Issue Brief February 2019 Survey Compares Adult and Pediatric Chronic Condition Management in Primary Care Practices by Edward L. Schor, MD, Lori Turk-Bicakci, PhD, Holly Henry, PhD Abstract Care management is a highly valued aspect of care for patients with chronic conditions, and its absence can create or exacerbate health problems. Though most commonly associated with adults, chronic care management is becoming increasingly important in pediatric practices as the number of children with complex chronic conditions continues to grow. Pediatric practices traditionally have been designed and staffed to provide acute and preventive care. Adult internal medicine practices see a preponderance of patients with chronic health problems, and presumably have designed their practices to serve this population well. This study compared data from a survey of primary care pediatricians and adult internists who care for patients with multiple chronic conditions. The data cover access to care, care coordination, health information technology, quality improvement, and satisfaction with patient care in their practices. Compared with pediatric patients, internists’ patients had more chronic illnesses and were much more likely to require home and palliative care; more internists than pediatricians reported that their practices were prepared to manage such patients. Pediatric practices reported greater ability to offer same-day appointments, but neither pediatric nor adult practices reported differences in offering after-hours care or using email to communicate with their patients. Both types of practitioners reported frequently coordinating care with social services, but internists had more patients requiring this service and reported being better prepared to provide it. Data from both types of practices indicated substantial room for improvement in their ability to provide high quality, comprehensive chronic care management of medical conditions. Introduction The different diseases and disorders that make The proportion of children with chronic up pediatric and adult-onset chronic conditions, physical, developmental, behavioral or and the contrast in their prevalence, have been emotional conditions ranges between 15-20 previously noted.1 Chronic health problems are percent nationally, depending on various highly prevalent among older adults2 and rates demographic indicators.3 Consequently, caring of chronic conditions increase with age. for children and adolescents with chronic health Survey Compares Adult and Pediatric Chronic Condition Management in Primary Care Practices 1 www.lpfch.org/cshcn problems is an important part of pediatric physicians. Details of the study methods have primary care practice. been previously published.4 The US sample included 288 internists and 237 pediatricians. The differences between children and adults, The remainder of the US sample (N=1001) were especially the central role parents play in the family medicine physicians and general management of children’s chronic medical care, practitioners who were excluded from the might lead to present study because they would be similarly Understanding differences in the equipped to manage chronically ill patients similarities and capacity and regardless of age. The response rate in the US differences between operation of pediatric was 31 percent. Although non-respondents these specialties could and internal might differ from respondents, data were be useful in identifying medicine practices. weighted to account for differential responses as ways to improve Understanding the well as geographic and demographic chronic care and in similarities and parameters. The final weighted analytic sample preparing patients and differences between included 367 internists and 214 pediatricians practices for the transition from these two specialties who saw patients with multiple chronic pediatric to adult care. can be useful in conditions. The survey was based on the views identifying ways to and experiences reported by physicians. The improve care of chronic conditions. results have not been validated by independently Anticipating differences is important in obtained data. preparing patients and practices for the transition from pediatric to adult care. The To the extent possible, survey items were prevalence of adult chronic conditions suggests aggregated within categories of chronic care that internal medicine practices might be better activities found in descriptions of chronic care equipped to provide chronic medical care. models5, 6, 7, 8 and standards for systems of care for children with special health care needs.9 The Access to data from an international study of significance of differences between responses management of chronic conditions in primary by internists and pediatricians was calculated care practices, including US practices, provided using Pearson Chi Square tests. the opportunity to examine whether pediatricians and internists manage their chronically ill patients differently.4 Results In the following comparisons, data from Method pediatric practices always precede data from internal medicine practices (Pediatric vs Internal The 2015 Commonwealth Fund International Medicine) regardless of the direction of Health Policy Survey of Primary Care difference. Many practice characteristics and Physicians was administered online and through behaviors differ significantly between pediatrics mail surveys to a random sample of internists and internal medicine (Table 1). However, some and pediatricians. Samples were drawn from practice behaviors did not differ (Table 2) government and private lists of primary care Survey Compares Adult and Pediatric Chronic Condition Management in Primary Care Practices 2 Lucile Packard Foundation for Children’s Health Table 1: Practice Characteristics and Behaviors that Differ Between Pediatrics and Internal Medicine Pediatrics Internal Medicine Category Practice Indicator (%) (%) Often sees patients with multiple chronic problems 46.0 98.4*** Patients in need of long-term home care 8.5 48.2*** Well-prepared to manage patients in need of long- 17.6 55.0*** Patient term home care Population Patients in need