Paediatric primary care quality and accessibility: Parents’ perspective

Abstract

OBJECTIVE

To measure parents’ satisfaction with paediatric primary care quality and accessibility.

BACKGROUND

High-quality paediatric primary care is a cornerstone of efforts to improve health outcomes and access to care, as well as to control health care spending. A strong primary care infrastructure is related to improved health outcomes, including an improved mortality rate.

METHODS

A cross-sectional survey using the Parents’ Perception of Primary Care questionnaire and evidence-based items from the Rourke Baby Record were used to measure parents’ satisfaction.

RESULTS

Of 200 questionnaires sent, 130 were returned. The mean number of children per family was 1.7±0.8 (mean ± SD). Sixty-six per cent of children received their primary care from general practitioners, 19% received their primary care from paediatricians, and 15% had no regular physician and identified other professionals (community nurses, midwives or chiropractors) as their primary care providers. Parents were questioned about their child’s hearing in 66% of cases. Only 41% of parents received guidance about breastfeeding, 37% about adequate sleeping position, 17% about the dangers of second-hand smoke and 16% about car safety seats. The level of satisfaction with communication, contextual knowledge and coordination of care was higher for families followed by general practitioners and paediatricians than for families followed by nonphysicians. According to the Parents’ Perception of Primary Care scores, the overall satisfaction with primary care was higher for care given by general practitioners and paediatricians than for care given by midwives or chiropractors, and intermediate when given by nurses.

CONCLUSION

In this survey, the majority of children received their primary care from physicians, most commonly general practitioners. Parents’ overall satisfaction regarding their infant’s primary health care was higher when it was delivered by physicians than by alternative health care providers. Evidence-based guidance recommendations were rarely followed.

High-quality paediatric primary care is one of the cornerstones of the health system that are needed to improve health outcomes, control health care spending and improve access to care (1). A strong primary care infrastructure is associated with improved health outcomes, including a decrease in the mortality rate (2). According to the Institute of Medicine (3), primary care is “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients and practicing in the context of family and community”. Definitions of these concepts may vary among researchers; nevertheless, all agree that primary care must be accessible, comprehensive, contextual (based on a provider’s accumulated knowledge of the patient and his or her family), based on adequate communication, longitudinally continuous and coordinated.

In Canada, even though many changes in the health care system have occurred over the past few decades, preoccupation with the quality and accessibility of primary health care for children is a more recent development. To our knowledge, there have been no published studies that have developed reliable and valid health indicators for Canadian children and youth. The current lack of indicators and standards of care makes it difficult to determine the status of health and health care of Canadian children, to conduct comparative analyses to assess performance and to establish benchmarks for the optimal level of health service delivery.

We conducted the present cross-sectional study using a survey to assess parents’ degree of satisfaction with paediatric primary care quality and accessibility, and to assess the compliance by health care providers with evidence-based guidelines.

METHODS

Instruments

Parental satisfaction:

The Parents’ Perception of Primary Care (P3C) questionnaire (4) was the instrument selected to measure parental satisfaction and was translated into French. It is based on the above-mentioned Institute of Medicine definition of primary care. The P3C questionnaire was designed to measure six components of care that, when present, constitute high-quality primary care: longitudinal continuity, access, contextual knowledge, communication, comprehensiveness and coordination (Table 1). Computing the mean of the nonmissing values on each scale formed the total score, as well as the score for each subscale. Scores ranged from 0 to 100, with high scores reflecting care conforming to this a priori definition. The P3C questionnaire is a practical, reliable and valid measure of parents’ satisfaction with paediatric primary care (4). It can be used alone or in conjunction with other measures to enhance outcomes and evaluate the impact of system changes on delivery of the main elements of primary care.

TABLE 1.

Parents’ Perception of Primary Care items

Longitudinal continuity

1. If there is one particular place that you take your child for almost all of his or her health care, how long has this been your child’s place for health care?

2. If there is one particular person who you think of as your child’s regular doctor or nurse, how long has this person been your child’s doctor or nurse?

Access

3. Is it easy for you to travel to the doctor?

4. Can you see the doctor as soon as you want for routine care (eg, checkups and physical examinations) for your child?

5. If your child is sick, can you see the doctor within one day?

6. Can you get help or advice on evenings or weekends?

Contextual knowledge

7. Do you feel the doctor knows your child’s medical history?

8. Do you feel the doctor knows your concerns about your child?

9. Do you feel the doctor knows your values and beliefs about health?

10. Do you feel the doctor knows your child overall?

Communication

11. Do you feel comfortable asking the doctor questions?

12. Does the doctor explain things to your satisfaction?

13. Does the doctor spend enough time with you and your child?

14. Does the doctor listen to you?

Comprehensiveness

15. Can the doctor take care of almost any problem your child may have?

16. Does the doctor talk to you about keeping your child healthy?

17. Does the doctor talk to you about safety (eg, car safety seats, seat belts, bike helmets and accidents)?

18. Does the doctor talk to you about your child’s growth?

19. Does the doctor talk to you about your child’s behaviour in general (eg, having friends and showing citizenship at school)?

