The Pediatric Primary Care-Specialist Interface: A Call For Action

      Infants, children, adolescents, and young adults (hereafter referred to as “children”) are increasingly using specialty medical services, defined herein as other physicians with additional training and expertise in a defined area. Among children ages 3-18 years, the number of ambulatory visits resulting in a referral to another physician more than doubled from 1999 to 2009, increasing from 4.93 to 10.5 million.
      • Mayer M.L.
      • Skinner A.C.
      • Slifkin R.T.
      Unmet need for routine and specialty care: data from the National Survey of Children With Special Health Care Needs.
      At the same time, for several populations of children with need for pediatric specialty care, access has become more difficult.
      • Mayer M.L.
      • Skinner A.C.
      • Slifkin R.T.
      Unmet need for routine and specialty care: data from the National Survey of Children With Special Health Care Needs.
      • Henrickson M.
      Policy challenges for the pediatric rheumatology workforce: part III. the international situation.
      Importantly, care is often fragmented between primary care and specialty clinicians, and coordination of care remains problematic, because of lack of payment for coordination activities, which are often time consuming; providers working in different healthcare systems without common electronic information sharing capabilities; and fee for service payments that encourage visits and discourage efficiencies that decrease duplication of services, as well as other contributing factors.



      EHR ( Electronic health record), FCMH ( Family-centered medical home), PCP ( Primary care provider)
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        • Mayer M.L.
        • Skinner A.C.
        • Slifkin R.T.
        Unmet need for routine and specialty care: data from the National Survey of Children With Special Health Care Needs.
        Pediatrics. 2004; 113: e109-15
        • Henrickson M.
        Policy challenges for the pediatric rheumatology workforce: part III. the international situation.
        Pediatr Rheumatol Online J. 2011; 9: 26
        • Medical Home Initiatives for Children With Special Needs Project Advisory Committee, American Academy of Pediatrics
        The medical home.
        Pediatrics. 2002; 110: 184-186
        • Stille C.
        • Turchi R.M.
        • Antonelli R.
        • Cabana M.D.
        • Cheng T.L.
        • Laraque D.
        • et al.
        The family- centered medical home: specific considerations for child health research and policy.
        Acad Pediatr. 2010; 10: 211-217
      1. American Academy of Pediatrics Committee on Pediatric Workforce. Pediatric workforce statement.
        Pediatrics. 1998; 102: 418-427
        • Cohen E.
        • Kuo D.Z.
        • Agrawal R.
        • Berry J.G.
        • Bhagat S.K.
        • Simon T.D.
        • et al.
        Children with medical complexity: an emerging population for clinical and research initiatives.
        Pediatrics. 2011; 127: 529-538
        • U.S. Department of Health and Human Services, Health Resources and Services Administration
        Recommendations for improving access to pediatric subspecialty care through the medical home.
        (December) (Accessed March 15, 2017)
        • Pletcher B.A.
        • Rimsza M.E.
        • Cull W.L.
        • Shipman S.A.
        • Shugerman R.P.
        • O'Connor K.G.
        Primary care pediatricians' satisfaction with subspecialty care, perceived supply, and barriers to care.
        J Pediatr. 2010; 156 (5 e1): 1011-1015
        • American Academy of Pediatrics
        America's Children Need Access to Pediatric Subspecialists.
        (Accessed March 15, 2017)
        • Freed G.L.
        • Nahra T.A.
        • Venus P.J.
        • Schech S.D.
        • Wheeler J.R.
        Changes in the proportion and volume of care provided to children by generalists and subspecialists.
        J Pediatr. 2005; 146: 14-19
        • Mayer M.L.
        Are we there yet? Distance to care and relative supply among pediatric medical subspecialties.
        Pediatrics. 2006; 118: 2313-2321
        • Landon B.E.
        Structuring payments to patient-centered medical homes.
        JAMA. 2014; 312: 1633-1634
        • Raphael J.L.
        • Rattler T.L.
        • Kowalkowski M.A.
        • Brousseau D.C.
        • Mueller B.U.
        • Giordano T.P.
        Association of care in a medical home and health care utilization among children with sickle cell disease.
        J Natl Med Assoc. 2013; 105: 157-165
        • Lahiri T.
        • Hempstead S.E.
        • Brady C.
        • Cannon C.L.
        • Clark K.
        • Condren M.E.
        • et al.
        Clinical practice guidelines from the cystic fibrosis foundation for preschoolers with cystic fibrosis.
