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  • Measure Summary
  • NQMC:006481
  • Aug 2001

Pediatric primary care: mean score on the "Comprehensiveness" subscale of the Parent's Perceptions of Primary Care (P3C) instrument.

Seid M, Varni JW, Bermudez LO, Zivkovic M, Far MD, Nelson M, Kurtin PS. Parents' Perceptions of Primary Care: measuring parents' experiences of pediatric primary care quality. Pediatrics. 2001 Aug;108(2):264-70. PubMed External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in December 2015.

Primary Measure Domain

Clinical Quality Measures: Patient Experience

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the parent's report of the extent to which a regular place and/or doctor provides care for acute and chronic problems and preventive services, based on the parent's responses ("0 = never," "1 = sometimes," "2 = often," "3 = almost always," "4 = always") to the "Comprehensiveness" items in the Parent's Perceptions of Primary Care (P3C) measure instrument:

  1. Can the doctor take care of almost any problem you child might have?
  2. Does the doctor talk to you about keeping your child healthy?
  3. Does the doctor talk to you about safety (like car seats, seat belts, bike helmets, accidents)?
  4. Does the doctor talk to you about your child's growth?
  5. Does the doctor talk to you about behavior in general (like having friends, citizenship at school)?

Rationale

High quality pediatric primary care is a cornerstone of efforts to improve health outcomes, control health care spending, and improve access to care. To improve the quality of pediatric primary care, a reliable and valid measure must exist. The ideal instrument is one that is brief, practical, reliable, and valid. Given the current high rate of uninsured children and children without a regular source of care, such an instrument must also be applicable regardless of insurance status and health plan membership or the presence of a regular provider of care.

The Parent's Perceptions of Primary Care (P3C) measure is based on the Institute of Medicine (IOM) definition of primary care, which is similar to the American Academy of Pediatrics concept of a medical home. With the use of this definition as a criterion, the P3C was designed to measure 6 components of care (longitudinal continuity, access, contextual knowledge, communication, comprehensiveness, and coordination) that, when present, constitute high-quality primary care experiences. High scores reflect care conforming to this a priori definition.

The P3C measures perceptions of quality based on parents' reports of their experiences, rather than ratings of satisfaction with those experiences. The P3C was designed to measure parents' perceptions of experiences in receiving primary care, rather than the quality of a particular provider of primary care. This was done so that the care received by children without a regular provider also could be described in relation to the IOM definition of quality primary care. This is important, given the large proportions of uninsured children and children without a regular source of care who receive primary health care at emergency departments or community clinics, where they might not see a consistent provider.

Evidence for Rationale

Halfon N, Newacheck PW, Wood DL, St Peter RF. Routine emergency department use for sick care by children in the United States. Pediatrics. 1996 Jul;98(1):28-34. PubMed External Web Site Policy

Institute of Medicine. Primary care: America's health in a new era. Washington (DC): National Academy Press; 1996.

McGlynn EA, Halfon N. Overview of issues in improving quality of care for children. Health Serv Res. 1998 Oct;33(4 Pt 2):977-1000. [69 references] PubMed External Web Site Policy

Medical Home Initiatives for Children With Special Needs Project Advisory Committee, American Academy of Pediatrics. The medical home. Pediatrics. 2002 Jul;110(1 Pt 1):184-6. PubMed External Web Site Policy

Seid M, Varni JW, Bermudez LO, Zivkovic M, Far MD, Nelson M, Kurtin PS. Parents' Perceptions of Primary Care: measuring parents' experiences of pediatric primary care quality. Pediatrics. 2001 Aug;108(2):264-70. PubMed External Web Site Policy

Seid M. Barriers to care and primary care for vulnerable children with asthma. Pediatrics. 2008 Nov;122(5):994-1002. PubMed External Web Site Policy

Starfield B, Simpson L. Primary care as part of US health services reform. JAMA. 1993 Jun 23-30;269(24):3136-9. PubMed External Web Site Policy

Starfield B. Primary care: balancing health needs, services, and technology. New York (NY): Oxford University Press; 1998.