Coordination

20. When necessary, can the doctor arrange for other health care for your child?

21. When necessary, do you feel that the doctor follows up on visits to other health care providers?

22. Do you feel the doctor communicates with other health providers about your child, when necessary?

23. When necessary, do the doctor and school work together for your child’s health?

Reproduced from reference 4

Evidence-based guidelines:

The present study used the Rourke Baby Record (5), an evidence-based system of well-infant and -child health maintenance that was revised and updated in 2000 and was promoted by the Canadian Paediatric Society (5) and the College of Family Physicians of Canada. Only the following seven evidence-based elements were included, these being the most representative of a good well-baby visit: guidance about breastfeeding, car safety seats, safe sleeping position, immunization and the danger of secondhand smoke; hearing inquiry; and examination of the hips.

The survey was sent to a randomly selected sample of 200 parents who had a newborn at the Centre hospitalier universitaire de Sherbooke (Sherbrooke, Quebec), a tertiary care centre, between January 1, 2002, and June 30, 2002. Children were between six and 12 months of age at the time of the study. Parents had to return the survey in a postage-paid envelope, but no reminder notices were sent to nonresponders.

Data analysis

Continuous variables are presented as mean ± SD. Ratios were compared using the χ² test. Mean values were tested using the Student’s t test for continuous and normally distributed variables. P<0.05 was considered to be statistically significant.

RESULTS

Patient characteristics

Of 200 questionnaires sent, 130 were returned; of those, 116 were completed (response rate of 58%) and 14 were not filled out correctly (13 wrong addresses and one English-speaking family). Of the 116 families who responded to the questionnaire, 66% of parents identified the main primary care provider for their child as a family physician, 19% identified a paediatrician, 9% identified a nurse, 2% identified a chiropractor, 2% identified a midwife and 2% identified nobody in particular. Nurses, chiropractors and midwives represented a small number of cases and were grouped into the ‘nonphysician’ category. The location of primary care services was identified as a private clinic by 54% of parents, a community health clinic by 23%, a hospital outpatient clinic by 17%, and a walk-in clinic or an emergency room by 5%. The mean age of the parents was 29±4 years and 8% of the families were headed by a single parent. The mean number of children per family was 1.7±0.8. Ten per cent of families were living in poverty (annual income of less than $20,000), while 59% earned more than $40,000 per year.

Compliance with evidence-based guidelines

The quality of paediatric primary care was assessed at two, four and six months using the Rourke Baby Record. According to parental recall, 40% of parents received advice about breastfeeding from their primary care provider at two months compared with 30% at four months and 22% at six months. Fourteen per cent of parents recalled receiving guidance about car safety seats at two months, while 9% remembered receiving it at four months and 9% at six months. Parents received guidance about sleeping position in 87% of cases at birth, 37% at two months, 22% at four months and 19% at six months. Primary care providers discussed the dangers of second-hand smoke in 17% of cases at two months and in 12% each at four months and six months. Sixty-one per cent of parents remembered being asked about their child’s hearing at two months, 58% at four months and 53% at six months. According to parents, 81% of children had their hips examined at two months, 74% at four months and 69% at six months. Finally, 94% discussed immunization with their primary care provider at two months, 91% at four months and 88% at six months (Figure 1).

Figure 1).

Compliance with evidence-based guidelines

Breastfeeding was discussed by family physicians in 41% of children compared with 36% of children followed by paediatricians and 47% by nonphysicians. None of the families with the lowest annual income remembered discussing breastfeeding with their primary care provider. Guidance about breastfeeding was given more often to higher income families than to lower income ones (46% versus 0%; P=0.01). Guidance about car safety seats was provided at least once by family physicians in 16% of children, by paediatricians in 14% and by nonphysicians in 24%. Sleeping in the supine position was encouraged at least once by family physicians in 32% of children, in 36% of children followed by paediatricians and in 59% of children followed by nonphysicians. Family physicians and nonphysicians inquired about hearing at least once in 65% of children compared with 68% of children followed by paediatricians. Guidance about the dangers of second-hand smoke was given more frequently by nonphysicians than by family physicians (47% versus 13%; P=0.007). It was given to 16% of children followed by paediatricians, with no significant difference. Hips were examined in 90% of children followed by family physicians, in 100% of children followed by paediatricians and in 82% of those followed by nonphysicians. Finally, immunization was discussed by family physicians and paediatricians in 95% of children, and by the nonphysicians in 88% of them.

Children followed by nonphysicians had more visits than children in the two other groups (10 visits with non-physicians versus seven with family physicians and six with paediatricians).

