Well-child care is a near-universal service for young children toward which a great deal of time and professional resources are devoted but for which there is scant evidence of effectiveness in routine practice. It is composed of many components, the value of which likely varies with the quality of their provision and the needs and priorities of the children and families who receive them. Achieving more efficient and effective preventive care will require that pediatric practices segment the population they serve and design schedules and staffing to match patients’ health, well-being, personal and social circumstances, and service needs. Care should be individualized and include essential screening, tests, procedures, and education on the basis of assessment of patients’ and families’ needs and priorities. The traditional schedule of individual, comprehensive preventive care visits should be reconsidered and replaced with a schedule that allows complete care to be provided over a series of visits, including those for acute and chronic care. Preventive pediatric care should be provided in family-centered, team-based practices with strong linkages to other providers in the community who serve and support children and families. Care should make use of the wide variety of modalities that exist, and face-to-face time should be reserved for those services that are both important and uniquely responsive to in-office intervention. This model of preventive care will require changes in training, responsibilities and reimbursement of health care team members, and enhanced communication and collaboration among all involved, especially with families.

Pediatric preventive care (PPC) has not realized its full potential. Core screening rates remain variable, health disparities by income and race and/or ethnicity are substantial, chronic illness increases throughout the life course, and life expectancy at birth has declined. The current approach is in need of fundamental change. The quality improvement field prioritizes systemic improvements to address such deficiencies to improve effectiveness and efficiency.1  In this article, we provide an overview of the current status of PPC and recommend systemic improvements that encompass national health policies, public health activities, payers’ procedures, professional education and care guidelines, and practice-level organization and operation.

To begin, there needs to be agreement on the goals and desired outcomes of well-child care (WCC) and identification of the gaps between intent and achievement. The objectives of PPC have changed over time, as has its content. They have evolved from averting disease and injury to promoting health and well-being, development (physical, cognitive, and socioemotional), and health-related quality of life.2  Recent expansions include addressing risks, including health behaviors, to prevent the emergence or reduce the impact of social and environmental conditions and experiences that can lead to poor health over the life course3  and promotion of flourishing and resiliency.4  Accordingly, these visits have changed to emphasize addressing parents’ needs for information, guidance, and support.5 

Parents’ expectations of WCC differ across and within groups defined by race, ethnicity, culture, and education. In general, parents seek guidance, advice and counseling, immunizations, physical examinations, and reassurance about how well they and their children are doing.6,7  Their expectations are personal and specific and require selective alignment with the extensive content of Bright Futures and numerous clinical reports and policy statements published by the American Academy of Pediatrics, which drive practice.5  The goal of PPC should be to match preventive services with child and family needs and priorities identified by the family and the pediatrician. Doing this effectively will require greater adherence to the components of the medical home concept (care that is accessible, continuous, patient centered, team based, and comprehensive) and will require applying principles of population health in practices while strengthening individualized care.

WCC visits make up a substantial and increasing part of pediatric practice.8,9  Unfortunately, there is scant evidence that WCC as typically provided has a demonstrable impact on children’s health and well-being.1012  Some individual components of WCC have been demonstrated to be feasible and efficacious in controlled studies, but there is less evidence that they are being effectively applied in practice. Significantly different rates of screening occur between feasibility of studies and surveys of practitioners. For example, in a quality improvement study of rates of adolescent depression screening in intervention practices, adolescents were 3.5 times more likely to be screened than those in other practices and had 37.5 times greater odds of being screened with a validated tool.13  The US Preventive Services Task Force, which applies the most rigorous criteria, has found sufficient evidence to recommend only a few components of usual WCC: immunizations and screening for vision, obesity, dental caries, and major depressive disorders among adolescents, as well as counseling adolescents about sexually transmitted diseases and tobacco use initiation.14 

