Assessing Health System Provision of Well-Child Care: The Promoting Healthy Development Survey

Abstract

Background. Preventive care guidelines for children include parent education and counseling, developmental assessment, and screening for psychosocial and safety risks. Health care providers are in a unique position to identify and follow up on potential problems and to influence parenting knowledge, attitudes, and behavior to ensure the healthy development of young children. Few quality measures are available to assess health care system performance in this important area. Objective. To develop a feasible, valid, and reliable methodology for evaluating health care system performance in providing family-centered anticipatory guidance and child and family assessment services on behalf of children from birth through 48 months old. Methods. The Promoting Healthy Development Survey (PHDS) was developed and tested with a diverse group of families in 3 managed care organizations (n = 1478). A standard mail administration protocol was used, including an informed consent with a waiver of documentation, 2 mailings, a postcard reminder, and telephone reminders. The 36-item parent survey assesses whether health care providers1 talk with parents about topics recommended in Bright Futures and the American Academy of Pediatrics Guidelines for Health Supervision,2 provide follow-up for children who may be at risk for developmental problems,3and address psychosocial well-being and safety within the family. The PHDS also assesses the degree to which parent's interactions with providers are family-centered, helpful, and facilitate parental confidence. Psychometric, bivariate, and multivariate analyses were conducted to assess the reliability, validity, and patterns of variation in the seven quality measures derived from the PHDS. Results. Psychometric analyses demonstrated that the PHDS quality measure scales have strong construct validity (mean factor loading: 0.69) and internal consistency (mean Cronbach's α: 0.80). Parents reporting positive parenting behaviors had significantly higher scores on the anticipatory guidance quality measure compared with parents not reporting positive behaviors. Parents who reported that their questions on specific anticipatory guidance topics were answered were more likely to report higher confidence in related parenting activities (odds ratio [OR]: 5.9, 95% confidence interval [CI]: 3.4–10.2; OR: 8.3, 95% CI: 5–13.8)and were less likely to report concerns about their child's development in related areas compared with parents who reported they wished they had talked more with their child's doctor about these topics (OR: 0.46, 95% CI: 0.29–0.72; OR: 0.58, 95% CI: 0.37–0.89). The 7 PHDS quality measure scores for health plans ranged from 17 to 67 (on a 0–100 scale; where 100 is the best score possible) and varied significantly across health plans. Performance was highest for provision of anticipatory guidance information from health plans and lowest for family psychosocial assessment. Scores for families with Medicaid coverage were significantly higher on 2 of the PHDS measures and significantly lower for 3 measures compared with scores for families with commercial insurance. Age of child, whether child is first- born, parental marital status, education, income, and race were significant predictors for 1 or more of the PHDS quality measures (average R2 = 0.05). Conclusions. The PHDS provides a comprehensive, psychometrically valid and reliable assessment of how well health plans and the health care providers working within these plans promote the healthy development of young children. The PHDS seems to differentiate among health care plans and among the different aspects of preventive care provided within a health plan. For the population studied here, there is significant room for improvement in ensuring families and children receive appropriate and family-centered care to promote the healthy development of children between 3 and 48 months old. Because the PHDS is conceptually based on national recommendations for child health supervision, improved performance on the PHDS would indicate greater adherence to these national recommendations and progress toward the achievement of Healthy People 2010 goals. The generalizability of the findings presented in this report are being examined using data collected in 5 statewide Medicaid samples (N = 11 696) and data from the National Survey of Early Childhood Health, which has incorporated most of the PHDS items.