Children were classified into acceptable and perfect follow-up categories. To be considered an acceptable follow-up, guidance about breastfeeding, car safety seats, sleeping position and the harms of second-hand smoke; inquiry about hearing; and examination of the hips had to be done at least once between two and six months of age. Also, immunization had to be given at two, four and six months. Only 4% of children (five families) had an acceptable follow-up. Six per cent of children had none of these seven criteria performed, and 28% had three of seven performed. To be considered a perfect follow-up, guidance about breastfeeding, car safety seats, sleeping position and the harms of second-hand smoke; inquiry about hearing; and examination of the hips had to be done at birth, and at two, four and six months. Immunization also had to be done at two, four and six months. Only 3% of children (three families) had a perfect follow-up.

Parents’ satisfaction with accessibility of paediatric primary care

Parents in all three groups had problems with accessibility. Fifty per cent could access their primary care provider easily, whereas 40% could not see their primary care provider in a timely manner for routine care. Fifty-eight per cent could not see their primary care provider within one day if their child was sick and 60% could not get help or advice on evenings or weekends.

Parents felt that family physicians and paediatricians had a better contextual knowledge than nonphysicians (P3C sub-scale of 67, 70 and 39, respectively). They also felt that family physicians and paediatricians had better communication skills and a better comprehensiveness of the patient, and were better at coordinating care when necessary (Figure 2).

Figure 2).

Parents’ satisfaction with paediatric primary care. *P values calculated with Student’s t test

Overall, parents’ evaluation of the provision of primary care was better when care was provided by family physicians (P3C score 70±21), by paediatricians (P3C score 69±17) and by nurses (P3C score 58±24) than when it was provided by midwives (P3C score 8±0) or chiropractors (P3C score 26±0).

DISCUSSION

In the present study population, 15% of children did not receive primary care from physicians. Evidence-based guidelines for paediatric primary care and guidance were rarely followed. Compliance with evidence-based guidelines was not better when the primary care provider was a physician than when it was a nonphysician. The only significant difference was the guidance about danger of secondhand smoke that was given more often by nonphysicians than by physicians. Even though good evidence-based guides of well-infant and -child health maintenance, such as the Rourke Baby Record, exist, they were not followed by primary care providers in the present study. The majority of children were followed by family physicians, which was expected because paediatricians are mainly asked to provide secondary and tertiary care. Parents whose children were followed by family physicians and paediatricians were more satisfied about the care they received than were those followed by midwives and chiropractors. Parents’ satisfaction with the care offered by nurses was intermediate.

Families in all three groups had problems with accessibility. Parents had difficulty accessing their primary care provider and getting an appointment in a timely matter for routine care. When their child was ill, it was hard to see their primary care provider within one day and to get help or advice on evenings or weekends. Physicians’ availability, setting and timing were all suboptimal for parents to get primary care for their child.

A recent survey done in the United States showed that of 432 children aged four to nine months, 82% were followed by paediatricians. In that population, nearly all parents had discussed immunization issues with their primary care provider, while approximately 90% of them had discussed breastfeeding and adequate sleeping position. Guidance about car safety seats was provided for 86% of parents (6). Also, 77% of paediatricians had discussed the dangers of second-hand smoke with parents (7). Finally, the global satisfaction rating of parents was 86.5% (8). Satisfaction was higher for children in excellent or very good health and for those where the duration of the visit was longer than 10 min. Satisfaction was the lowest for Hispanic children, for those who received their care in a community health centre or a hospital clinic, and for those who had missed or delayed care (8).

Immunization issues were discussed as often in the present study as in the American survey (7). Guidance about breastfeeding, adequate sleeping position, car safety seats and the dangers of second-hand smoke was given less frequently in our population than in the population in the American study. Satisfaction with primary care was similar between the two populations.

Primary care providers need to use already existing and easily available tools, such as the Rourke Baby Record, to improve the quality of paediatric primary care. The challenge is to find a way to facilitate and support the application of evidence-based practice and policies.

Finally, there are limitations to the present study. The cohort was small and originated from a small geographical area, which limits the generalizability of the study results. Also, there may have been a response bias: parents who were less satisfied about the care they received or those who had a bad experience may have been more prone to complete the questionnaire to manifest their displeasure. Finally, there was probably a recall bias. Parents may not have remembered six months later everything that was said or done at the time of their visit with their primary care provider. On the other hand, because five of the seven criteria of the Rourke Baby Record are related to guidance, we believe that if parents did not remember the guidance provided, the goal of the encounter was not achieved. The health care providers may have given more accurate data.

CONCLUSION

Because the maintenance of good health starts with prevention, paediatric primary care should be a priority of Canada’s health care system. Parents were more satisfied with the primary health care of their infants when it was delivered by physicians than by alternative health care providers. Evidence-based guidelines were rarely followed by health care providers in the study population. Studies and strategies need to be identified to improve the quality and accessibility of primary care for children.