Although expansion of public health insurance has noticeably increased children’s potential access to preventive care, the 2017 national average use rate for preventive services by children enrolled in Medicaid and the Children’s Health Insurance Program was 58% of recommended visits. It is highest in the first year of life, then drops substantially,6,1517  but is higher when patients have a regular source of care.18,19  Screening rates remain low, immunizations are not complete, parents report unmet needs, and attendance is not good, remaining far below what is recommended. There are no data on the extent to which preventive visit content is individualized, but studies reveal that content is often incomplete relative to professional recommendations.2026  For example, even with clear policy recommendations for universal developmental screening27  since 2006, current screening rates of young children28,29  range between ∼30% and 36%. Similarly, only 72.5% of children 5 years old have ever had their vision tested.30  Anticipatory guidance, despite consuming up to one-third of visit time, does not consistently meet families’ needs.31 

Contributing to these data, some parents do not see value in WCC beyond immunizations, and for others, the failure to address their concerns, questions, and priorities reduces the perceived value of and attendance at these visits. Even when visits are made, the breadth and depth of preventive services delivered vary widely because of factors such as continuity, privacy, clinician skill, race and/or ethnicity, language, gender, and clinician time.3234  Ironically, children with potentially the greatest need for PPC, those in low-income and racial minority families or whose parents have lower educational attainment, are less likely to receive preventive care.3537  Challenging change and contrary to evidence, pediatricians generally feel that preventive care is going well.38  Most have positive attitudes toward serving as a medical home for their patients, although they feel that their positive mindsets are not sufficient to overcome the barriers they perceive in terms of personnel, skills, and time.39 

Perhaps too much is being expected of pediatric practices,40,41  especially in the limited time pediatricians have available.34  Perhaps some of what is being provided is not necessary for every child or family.4244  Perhaps some is not necessary at all.45  The question may not be if PPC is effective, but rather for whom, by whom, with what content, with what modalities, in what circumstances, and over what period is it effective.

The previous observations suggest several systemic recommendations for the profession to consider, many of which have been advocated for previously.

The transformation of PPC into a system of care that is valued, high quality, and enhances the well-being of children is possible because most pediatricians value their role in promoting children’s health and desire to provide appropriate and effective care.46  It requires care tailored to the needs and preferences of families, a team-based approach, external partnerships and adjunctive support to pediatric practices, individualized content and periodicity schedules, changes in how families access care, and use of technology to assess needs, monitor health and development, and educate families. In addition, the profession needs to promote preventive care by distinguishing it from treatment care and encouraging attendance47  through public education, outreach to patients, and advocacy for social policy to promote prevention as a social norm and as an investment in human capital.48  Payers, public and private, need to be educated about the value to them and society of promoting children’s health.

Key to practice transformation is a two-step approach to better align services with families’ needs, priorities, and strengths. The first step, based on principles of population health, requires characterizing and segmenting the practice’s population according to health status and/or social risk factors. This tiering is intended to allow practices to prospectively identify the number and type of patients who will need more or less intense and complex preventive care. With this knowledge, practices can adjust scheduling, staffing, and other practice characteristics for greatest efficiency.

Practices can segment their population using their own strategies and a variety of risk indicators available through patient registries, public databases, medical records, and their own observations. These indicators are usually sorted into domains, especially demographic, social, economic, educational, health, and environmental. Many of these indicators co-occur.4954  Thoughtfully done and with the advice of families, such practice population tiering can help determine the types of services and resources that are needed to meet primary, secondary, and tertiary preventive care needs. Health plans can assist practices by applying tiering algorithms based on the administrative data of their enrollees55,56  and sharing the results with the practices serving those patients.

Segmenting patient populations is useful for planning and redesign at a practice or system level, but it is a relatively coarse tool and may misclassify families and not accurately reflect recent movement between risk tiers. To alleviate these concerns and ensure appropriate care, the second step is to individualize visit schedules, content, and modalities. Key to individualization is that practices regularly employ standardized assessment protocols to identify both the strengths and needs of individual patients and families and use this information as the basis of a care plan for each child.

