Improving Health Care for Children

Generalist Physician Faculty Scholar Dimitri A. Christakis MD, MPH, finds continuity of care improves health care use and outcomes.

    • July 15, 2009

The Problem: The value of having consistent contact with a primary care provider (continuity of care) in maintaining patients’ health had been generally accepted, but there was little evidence about whether continuity of care improved use of health care services and health outcomes for children.

Grantee Perspective: Dimitri A. Christakis MD, MPH, an assistant professor of pediatrics at the University of Washington, Seattle, wanted to learn more about the benefits of continuity of care for children. As a participant in the Robert Wood Johnson Foundation (RWJF) Generalist Physician Faculty Scholars Program from 1999 to 2004, Christakis conducted several studies related to his interest.

In one study, Christakis and colleagues surveyed 759 parents of patients at the University of Washington’s Pediatric Care Center about the quality of care provided and how well their children’s care was coordinated. In another study, they used HMO data from 46,097 children to analyze the relationship between continuity of primary care and hospital and emergency department use.

In a third study, Christakis et al. studied whether automated alerts to providers and schedulers at the Pediatric Care Center improved continuity of care. The alerts note that a scheduled patient has poor continuity of care and ask the provider or scheduler to help the patient connect with a provider.

Researchers randomly assigned providers and schedulers for 409 patients with low continuity of care to receive either no alert, alert to provider only, alert to scheduler only, or alert to both provider and scheduler.

Results: Christakis et al. reported the following findings from his work.

In the parent survey, researchers found:

  • Greater continuity of primary care is associated with higher quality of care as reported by parents. (Pediatrics, 2002)
  • Greater continuity of primary care is associated with better care coordination as perceived by parents. (Ambulatory Pediatrics, 2003)

In the study based on claims data, researchers found:

  • Lower continuity of primary care is associated with higher risk of emergency department use and hospitalization. (Pediatrics, 2001)

Based on these two studies, Christakis et al. concluded that efforts to improve and maintain continuity of care are warranted.

In the study of automated reminders, Christakis et al. found:

  • The provider-only alert group and provider-and-scheduler alert group were associated with increased continuity of care compared with the no-alert group. (Ambulatory Pediatrics, 2004)

As a result of these studies, the Pediatric Care Center routinely collects and reports data on continuity of care for all patients, and it uses the alert system. The Washington State Medicaid office now requires disease-management vendors to target improving continuity of care for chronic disease patients.

"The Generalist Physician Faculty Scholars Program was formative. I owe an enormous amount of my success to the support of the Robert Wood Johnson Foundation, both the Clinical Scholars Program and the Generalist Faculty Scholars Program," said Christakis, who was also a Robert Wood Johnson Foundation Clinical Scholar, and is now the George Adkins Professor of Pediatrics at the University of Washington and director of the Center for Child Health, Behavior and Development at the Seattle Children’s Hospital Research Institute.

He noted that the Generalist Physician Faculty Scholars Program provided him with protected time for research, outstanding mentorship and a cadre of supportive colleagues who are still part of his network.

After completing the program, Christakis received a $2.4-million grant (2002–06) from the Agency for Healthcare Research and Quality to evaluate the Parent Initiated Prevention Program (My Healthy Child), a Web-based program that helps parents prepare for well-child visits. Christakis said that his research on continuity of care helped him get this grant.

Christakis is also an associate editor of Archives of Pediatrics and Adolescent Medicine and a member of the National Institutes of Health’s Health Services Organization and Delivery study section.

RWJF Perspective: The Robert Wood Johnson Foundation established the Generalist Physician Faculty Scholars Program to create a cadre of respected generalist leaders in medical schools who would be in a position to influence curriculum, admissions and scholarship. Junior faculty in family medicine, internal medicine and pediatrics conducted research and built their careers under the guidance of mentors.

"Given the shortage of primary care physicians, we need innovative approaches to encourage medical students to choose careers in generalist fields. The Generalist Physician Faculty Scholars Program was designed to emphasize a scholarly foundation for generalism and improve the quality of the education provided to students who choose this important career path," said Pamela S. Dickson, MBA, assistant vice president of RWJF’s Health Care Group.

When the program ended in 2008, RWJF created the Robert Wood Johnson Physician Faculty Scholars Program to strengthen the leadership and academic productivity of junior medical school faculty who are dedicated to improving health and health care. It is open not only to generalists, but all physicians.