of palliative care 6.1 32.4*** Well-prepared to manage care of patients in need of 8.1 52.6*** palliative care Major problem getting patients medication or 41.0 62.0*** treatments because of coverage restrictions Well-prepared to care for patients with multiple 57.5 87.1*** chronic conditions Provide same or next-day appointments for almost 71.8 46.8*** all patients Access Often long waiting times to see a specialist 40.1 28.6*** to Care Patients often need to get specialized diagnostic 19.8 27.4* tests At least 80% of physician time spent on face-to- 61.3 48.2*** face contact Often or sometimes having patients in need of 58.4 83.0*** social services Well prepared to help patients in need of social 24.6 36.7** services Coordinating with social services was easy or very 31.3 39.9* Care easy Coordination Patients experienced problems because care was 34.1 45.7** not well coordinated Frequently contacts patients between visits to 49.3 38.5** monitor conditions Frequently coordinated follow-up care for patients 51.9 66.7** discharged from hospital Received, reviewed data on preventive care 51.9 61.3* Quality Improvement Received, reviewed data on clinical outcomes 43.4 59.2*** Satisfaction Amount of medical care too much or much too with patient 29.3 44.3** much time *** < .001; ** < .01; * < .0 Survey Compares Adult and Pediatric Chronic Condition Management in Primary Care Practices 3 www.lpfch.org/cshcn Table 2: Practice Behaviors that Do Not Differ Between Pediatrics and Internal Medicine Internal Pediatrics Category Practice Indicator Medicine (%) (%) Often see of patients with severe mental illness 24.9 26.7 Patient Somewhat or well-prepared to care for patients with severe 56.6 55.7 Population mental illness Routinely communicate with home care providers 48.1 58.2 Access Available after-hours care 44.1 40.1 to Care Communicate with patients via email 52.9 57.8 Coordinate frequently with social services 40.2 48.5 Easy or very easy communicating with social services 31.3 39.9 Care Well prepared to meet patients’ need for language translation 39.2 38.5 Coordination Routinely provide written instructions for self-management 52.3 49.7 support Routinely record self-management goals 39.3 37.1 Use of electronic medical records 84.4 84.1 Meaningful use of electronic medical records: Health • Exchange clinical summaries Information 44.1 45.8 • Generate registries by diagnosis Technology 80.1 75.1 • List patients due for care 65.9 67.2 • Comprehensive medication list 70.5 74.9 Quality Receipt of financial incentives tied to patient satisfaction 23.1 29.1 Improvement ratings Patient Population Internal medicine practices were significantly 53%; p<.001). Internal medicine practices more likely to see patients with multiple chronic experienced greater difficulty getting patients problems often (45% vs 98%; p<.001). They needed medication or treatments because of were much more likely to often have patients in coverage restrictions (41% vs 62%; p<.001). need of long-term home care (9% vs 48%; There were no significant differences between p<.001) and report higher rates of being well- the practices routinely communicating with prepared to manage such patients (18% vs 55%; home care providers (48% vs 58%). p<.001). They also reported significantly higher Both reported similar rates of often seeing rates of often and sometimes having patients in patients with severe mental health problems need of palliative care (17% vs 84%; p<.001) (25% vs 27%), and both reported similar but and of being well-prepared to manage the care low rates of being somewhat or well-prepared to of patients in need of palliative care (8% vs care for those patients (57% vs 56%). Survey Compares Adult and Pediatric Chronic Condition Management in Primary Care Practices 4 Lucile Packard Foundation for Children’s Health Access to Care similar rates of providing patients with chronic conditions with written instructions for self- Internists reported higher rates of being well- management (52% vs 50%) and for recording prepared to care for patients with multiple self-management goals in patients’ medical chronic conditions (58% vs 87%; p<.001), while records (39% vs 37%). Pediatricians’ said their pediatricians reported a significantly greater patients reported fewer problems due to a lack ability to provide same or next-day of care coordination than did internists’ patients appointments for almost all their patients (72% (34% vs 46%: p<.01). vs 47%; p<.001). The specialties differed little in terms of having an arrangement for after- Pediatric and internal medicine practices did not hours care (44% vs 40%) or offering email report significant differences in having office communication with patients about medical personnel monitor and manage patients with concerns (53% vs 58%). There were expected chronic conditions who need regular follow up differences in the frequency with which patients (62% vs 70%), but among both types of required long-term home care and palliative care practices, those that were part of a larger, services, with internists experiencing this need integrated provider system, e.g., Kaiser about five times more often than pediatricians. Permanente, Mayo Clinic, etc., were one-and-a- Internists’ patients less often experienced long half times more likely to use office personnel to wait times to see a specialist (40% vs 29%; monitor and manage care of patients needing p<.001) but had slightly more difficulty getting regular follow-up than non-system practices specialized diagnostic tests (20% vs 27%; (82% vs 60%; p<.01). Pediatric practices more p<.05). A higher percentage of pediatricians frequently contact patients between visits to reported spending 80% or more of their time on monitor their conditions (49% vs 39%; p<.01). face-to-face contact with their patients More internal medicine practices reported compared with internists (61% vs 48%; p<.001). frequently coordinating follow-up care for patients being discharged from hospital (52% vs Care Coordination 67%; p<.01). Both practices had equal proportions reporting they were well-prepared Less than half of both types of practices to meet patients’ need for language