Care should be based on a relationship of trust, a continuous, therapeutic relationship between the patient, family, and health care professional(s). PPC visits are an important opportunity for that to develop46,57,58 ; healing relationships can be created in all types of patient encounters when the principles of patient-centered care are applied.59,60  Such care is empathetic and respectful of parents’ expertise and responsive to individual patients’ beliefs, preferences, priorities, and needs; it ensures that families’ values guide all medical decisions.5,6165 

Relationships are a two-way street and, as such, are influenced by patients’ beliefs, attitudes, and experiences.6668  Trust in the medical profession may be in short supply by some groups, especially African Americans, who have a history of being mistreated by health care providers.69  The intersection of trust and patients’ beliefs has been evident in parents’ attitudes toward accepting advice on immunizations versus other topics.7072  Trust can be built by providing prepared, individualized discussion of the personal circumstances of the patient; continuity; and active collaboration in decision-making about what problems to address, the content of treatment plans, and the promotion of health.7377 

The use of team-based care, including colocation, has been shown to result in more appropriate use and adherence, enhanced referrals, reduced hospitalizations and other efficiencies, and improved patient functional status and satisfaction with care.7882  Pediatricians have supported changing their role and sharing and coordinating some key responsibilities for preventive care with a variety of professionals within and outside the practice,31,83  yet change has lagged. Slow adoption reflects the often required changes in the culture and organization of practices and reimbursement for care, in interactions within the practice, and in education and training.84,85 

The use of technologies to enhance access to PPC is not new,86  but they have been underused.87,88  The coronavirus disease 2019 pandemic prompted rapid, widespread adoption of virtual preventive, acute, and chronic care. Despite the profession’s preference for in-person care,89,90  telehealth and asynchronous communication are more convenient for families who must otherwise devote time and resources to travel, and families will increasingly expect practices to routinely use this technology. Other technologies, such as texting and remote monitoring, allow for timely reminders and more continuous monitoring of children, as well as real-time communication with the provider team. The use of new technologies has been supported by research demonstrating technology’s value in patient education and adherence and health care quality.91,92  Changes in state health policies and in reimbursement are also needed to enable practices to use more technology in all aspects of care while retaining in-person visits as a means to monitor, diagnose, and communicate only when necessary.

Pediatricians know that providing all patients with the same bundle of preventive services, including services to promote health and development, makes no sense. Bright Futures’ guidance provides a thoughtful and comprehensive menu for the content of PPC visits that can be used by pediatricians and parents to individualize anticipatory guidance. Its wealth of suggested content requires prioritization by the pediatrician and parents, so expectations for visits are reasonable and meet the existing and anticipated needs of the family.38,93 

Structured, individualized assessments, including elucidating families’ goals, can help match visit contents with child and family needs. To enhance efficiency, some of these assessments can be done before the visit, allowing the pediatrician to tailor the encounter to meet parents’ concerns, questions, and priorities.94  Tools such as the Well Visit Planner have been shown to assist parents in understanding their goals for their child, prioritize topics for discussion during the well-child encounter, and decrease the number of visits to the emergency department.95,96  Special consideration needs to be given on how to best provide preventive care to children in low-income families, those living geographically distant from medical care, recent or not fully acculturated immigrants, children with special health care needs, and children who have experienced trauma or discrimination, as well as families with language barriers or low health literacy and families troubled by mental illness, substance abuse, or interpersonal violence. Tiering practice populations can assist with this determination.

Families have the primary responsibility for children’s health and development and health and health care behaviors, and pediatricians appreciate that often the best way to help children is to help their parents. To accomplish this, focusing on families’ needs, capacity, and goals is essential as advice and guidance are offered.

Pediatrician-provided anticipatory guidance is the near-universal approach to facilitating the families’ role in their children’s health and well-being. Anticipatory guidance includes child development and behavior, safety, nutrition, oral health, family support, physical activity, and community ties. Being able to provide guidance on all those topics means overcoming a number of systemic barriers and can be a daunting, if not impossible, task for the pediatrician; documented successful anticipatory interventions are limited.9799  Most successful guidance requires multiple contacts over an extended period. Maximizing the impact of PPC requires that care be individualized, perhaps by using a list of anticipatory guidance topics for each family based on their needs and interpreted within the context of the families’ personal history, their cultural background, and their children’s health and development.

