Original Article
Changes in the proportion and volume of care provided to children by generalists and subspecialists

https://doi.org/10.1016/j.jpeds.2004.08.054Get rights and content

Objective

To assess whether primary care physicians, via referrals or other mechanisms, are now providing proportionally less care for children with specific common diagnoses, thus driving greater demand for specialist services.

Study design

Secondary data analysis (1993-2001) from one of the largest commercial healthcare organizations in the United States. Evaluation and management (E/M) common procedural terminology (CPT) visit codes and International Classification of Diseases (ICD) codes pertaining to asthma, constipation, headache, and heart murmurs were selected. Visits were then assigned to the specialty of physician providing care. Significant differences between and among categories of physicians were tested using logistic regression.

Results

Overall, pediatrician generalists and specialists provided a greater proportion of E/M visits to children in 2001 than in 1993, compared with nonpediatrician providers. However, although the absolute increase in the proportion of all E/M visits by children <18 years of age to pediatrician generalists was greater than that of pediatrician subspecialists (4.77% vs 0.69%; P <.0001), the relative increase was much smaller for the generalists (8.9% vs 19.7%; P <.0001). Findings were consistent for most of the specific diagnoses examined.

Conclusions

The increases in both the proportion and number of visits made to specialists has not been accompanied by a decrease in visits to generalists.

Section snippets

Methods

Data for this project are for the years 1993 to 2001 and originate from a large multi-state healthcare organization in the United States. Five commercial HMO and point-of-service plans within the organization were selected based on plan maturity, regional diversity, and size of membership enrollment. Located in the Southeast, Midwest, Northeast, and West, total combined enrollment of these plans exceeded 1.7 million clients for 2001. Enrollment in these plans increased approximately 100% during

Results

Overall, pediatrician generalists and pediatrician specialists provided a greater proportion of E/M visits for all causes to children in 2001 compared with 1993, concomitant with similar decreases in the proportion of care provided by nonpediatrician providers (Table I). Further, although the absolute increase in the proportion of all E/M visits by children <18 years of age to pediatrician generalists was greater than that of pediatrician subspecialists (4.77 percentage points vs 0.69

Discussion

Our findings demonstrate that for E/M visits overall, and for patients with two of the four conditions examined (constipation or headache), there has been an increase in the proportion of care provided by pediatrician generalists and pediatric specialists as well as an increase in the number of visits per 1000 members <18 years of age to these physicians. Some of the change appears as a result of growth in the market share of pediatricians (both generalists and specialists) relative to

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Supported by a grant from the American Board of Pediatrics Foundation.

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