Starfield B. Public health and primary care: a framework for proposed linkages. Am J Public Health. 1996 Oct;86(10):1365-9. [28 references] PubMed External Web Site Policy

US Bureau of the Census, US Department of Commerce. Census brief: children without health insurance. Washington (DC): US Bureau of the Census; 1998.  (Publication; no. CENBR/98-1). 

Varni JW, Seid M, Kurtin PS. Pediatric health-related quality of life measurement technology: a guide for health care decision makers. J Clin Outcomes Manag. 1999;6:33-40.

Wood DL, Hayward RA, Corey CR, Freeman HE, Shapiro MF. Access to medical care for children and adolescents in the United States. Pediatrics. 1990 Nov;86(5):666-73. PubMed External Web Site Policy

Primary Health Components

Pediatric primary care; patient experience; parent perception; comprehensiveness of care

Denominator Description

Children whose parent or guardian answered the "Comprehensiveness" items on the Parent's Perceptions of Primary Care (P3C) measure instrument

Numerator Description

The number of responses ("0 = never," "1 = sometimes," "2 = often," "3 = almost always," "4 = always") to the "Comprehensiveness" items in the Parent's Perceptions of Primary Care (P3C) measure instrument (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

  • A need exists for an instrument that is at once a brief, practical, reliable, and valid measure of pediatric primary care that can be used irrespective of insurance status or the presence of an established clinician-patient relationship. Although others have posited that an established clinician-patient relationship is necessary for the existence of primary care, and have therefore restricted measurement of primary care to those patients with such a relationship, the fact remains that many children, both insured and uninsured, lack a regular site of care or a regular provider of care. It behooves researchers, clinicians, and policy makers to develop and use measures that encompass the experiences of these children, as well.
  • The ability to measure the quality of children's health care effectively is challenging because of a number of factors, including the child's dependence on caregivers, changing development, and demographics. Although some proxy measures for quality that do not depend on parents exist, such as immunization rates and frequency of screening for lead and anemia, these measures may reflect the quality of systems rather than providers.
  • Hospital-based primary care clinics, where residents are often the primary care providers, provide care to ~21% of the socioeconomically disadvantaged families in the United States, as well as to children with chronic health care needs. With the structural challenges of resident training, there may be concerns about a lower quality of care received by patients.
  • Access to primary care is associated with better outcomes for children with asthma, in all likelihood because the hallmarks of high-quality primary care, namely, continuity, comprehensiveness, communication, contextual knowledge, coordination, and accessibility, are key to good asthma care. However, it is well known that certain groups of children with asthma, those defined by sociodemographic and access indicators such as minority race/ethnicity, low parental education, poverty, limited English language ability, lack of insurance, no usual source of care, and unmet health care needs, are less likely to receive high-quality primary care and are more vulnerable to poor health outcomes.
  • Children of farm workers, especially migrant farm workers, are particularly vulnerable to poor health outcomes. These children may live in families that are highly transient and may face substandard living conditions. They are likely to experience high rates of physical, mental, and oral health conditions. And children of Latino farm workers face multiple financial, cultural, and linguistic barriers to quality health care. Given the special vulnerability of this population, there is a pressing need for a brief, feasible, reliable, and valid measure of primary care characteristics for these children.

Evidence for Additional Information Supporting Need for the Measure

Akinbami LJ, Schoendorf KC. Trends in childhood asthma: prevalence, health care utilization, and mortality. Pediatrics. 2002 Aug;110(2 Pt 1):315-22. PubMed External Web Site Policy

Beal AC, Co JP, Dougherty D, Jorsling T, Kam J, Perrin J, Palmer RH. Quality measures for children's health care. Pediatrics. 2004 Jan;113(1 Pt 2):199-209. PubMed External Web Site Policy

Brotanek JM, Halterman J, Auinger P, Weitzman M. Inadequate access to care among children with asthma from Spanish-speaking families. J Health Care Poor Underserved. 2005 Feb;16(1):63-73. PubMed External Web Site Policy

Canino G, Koinis-Mitchell D, Ortega AN, McQuaid EL, Fritz GK, Alegria M. Asthma disparities in the prevalence, morbidity, and treatment of Latino children. Soc Sci Med. 2006 Dec;63(11):2926-37. [80 references] PubMed External Web Site Policy