Words have meaning, so the term “well-child care” should be reconsidered. Many children are not truly well. They may have a chronic illness or significant risks, including social, psychological, educational, and medical, and may be in greater need of preventive services than others. Preventive services should not be confined to scheduled preventive care visits.100,101 

PPC visits generally follow the American Academy of Pediatrics’ periodicity schedule, a timetable initially driven by immunization schedules and the child’s age.102  Strict adherence to standard schedules and content for each PPC visit for all children is likely to be inefficient and variably effective, but there are no data on how often different schedules are used. Fewer visits may be sufficient for healthy103  or latter-born children, and additional visits may be necessary for some children and families. Standardized preventive care schedules may work for most children, but, like PPC, visit content and schedules should be individualized to account for different care needs.

The provision of pediatric care is only one contributor to achieving optimal child health and development. Pediatricians have an important role in preventing the adverse impacts of social factors on children’s health and families’ functioning, primarily by effectively screening children’s and families’ circumstances, needs, and strengths, and connecting families to appropriate and acceptable sources of social assistance either embedded in their practices or in the community.104107  Consequently, the services of many sectors (medical, social services, public health, education, religion, recreation, and environment) are required. To connect families to these other services, practices must have established linkages with community programs, supported by good communication, navigation, and care coordination. There is evidence that screening followed by appropriate referrals can enhance families’ ability to meet their children’s needs.108,109 

When partnering with others to promote children’s healthy development, the use of similar screening instruments and protocols, shared care planning and plans, shared data, common metrics, memoranda of understanding, colocation, and enhanced communication by using information technology can be helpful.110 

There are a growing number of programs specifically designed to supplement and support the services provided by primary care practices.26,111  These include such things as developmental screening and school-readiness assessments done in early care and education settings, referral support and care coordination, legal assistance, behavioral health care, child development expertise, parent education, and home visiting. Although some of these programs are well established and evidence based, few are reaching significant numbers of practices and families.

Practice change should be driven by achievement of desired outcomes through quality measurement and improvement. Unfortunately, there is little agreement on how best to measure the quality of PPC. Most measures are counts of processes enumerated in the periodicity schedule and rates of attendance at visits. These measures fail to capture the totality of WCC or reflect the substantial efforts made by child health care providers to improve the health and well-being of their patients.

To improve quality measurement, a crucial first step would be reaching agreement on the intended outcomes of PPC.112  For example, PPC for children aged 0 to 5 years could emphasize the contributions of health care to school-readiness outcomes, which have been previously described; although most are assessed through process measures, they document the provision of important services.113  The creation of individualized preventive care plans and shared plans of care can guide care and provide the basis for assessing the achievement of desired outcomes. Quality measurement can also document actions consequent to screening, generally referral to community-based programs.

Most measures of PPC quality cannot be based on child outcomes given the difficulty ascribing credit to brief intermittent clinical encounters, the multifactorial etiology of the desired outcomes, and their manifestations distant in time from preventive care. The impact of preventive care is the result of cumulative health care encounters over time and calls for a unit of analysis composed of a series of visits or episodes of care rather than a single intervention.114  PPC quality measurement could focus on the proximal outcomes of attaining desired changes in parents’ knowledge, attitudes, and behaviors vis-à-vis their children and on changes in children’s health behaviors, such as exercise and healthy eating, in response to their parents’ cues and guidance.

PPC done well must provide greater equity in children’s care and outcomes across races and/or ethnicities, socioeconomic status, and insurance status. Examining quality performance by those demographic variables, as well as providing a more comprehensive view of family well-being by using health-related quality of life measures, can help ensure parity of care across diverse groups.

Payers determine which services will be paid for and which providers are eligible for payment. Administratively, little distinction is made between preventive care and treatment, so the same rules tend to apply to both. Because much of preventive care can be provided by nonphysicians and some by nonprofessionals, existing provider eligibility and scope-of-practice rules may be restricting efficiency and innovation in preventive care.

Preventive care does not align well with insured services because most services and associated costs, when adjusted for population characteristics, are predictable and thus do not require the shared risk underlying insurance. Preventive care financing could be separated from other health care financing, especially when volume-based fee-for-service payment is used and covered as a universal benefit without copayments.115  Similarly, PPC could be funded through a risk- or tier-adjusted capitated payment, allowing resources to better match patients’ needs.116  Another proposed approach is a blended or braided multisector fund supported by public programs in health, education, child welfare, and juvenile justice to address social factors affecting their clients.117  All of these approaches provide flexibility and opportunities for innovation not easily available under a fee-for-service system. As has been done in some other countries,84  they would enable a wider variety of care providers to be reimbursed for their services; would enable care to be provided at additional sites, such as schools and homes; and would enable wrap-around services, such as outreach and care coordination, to be provided. All would provide health care systems and practices with ways to address social determinants of health and thus reduce some health disparities.