translation reported frequently coordinating care with (39% both groups). social services or other community providers (40% vs 49%), though internal medicine Health Information Technology practices reported significantly higher rates of often or sometimes having patients in need of There were no significant differences reported social services (58% vs 83%; p<.001) and being between pediatric and internal medicine well prepared to help patients in need of those practices regarding the availability of electronic services (25% vs 37%; p<.01). The specialties medical records (EMRs) or meaningful use of differed in reporting that coordinating with that technology. About 84% of both practices social services was easy or very easy (31% vs reported using electronic medical records, but 40%; p<.05). Both types of practices reported only about half can exchange information with 5 Survey Compares Adult and Pediatric Chronic Condition Management in Primary Care Practices 5 www.lpfch.org/cshcn physicians outside of their practice (44% vs Discussion 46%). At least three-quarters can produce a computerized registry of patients by diagnoses The patient populations seen in internal (80% vs 75%); two-thirds can identify patients medicine and pediatric practices in the US differ who are due or overdue for preventive care in terms of their requirements for management (66% vs 67%). About three-quarters can list all of chronic conditions. More than half of US medications taken by an individual patient (71% adults over 20 years of age have at least one vs 75%), and 76% provide a clinical summary chronic condition, and many have multiple of each visit to give to patients. conditions. The majority of conditions are among six to eight diseases that internists are Quality Improvement trained to manage.10 Chronic medical care for adults constitutes 33 to 56 percent of Both types of practices were equally likely to ambulatory care visits, with higher rates at older receive and review survey data on patient ages.11 Pediatric chronic medical conditions are satisfaction (66%), though internal medicine much more varied and less prevalent. Broad, practices were more likely to receive data on multi-dimensional definitions suggest that up to provision of recommended preventive care about 20 percent of children and adolescents (52% vs 61%; p<.05). Internists were more have a chronic condition, but when chronic likely than pediatricians to receive and review intermittent conditions (e.g., allergies) that don’t data on clinical outcomes of their patients (43% limit daily functioning are excluded, prevalence vs 59%; p<.001). A similar proportion of both is about 4 to 7 percent,12, 13 and children with types of specialists received extra financial multiple chronic conditions comprise less than 1 support or incentives for high patient percent of all children.14 Consequently, satisfaction ratings (23% vs 29%). compared to internal medicine practices, pediatric practices contain fewer chronic and Time for Patient Care complex patients and fewer patients needing home care, palliative care or medications or Only 9% of both pediatric and internal medicine treatments that are difficult to obtain. However, practitioners reported being very satisfied and children with chronic conditions are relatively 47% were satisfied with the time available to high utilizers of care, so they constitute a spend with patients. Forty-four percent of disproportionate amount of pediatric practice internists and 29% of pediatricians reported that visits, reported in two studies as 21 percent15 the amount of medical care their patients and 27 percent.16 Most of those visits were received from them and other providers was too made by patients with high prevalence and low much or much too much (p<.01). severity conditions, e.g., asthma, obesity. Overall, this study found few significant differences between internal medicine and pediatric practices’ management of patients with chronic health conditions, and both have Survey Compares Adult and Pediatric Chronic Condition Management in Primary Care Practices 6 Lucile Packard Foundation for Children’s Health considerable room for improvement in their care that coordination than were pediatric practices. of that population. Opportunities for Pediatric practices reported more frequent improvements were especially notable in contacts with patients between visits. assuring ready access to timely and appropriate care, coordinating care, and organizing Care coordination is an important component of resources and practices so that personnel and the care of patients with chronic conditions and time are available to provide good quality care. its absence can create or exacerbate health In previous studies, pediatricians have similarly problems.23 Among those caring for children reported that lack of adequate time for patient with complex needs, having to coordinate with care, administrative demands, and too few staff many subspecialists can be a barrier to meeting are practice barriers. Few studies have identified children’s needs.21, 24 Pediatric and internal inadequate financial reimbursement as a priority medicine practices were equally likely to barrier affecting care, though payment rates monitor patients with chronic conditions, but have been shown to affect access for those practices that were part of organized Medicaid patients.17, 18 health care systems were significantly more likely to provide that service than those that Accessing subspecialty care was a shared were not part of an organized system. Larger problem, somewhat greater for providers of systems may be better organized and staffed to pediatric care. Previous surveys have identified provide such services. a long list of pediatric subspecialties for which referrals are difficult to arrange.15, 19, 20 Neither specialties’ physicians were very satisfied with the time they have available to Both specialties, but especially internal spend with their patients (9%), though 47% medicine, reported that their patients frequently were satisfied. Pediatricians reported spending needed social and other community-based slightly more time face-to-face with their services, but