Practice-based education for doctors improves delivery of preventive child care: UNC study

February 13, 2004

CHAPEL HILL — Child health experts widely agree that children should receive a wide range of preventive services to ensure normal development, but the statistics on a variety of health screenings are somewhat discouraging.Statistics show only about 75 percent of 2-year-olds nationwide are fully immunized, and fewer than half of parents receive the information they want about child-rearing or development. The identification of treatable risk factors, such as maternal depression, is extremely low.

A new study led by researchers at the University of North Carolina at Chapel Hill shows that a program of coaching pediatricians and their staff in measuring their performance and implementing new approaches to health-care delivery can dramatically increase the number of children who receive age-appropriate preventive services.

“This study was focused on making sure that kids get the right preventive services at the right time,” said Dr. Peter Margolis, the study’s lead author and a professor of pediatrics and epidemiology in UNC’s schools of medicine and public health. “The idea is to help pediatric practices create a system for improving delivery of preventive services that involves everyone in the office.”

The study was published Feb. 6 on the Web site of the British Medical Journal and will be published in the journal’s print version Saturday (Feb. 14).

Margolis and colleagues randomly selected 44 N.C. pediatric practices that met certain characteristics to take part in the study. Half of the practices received office-based continuing medical education about preventive services as well as training in methods, often applied in industrial settings, to improve health-care delivery. The other half received only a package of information by mail that advocated changes in preventive care delivery.

Project staff working with the researchers used a four-step process to provide education and training to the intervention group. In step one, each practice formed an improvement team of clerical, nursing and physician staff. In step two, project staff provided education about preventive care and effective service delivery strategies, such as developing a preventive services summary or establishing a tracking or recall system. The practices then selected performance improvement goals and strategies for meeting them.

In step three, project staff helped the practices repeatedly test the new strategies in small samples of patients and adapt new approaches to current office routines. Finally, in step four, changes shown to improve delivery of preventive services were implemented throughout the practice by training staff in new roles.

One example of an improvement adopted as a result of study participation was having a nurse screen a child’s medical record at the beginning of each visit. The nurse would then let the doctor know which preventive services that child needed. The medical record screening methods varied from practice to practice; some used a formal checklist while others simply placed brightly colored adhesive notes on a child’s chart to call the doctor’s attention to the child’s preventive services needs.

These and other changes led to big improvements, said Margolis. When the study began, about 11 percent of children in all of the practices had the four age-appropriate preventive services documented in their medical records. When the study ended, 4.6 times as many children cared for by the doctors in the intervention group had received these services as those in the control group.

The intervention’s greatest impact was on screening for lead, tuberculosis and anemia, he added. For example, by the study’s completion, 68 percent of children in the intervention group had received screening for lead compared to only 30 percent of the children in the control group. A similar increase was seen for tuberculosis screening, with 54 percent of children in the intervention group receiving it, compared to 32 percent in the control group.

The continuing education program used in the study, which was designed to help primary-care practices test and implement new “office systems” for prevention, “produced clinically and statistically significant improvement in rates of preventive care for children,” the researchers said.

The methods used to generate these improvements could be summarized as “teaching practices how to take what seems to be a very big change and breaking it into small parts so that they can learn how to do it,” Margolis said. North Carolina’s Agricultural Extension Service uses essentially the same model in teaching farmers to make changes based on science, he added.

The study, funded by the Agency for Healthcare Research and Quality, was a project of the N.C. Center for Children’s Healthcare Improvement in UNC’s department of pediatrics. Other study authors were Dr. Carole M. Lannon, associate professor of pediatrics and internal medicine in UNC’s School of Medicine; Jayne M. Stuart, research associate in the School of Medicine; Dr. Bruce Fried, director of the residential master’s degree program in health policy and administration in UNC’s School of Public Health; Dr. Lynnette Keyes-Elstein, assistant director of biostatistics in the FPG Child Development Institute; and Dr. Donald E. Moore Jr., director of the Division of Continuing Medical Education.

This news release was researched and written by Tom Hughes of the UNC School of Medicine.

Note: Contact Margolis at (919) 843-7245 or To read the article, click on

UNC School of Medicine contact: Stephanie Crayton-Robinson, (919) 966-2860 UNC School of Public Health contact: Lisa Katz, (919) 966-7467