Christakis DA, Mell L, Koepsell TD, Zimmerman FJ, Connell FA. Association of lower continuity of care with greater risk of emergency department use and hospitalization in children. Pediatrics. 2001 Mar;107(3):524-9. PubMed External Web Site Policy

Cree M, Bell NR, Johnson D, Carriere KC. Increased continuity of care associated with decreased hospital care and emergency department visits for patients with asthma. Dis Manage. 2006 Feb;9(1):63-71. PubMed External Web Site Policy

Dougherty D, Meikle SF, Owens P, Kelley E, Moy E. Children's Health Care in the First National Healthcare Quality Report and National Healthcare Disparities Report. Med Care. 2005 Mar;43(3 Suppl):I58-63. PubMed External Web Site Policy

Eshleman MJ, Davidhizar R. Life in migrant camps for children-a hazard to health. J Cult Divers. 1997 Spring;4(1):13-7. PubMed External Web Site Policy

Flores G, Abreu M, Olivar MA, Kastner B. Access barriers to health care for Latino children. Arch Pediatr Adolesc Med. 1998 Nov;152(11):1119-25. PubMed External Web Site Policy

Flores G, Bauchner H, Feinstein AR, Nguyen US. The impact of ethnicity, family income, and parental education on children's health and use of health services. Am J Public Health. 1999 Jul;89(7):1066-71. PubMed External Web Site Policy

Flores G, Fuentes-Afflick E, Barbot O, Carter-Pokras O, Claudio L, Lara M, McLaurin JA, Pachter L, Ramos-Gomez FJ, Mendoza F, Valdez RB, Villarruel AM, Zambrana RE, Greenberg R, Weitzman M. The health of Latino children: urgent priorities, unanswered questions, and a research agenda. JAMA. 2002 Jul 3;288(1):82-90. PubMed External Web Site Policy

Forrest CB, Simpson L, Clancy C. Child health services research. Challenges and opportunities. JAMA. 1997 Jun 11;277(22):1787-93. PubMed External Web Site Policy

Gwyther ME, Jenkins M. Migrant farmworker children: health status, barriers to care, and nursing innovations in health care delivery. J Pediatr Health Care. 1998 Mar-Apr;12(2):60-6. [43 references] PubMed External Web Site Policy

Halfon N, Inkelas M, Wood D. Nonfinancial barriers to care for children and youth. Annu Rev Public Health. 1995;16:447-72. [108 references] PubMed External Web Site Policy

Huang ZJ, Kogan MD, Yu SM, Strickland B. Delayed or forgone care among children with special health care needs: an analysis of the 2001 National Survey of Children with Special Health Care Needs. Ambul Pediatr. 2005 Jan-Feb;5(1):60-7. PubMed External Web Site Policy

Institute of Medicine, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal treatment: confronting racial and ethnic disparities in health care. Washington (DC): National Academies Press; 2002.

Javier JR, Wise PH, Mendoza FS. The relationship of immigrant status with access, utilization, and health status for children with asthma. Ambul Pediatr. 2007 Nov-Dec;7(6):421-30. PubMed External Web Site Policy

Krugman SD, Racine A, Dabrow S, Sanguino S, Meyer W, Seid M, Serwint JR, Continuity Research Network. Measuring primary care of children in pediatric resident continuity practices: a Continuity Research Network study. Pediatrics. 2007 Aug;120(2):e262-71. PubMed External Web Site Policy

Kupersmidt JB, Martin SL. Mental health problems of children of migrant and seasonal farm workers: a pilot study. J Am Acad Child Adolesc Psychiatry. 1997 Feb;36(2):224-32. PubMed External Web Site Policy

Martin SL, Kupersmidt JB, Harter KS. Children of farm laborers: utilization of services for mental health problems. Community Ment Health J. 1996 Aug;32(4):327-40. PubMed External Web Site Policy

McDaniel M, Paxson C, Waldfogel J. Racial disparities in childhood asthma in the United States: evidence from the National Health Interview Survey, 1997 to 2003. Pediatrics. 2006 May;117(5):e868-77. PubMed External Web Site Policy

