CHANGES IN THE DAILY PRACTICE OF PRIMARY-CARE FOR CHILDREN

Background: The environment in which medicine is practiced has changed in the past 2 decades, but little information has been available on h ow the day-to-day practice of primary care for children has changed du ring this period. Objective: To identify aspects of primary care pract ices for children that are undergoing substantial changes. Design: Ana lysis of National Ambulatory Medical Care Surveys from 1979 to 1981, 1 985, and 1989 to 1994. Participants: Primary care practitioners record ed data on 58 488 child visits.Main Outcome Measures: Characteristics and insurance status of children, physician activities during visits, and disposition after visit. Results: Child visits to primary care phy sicians increased by 22% between 1979 and 1994. The mean age of childr en visiting primary care physicians decreased from 6.7 years in 1979 t o 5.7 years in 1994 (P for trend, <.001). The ethnic diversity of chil d visits increased primarily as a result of an increasing proportion o f visits by Hispanic (6.0% in 1979 to 12.6% in 1994, P for trend, <.00 1) and Asian patients (1.6% in 1979 to 4.1% in 1994, P for trend, <.00 1). Medicaid and managed care increased dramatically as sources of pay ment. Changes in physician activities included an increase in some pre ventive services, changes in the most commonly encountered medications , and an increased mean duration of patient visits (11.8 minutes in 19 79 to 14.2 minutes in 1994, P for trend, <.001). Conclusions: These da ta may assist in the development of educational and research initiativ es for physicians caring for children. The declining proportion of ado lescent visits may present physicians with challenges in the care of a dolescents. Physician prescribing practices showed changes without evi dence of a benefit to child health. The increased ethnic diversity and provision of preventive services were associated with an increased me an duration of primary care visits. The increased duration of child vi sits may conflict with the managed care emphasis on physician producti vity.