only about one-quarter of patients, though this study did not include pediatricians and about one-third of internists information on usual visit length. A previous reported being particularly well-prepared to study reported that only 46% of primary care coordinate that care. Previous studies of pediatricians strongly agreed that they were pediatricians have reported substantial lack of satisfied with the care they could deliver to most knowledge about available services21 and of the children with special health care needs in difficulty accessing outside case managers, their practice.17 A substantial portion of home nursing care, and support services internists and somewhat fewer pediatricians for families.22 reported that their patients received too much medical care, an opinion substantiated by Although internal medicine practices reported other research.25 higher rates of patients needing social and other community services and appeared to be better The use of health information technology was prepared to coordinate with those service equivalent between both types of specialty providers, they were no more likely to provide practices. Most practices reported using 7 Survey Compares Adult and Pediatric Chronic Condition Management in Primary Care Practices 7 www.lpfch.org/cshcn electronic medical records and most could from this study suggest that the differences in produce patient registries by diagnosis, identify care, at least in terms of the capacity to manage patients due for care, and provide clinical chronic illness, are not great. summaries after each visit. While both presumably could provide written instructions For pediatricians, the increasing prevalence of for self-management, only about half of the chronic illness among children demands practices did. This is concerning, as providing enhancement of the capacity of pediatricians this type of information is critical to chronic and pediatric practices to better manage their care management. care. Pediatric training programs are required to include exposure to the longitudinal Encouragement to improve the quality of management of children with special needs and chronic care often takes the form of data from chronic conditions,26 but that exposure is health insurers who provide information on effectively cross-sectional and brief relative to patient satisfaction, provision of recommended the life of a child. preventive services, and clinical outcomes, and who may tie financial incentives to good In terms of practice improvements and redesign, performance on these measures. Internal several items should be high on the change medicine practices are more likely than pediatric agenda: better procedures for after-hours care; practices to receive performance data. The aging increasing subspecialty access; improving care of pediatric patients with chronic medical coordination among physicians and with various conditions has led to much discussion about community service providers; supporting self- how to facilitate the transition from pediatric to management by patients and their family adult care. Internists may lack familiarity with members; and advocating for resources to many pediatric chronic conditions and will need appropriately staff practices to meet the needs of consultation and guidance in their management. chronically ill patients. In addition, some have described pediatric care as more nurturing. The increasing prevalence of chronic illness among adults suggests that pediatrics may not Conclusion be doing all it could to adopt a life course perspective and prevent adult morbidity. The Despite some statistically significant differences need for both specialties, as well as other health between internal medicine and pediatric care providers, to address the personal and practices in the care of patients with chronic social factors contributing to the frequency and health problems, clinically meaningful cost of chronic illness remains an important differences, except for palliative and long-term shortcoming in the US health care system. home care, are overshadowed by the need for both specialties to improve their management of these patients. Though there has been substantial discussion about facilitating the transition from pediatric to adult care, the data Survey Compares Adult and Pediatric Chronic Condition Management in Primary Care Practices 8 Lucile Packard Foundation for Children’s Health References 1. Schor EL, Cohen E. Apples and Oranges: Serious Chronic Illness in Adults and Children. J Pediatrics 2016; 17:256–258 2. 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Stewart K, Bradley KWV, Zickafoose JS, Hildrich R, Ireys HT, Brown RS. Care Coordination for Children in Medicaid: Lessons from Medicare. American Journal of Managed Care, 2018 (in press) 24. Foster CC, Mangione-Smith R, Simon TD. Caring for children with medical complexity: Perspectives of primary care providers. The Journal of Pediatrics, 2017; 182:274-282 25. Schwartz AL, Landon BE, Elshaug AG, et al. Measuring low-value care in Medicare. JAMA Internal Medicine, 2014; 174(7):1067-1076 26. ACGME Program Requirements for Graduate Medical Education in Pediatrics. Accreditation Council for Graduate Medical Education, Revised February 6, 2017; effective July 1, 2017. ABOUT THE FOUNDATION: The Lucile Packard Foundation for Children's Health is a public charity, founded in 1997. Its mission is to elevate the priority of children's health, and to increase the quality and accessibility of children's health care through leadership and direct investment. Through its Program for Children with Special Health Care Needs, the Foundation supports development of a high-quality health care system that results in better health outcomes for children and enhanced quality of life for families. The Foundation encourages dissemination of its publications. A complete list of publications is available at http://www.lpfch.org/publications CONTACT: The Lucile Packard Foundation for Children’s Health, 400 Hamilton Avenue, Suite 340, Palo Alto, CA 94301 cshcn@lpfch.org (650) 497-8365 Survey Compares Adult and Pediatric Chronic Condition Management in Primary Care Practices 10