Mueller KJ, Patil K, Boilesen E. The role of uninsurance and race in healthcare utilization by rural minorities. Health Serv Res. 1998 Aug;33(3 Pt 1):597-610. PubMed External Web Site Policy

Nurko C, Aponte-Merced L, Bradley EL, Fox L. Dental caries prevalence and dental health care of Mexican-American workers' children. ASDC J Dent Child. 1998 Jan-Feb;65(1):65-72. PubMed External Web Site Policy

Perrin JM, Homer CJ, Berwick DM, Woolf AD, Freeman JL, Wennberg JE. Variations in rates of hospitalization of children in three urban communities. N Engl J Med. 1989 May 4;320(18):1183-7. PubMed External Web Site Policy

Seid M, Stevens GD, Varni JW. Parents' perceptions of pediatric primary care quality: effects of race/ethnicity, language, and access. Health Serv Res. 2003 Aug;38(4):1009-31. PubMed External Web Site Policy

Seid M, Stevens GD. Access to care and children's primary care experiences: results from a prospective cohort study. Health Serv Res. 2005 Dec;40(6 Pt 1):1758-80. PubMed External Web Site Policy

Seid M, Varni JW, Bermudez LO, Zivkovic M, Far MD, Nelson M, Kurtin PS. Parents' Perceptions of Primary Care: measuring parents' experiences of pediatric primary care quality. Pediatrics. 2001 Aug;108(2):264-70. PubMed External Web Site Policy

Seid M, Varni JW. Measuring primary care for children of Latino farmworkers: reliability and validity of the parent's perceptions of primary care measure (P3C). Matern Child Health J. 2005 Mar;9(1):49-57. PubMed External Web Site Policy

Seid M. Barriers to care and primary care for vulnerable children with asthma. Pediatrics. 2008 Nov;122(5):994-1002. PubMed External Web Site Policy

Slesinger DP, Christenson BA, Cautley E. Health and mortality of migrant farm children. Soc Sci Med. 1986;23(1):65-74. PubMed External Web Site Policy

Slesinger DP. Health status and needs of migrant farm workers in the United States: a literature review. J Rural Health. 1992 Summer;8(3):227-34. [54 references] PubMed External Web Site Policy

Weitzman M, Byrd RS, Aguinger P. Children in big cities in the United States: health and related needs and services. Ambul Child Health. 1996;1:347-59.

Woolfolk M, Hamard M, Bagramian RA, Sgan-Cohen H. Oral health of children of migrant farm workers in northwest Michigan. J Public Health Dent. 1984 Summer;44(3):101-5. PubMed External Web Site Policy

Yoon EY, Davis MM, Van Cleave J, Maheshwari S, Cabana MD. Factors associated with non-attendance at pediatric subspecialty asthma clinics. J Asthma. 2005 Sep;42(7):555-9. PubMed External Web Site Policy

Extent of Measure Testing

Pilot Testing

To ensure content validity and that the Parent's Perceptions of Primary Care (P3C) measure encompasses all appropriate domains of interest, 12 groups of 3 parents each were interviewed in small-group settings at an elementary school and parents completed pilot versions of the measure. To ensure item clarity and to identify and modify unclear items, the modified instrument was then piloted with 15 additional parents at an elementary school and a preschool using cognitive interviewing methodology.

Feasibility, Reliability and Validity Testing

As part of a larger study to validate a measure of quality of care for vulnerable children, the P3C was administered to 3,371 parents of children in 228 classes, from kindergarten through the sixth grade, at 18 elementary schools within a large, urban school district. The percentage of missing values for the overall sample was 1.88%, indicating acceptable feasibility. Range of measurement, assessed via floor and ceiling effects, was moderate to good. Cronbach's coefficient alpha, an indicator of scale internal consistency reliability, was 0.95 for the P3C total scale. Factor analysis supported the subscale structure, and P3C scores were higher for children with health insurance, whose parents completed the survey in English, and who had a regular physician. P3C scores were positively related to parent reports of the child's health-related quality of life. These data imply that the P3C is a feasible, reliable, and valid measure of primary care characteristics, suitable for use in large, diverse community samples. Additional field testing is planned to address test-retest reliability.