        Pediatrics. 2016; 137: 1784
        • Stille C.J.
        • McLaughlin T.J.
        • Primack W.A.
        • Mazor K.M.
        • Wasserman R.C.
        Determinants and impact of generalist-specialist communication about pediatric outpatient referrals.
        Pediatrics. 2006; 118: 1341-1349
        • Stille C.J.
        • Primack W.A.
        • McLaughlin T.J.
        • Wasserman R.C.
        Parents as information intermediaries between primary care and specialty physicians.
        Pediatrics. 2007; 120: 1238-1246
        • American Academy of Pediatrics, Division of Health Policy Research
        Periodic survey #44: health services for children with and without special needs: the medical home concept.
        (Accessed March 15, 2017)
        • Forrest C.B.
        • Glade G.B.
        • Baker A.E.
        • Bocian A.B.
        • Kang M.
        • Starfield B.
        The pediatric primary-specialty care interface: how pediatricians refer children and adolescents to specialty care.
        Arch Pediatr Adolesc Med. 1999; 153: 705-714
        • National Committee on Quality Assurance
        Medical home recognition standard.
        • National Center for Quality Assurance
        Patient-centered specialty practice recognition.
        (Accessed Marh 15, 2017)
        • Van Vleet A.
        • Paradise J.
        The state innovation models (SIM) program: an overview.
        (Accessed March 15, 2017)
        • Christensen E.W.
        • Payne N.R.
        Effect of attribution length on the use and cost of health care for a pediatric medicaid accountable care organization.
        JAMA Pediatr. 2016; 170: 148-154
        The Direct Project overview.
        (Accessed March 15, 2017)
        • Ketterer T.
        • West D.W.
        • Sanders V.P.
        • Hossain J.
        • Kondo M.C.
        • Sharif I.
        Correlates of patient portal enrollment and activation in primary care pediatrics.
        Acad Pediatr. 2013; 13: 264-271
        • Fiks A.G.
        • Mayne S.L.
        • Karavite D.J.
        • Suh A.
        • O'Hara R.
        • Localio A.R.
        • et al.
        Parent-reported outcomes of a shared decision-making portal in asthma: a practice-based RCT.
        Pediatrics. 2015; 135: e965-73
        • Children's Oncology Group
        Summary of Cancer Treatment (Comprehensive).
        (Accessed March 15, 2017)
        • Huang X.
        • Rosenthal M.B.
        Transforming specialty practice–the patient-centered medical neighborhood.
        N Engl J Med. 2014; 370: 1376-1379
        • Cooley W.C.
        • Kemper A.R.
        • Medical Home Workgroup of the National Coordinating Center for the Regional Genetic and Newborn Screening Service
        An approach to family-centered coordinated co-management for individuals with conditions identified through newborn screening.
        Genet Med. 2013; 15: 174-177
        • Agency for Healthcare Research and Quality
        CAHPS surveys and tools to advance patient-centered care.
        (Accessed March 15, 2017)
        • Feyissa E.A.
        • Cornell E.
        • Chandhok L.
        • Wang D.
        • Ionita C.
        • Schwab J.
        • et al.
        Impact of Co- management at the primary-subspecialty care interface on follow-up and referral patterns for patients with concussion.
        Clin Pediatr (Phila). 2015; 54: 969-975
        • Rubin K.
        • Cornell E.
        • Feyissa E.
        • Macary S.
        • Chandhok L.
        • Honigfeld L.
        Working together to meet children's health needs: primary and specialty care co-management.
        (Accessed March 15, 2017)
        • Campanella N.
        • Morosini P.
        • Sampaolo G.
        • Catozzo V.
        • Caso A.
        • Ferretti M.
        • et al.
        Medical teleconsultation to general practitioners reduces the medical error vulnerability of internal medicine patients.
        Eur J Intern Med. 2015; 26: 675-679
        • Youngblade L.
        • Malasanos T.
        • Shandman E.A.
        • Aydede S.
        • Nackashi J.M.
        • Tuli S.
        • et al.
        Telemedicine for CSHCN: a state-by- state comparison of medicaid reimbursement policies and title V activities telehealth connections for children and youth.
        (Accessed March 15, 2017)
        • Utidjian L.
        • Abramson E.
        Pediatric telehealth: opportunities and challenges.
        Pediatr Clin North Am. 2016; 63: 367-378
        • Schor E.L.
        Transition: changing old habits.
        Pediatrics. 2015; 135: 958-960