Lastly, successful practice transformation depends on the presence of key drivers for change. These drivers can be divided into 3 categories: cultural, financial, and personal. Cultural change includes an enhanced valuing of child development and PPC on the part of both providers and parents. PPC lacks a “burning platform” to motivate change and will require enhanced recognition of the value of individualized PPC in achieving long-term outcomes for children’s health and development. A financial impetus of change has been discussed above and requires alignment of resources to support PPC. A cultural change asks providers to reassert the value of developing long-term, healing relationships with families as consistent with their vision of becoming a health care professional and as an antidote to disenchantment with practice.

Unlike most other developed countries, the Unite States has no comprehensive federal oversight or planning for either adult preventive care or PPC, no defined infrastructure for prevention within medical practices or in communities, and demonstrably inadequate support for existing public health systems.118,119  Some assurance that children will access some aspects of preventive care is provided by states through immunization policies and Medicaid Early and Periodic Screening, Diagnostic, and Treatment benefits and other public insurance programs and locales through child care and school entry and participation requirements. Medical care is partly driven by budgetary considerations even in nonprofit settings. Consequently, there is substantial variability in access, content, and quality of PPC depending on where a child lives and how care is reimbursed.120  Health care reform efforts over the past 2 decades have focused on short-term cost containment primarily related to adult chronic illness. In contrast, expenditures on health care for children and young adults must be viewed as a long-term societal investment, a view that is at odds with our current budgetary approach, which focuses on short-term returns on investments.114,121,122  Consequently, it is unlikely that market forces alone can accomplish the changes needed to better finance PPC; this will require legislative and regulatory action as well.123  In most states, Medicaid pays less for medical care than Medicare or commercial insurance. Because Medicaid is disproportionately the source of payment for medical care for children from low-income families and children of color, their care is especially susceptible to the effects of poor payment.124  Publicly financed health care, Medicare and Medicaid, should provide parity of payment, especially for preventive care, regardless of the age of the patient, so that providers caring for children with public insurance are paid adequately and so opportunities for access and quality exist.

There is a need for articulated policy goals and visible action to improve the health of children and the functioning of their families.123  Governments, informed by families and professionals, should establish and enforce system and care standards to ensure capacity for equity, provision of indicated services, and monitoring of performance.125  A priority of those efforts should be to reduce disparities in the health of children in the Unites States. Achieving health equality will require policy support for multisector efforts to address the medical, social, and educational factors influencing children’s health and well-being. The Integrated Care for Kids model of the Center for Medicare and Medicaid Innovation is such an effort and is aimed at integrating care across behavioral, physical, and other health-related social services and community-based child providers while sharing accountability for cost and outcomes.126 

PPC requires thoughtful differentiation from acute and chronic care within practices and substantial change from current practice. Changes should address intervals and durations of visits, visit contents, pre- and postvisit actions, staffing and team membership, the application of new technologies, and formal linkages to adjunctive and supportive community services.127  Preventive care can be more efficient and effective by applying principles of population health management that reflect the impact of families’ values and social circumstances and by individualizing care on the basis of standardized, comprehensive assessment. New quality measures are needed for key processes, including those that address social determinants of health and behavioral outcomes of the child and family. Payment needs to evolve toward risk-adjusted capitation that supports practice infrastructure, collaboration, direct services to the child, and interventions to enhance parents’ capacity to promote their children’s health and development.

Dr Schor conceptualized the article, drafted the initial manuscript, and reviewed and revised the manuscript. Dr Bergman drafted the initial manuscript and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

This special article does not contain a discussion of an unapproved/investigative use of a commercial product or device.

FUNDING: No external funding.

PPC

pediatric preventive care

WCC

well-child care

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.