequent prescription for children.
"The increased use of antibiotics and Ritalin signals a need for further study, because we really don't have evidence that these changes are beneficial to our patients," Ferris says. "There is particular concern that the increased use of antibiotics is related to the growing prevalence of antibiotic-resistant bacteria."
Ferris's coauthors include David Blumenthal, MD, MPP, director of the MGH Health Policy Research and Development Unit and the study's senior author; Demet Saglam, Randall Stafford, MD, PhD, and Nancyanne Causino, EdD, of the MGH; Barbara Starfield, MD, MPH, of the Johns Hopkins School of Hygiene and Public Health; and Larry Culpepper, MD, MPH, of the Department of Family Medicine at Boston University School of Medicine. The study was supported by the Agency for Health Care Policy and the National Institutes of Health.
Journal
Archives of Pediatrics and Adolescent Medicine