An additional study suggests that the P3C is a feasible, reliable and valid measure of primary care characteristics for an underserved population: children of Latino farm workers.

Evidence for Extent of Measure Testing

Schwartz CE, Kozora E, Zeng Q. Towards patient collaboration in cognitive assessment: specificity, sensitivity, and incremental validity of self-report. Ann Behav Med. 1996;18:177-84.

Schwarz N, Sudman N. Answering questions: methodology for determining cognitive and communicative processes in survey research. San Francisco (CA): Jossey-Bass; 1996.

Seid M, Varni JW, Bermudez LO, Zivkovic M, Far MD, Nelson M, Kurtin PS. Parents' Perceptions of Primary Care: measuring parents' experiences of pediatric primary care quality. Pediatrics. 2001 Aug;108(2):264-70. PubMed External Web Site Policy

Seid M, Varni JW. Measuring primary care for children of Latino farmworkers: reliability and validity of the parent's perceptions of primary care measure (P3C). Matern Child Health J. 2005 Mar;9(1):49-57. PubMed External Web Site Policy

State of Use

Current routine use

Current Use

Decision-making by consumers about health plan/provider choice

Internal quality improvement

National health policymaking

Quality of care research

Regional, county, or city health policymaking

State/Provincial health policymaking

Measurement Setting

Ambulatory/Office-based Care

Patient-centered Medical Homes

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Nurses

Physician Assistants

Physicians

Least Aggregated Level of Services Delivery Addressed

Individual Clinicians or Public Health Professionals

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Children

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Person- and Family-centered Care

IOM Care Need

Getting Better

Living with Illness

Staying Healthy

IOM Domain

Patient-centeredness

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Children whose parent or guardian answered the "Comprehensiveness" items on the Parent's Perceptions of Primary Care (P3C) measure instrument

Exclusions
Unspecified

Exclusions/Exceptions

Does not apply to this measure

Numerator Inclusions/Exclusions

Inclusions
The number of responses ("0 = never," "1 = sometimes," "2 = often," "3 = almost always," "4 = always") to the "Comprehensiveness" items in the Parent's Perceptions of Primary Care (P3C) measure instrument

Note: These items are transformed to a 0 to 100 scale, with 100 being the best, as follows: 0 = 0, 1 = 25, 2 = 50, 3 = 75, 4 = 100. Computing the mean of the nonmissing values forms the subscale score.

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Patient/Individual survey

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Parent's Perceptions of Primary Care (P3C) instrument

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Composite/Scale

Mean/Median

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Parent's Perceptions of Primary Care (P3C): comprehensiveness.

Measure Collection Name

Parent's Perceptions of Primary Care (P3C) Instrument

Submitter

Seid, Michael, PhD, Cincinnati Children's Hospital Medical Center

Developer

Seid, Michael, PhD, Cincinnati Children's Hospital Medical Center

Funding Source(s)

This research was supported by the Agency for Healthcare Research and Quality (AHRQ) (Grant R01 HS10317) and the Substance Abuse and Mental Health Services Administration (SAMHSA).

Composition of the Group that Developed the Measure

Michael Seid, PhD; James W. Varni, PhD; Laura Olson Bermudez, PhD; Mirjana Zivkovic, MD, PhD; Maryam Davodi Far, PhD; Melissa Nelson, MPH; and Paul S. Kurtin, MD

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2001 Aug

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in December 2015.

Source(s)

Seid M, Varni JW, Bermudez LO, Zivkovic M, Far MD, Nelson M, Kurtin PS. Parents' Perceptions of Primary Care: measuring parents' experiences of pediatric primary care quality. Pediatrics. 2001 Aug;108(2):264-70. PubMed External Web Site Policy

Measure Availability

Source available on the American Academy of Pediatrics (AAP) Web site External Web Site Policy.

For more information, please contact Michael Seid, PhD, at the Center for Child Health Outcomes, 3020 Children's Way, MC 5053, San Diego, CA 92123. E-mail: mseid@chsd.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on October 12, 2012. The information was not verified by the measure developer.

The information was reaffirmed by the measure developer on December 17, 2015.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the American Academy of Pediatrics (AAP) copyright restrictions.

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