Child's Primary Care Provider Research Articles

Feasibility of Implementation of a Mobile Digital Personal Health Record to Coordinate Care for Children and Youth With Special Health Care Needs in Primary Care: Protocol for a Mixed Methods Study.

Electronic health record (EHR)-integrated digital personal health records (PHRs) via Fast Healthcare Interoperability Resources (FHIR) are promising digital health tools to support care coordination (CC) for children and youth with special health care needs but remain widely unadopted; as their adoption grows, mixed methods and implementation research could guide real-world implementation and evaluation. This study (1) evaluates the feasibility of an FHIR-enabled digital PHR app for CC for children and youth with special health care needs, (2) characterizes determinants of implementation, and (3) explores associations between adoption and patient- or family-reported outcomes. This nonrandomized, single-arm, prospective feasibility trial will test an FHIR-enabled digital PHR app's use among families of children and youth with special health care needs in primary care settings. Key app features are FHIR-enabled access to structured data from the child's medical record, families' abilities to longitudinally track patient- or family-centered care goals, and sharing progress toward care goals with the child's primary care provider via a clinician dashboard. We shall enroll 40 parents or caregivers of children and youth with special health care needs to use the app for 6 months. Inclusion criteria for children and youth with special health care needs are age 0-16 years; primary care at a participating site; complex needs benefiting from CC; high hospitalization risk in the next 6 months; English speaking; having requisite technology at home (internet access, Apple iOS mobile device); and an active web-based EHR patient portal account to which a parent or caregiver has full proxy access. Digital prescriptions will be used to disseminate study recruitment materials directly to eligible participants via their existing EHR patient portal accounts. We will apply an intervention mixed methods design to link quantitative and qualitative (semistructured interviews and family engagement panels with parents of children and youth with special health care needs) data and characterize implementation determinants. Two CC frameworks (Pediatric Care Coordination Framework; Patient-Centered Medical Home) and 2 evaluation frameworks (Consolidated Framework for Implementation Research; Technology Acceptance Model) provide theoretical foundations for this study. Participant recruitment began in fall 2022, before which we identified >300 potentially eligible patients in EHR data. A family engagement panel in fall 2021 generated formative feedback from family partners. Integrated analysis of pretrial quantitative and qualitative data informed family-centered enhancements to study procedures. Our findings will inform how to integrate an FHIR-enabled digital PHR app for children and youth with special health care needs into clinical care. Mixed methods and implementation research will help strengthen implementation in diverse clinical settings. The study is positioned to advance knowledge of how to use digital health innovations for improving care and outcomes for children and youth with special health care needs and their families. ClinicalTrials.gov NCT05513235; https://clinicaltrials.gov/study/NCT05513235. DERR1-10.2196/46847.

Evaluation of a Nature Prescription Program in Schools to Increase Nature-Based Physical Activity and Time Spent Outdoors: Implementation of the Kids in Parks TRACK Rx Program by the School Nurse.

This study assessed the effectiveness of the TRACK Rx program. Track Rx is a program for healthcare professionals to counsel and prescribe outdoor physical activity (PA) to children. The program was implemented by a school nurse to increase children's time spent outdoors, increase a child's nature-based PA, and increase parents' intention for their child to spend time outdoors. Parents/guardians of children in 1st-3rd grade (intervention = 51; control = 27) completed a baseline and 3-month follow-up survey. Children's nature-based PA significantly increased on the weekend in the intervention group compared to the control group. There was no significant change in the other study variables. Parental trust in the school nurse was similar to parent trust in their child's primary health care provider. School nurses can implement TRACK Rx and other nature and nature-based PA prescription programs throughout the school (classroom, physical education, recess, and after-school programming).

Parents of Children with Down Syndrome and Their Interactions with Pediatric Health Care Providers

Purpose The purpose of this study was to gain a deeper understanding of parent's, who have a child with Down Syndrome (DS), personal experiences with their child's primary pediatric health care providers (PPHCPs). Background Literature has shown that parents are often dissatisfied with health care providers interactions at the time of their child's initial diagnosis with DS. The literature is lacking in describing parental experiences, beyond the initial diagnosis, with PPHCPs, as their child ages. Method This was a qualitative inquiry using a descriptive phenomenological methodology. The parents were self-identified as the child's primary care-taker and the main parent that accompanies the child to health care appointments. The inquiry consisted of recorded, semi-structured interviews that were transcribed. Colaizzi's (1978) seven-step method and NVivo software were used to extract overall themes that describe the phenomenon. Results The sample consisted of 10 parents who have a school-aged child with DS between the ages of 6-11 years. The following nine parental themes emerged: (1) the need for their children with DS to be viewed and treated as individuals; (2) personal hopes and dreams for their children; (3) the need for respectful empathetic communication; (4) a PPHCP that is knowledgeable about DS; (5) acknowledgment that the parent is an expert regarding their child and is a partner in care; (6) PPHCP collaboration with specialists and navigation of care; (7) a desire for a trusting relationship with the PPHCP ensuring the child and parental needs will be met; (8) anticipatory guidance about their child's individual growth and development; (9) reliance upon the DS community for recommendations on resources for their child. Conclusions This study provided insight on communication and interactions between parents of school-aged children with DS and their PPHCPs. Parental needs are an important consideration in this setting. PPHCPs interactions with parents on condition-specific health education and anticipatory guidance can direct relationship-based care necessary to optimize outcomes of the child with DS. The purpose of this study was to gain a deeper understanding of parent's, who have a child with Down Syndrome (DS), personal experiences with their child's primary pediatric health care providers (PPHCPs). Literature has shown that parents are often dissatisfied with health care providers interactions at the time of their child's initial diagnosis with DS. The literature is lacking in describing parental experiences, beyond the initial diagnosis, with PPHCPs, as their child ages. This was a qualitative inquiry using a descriptive phenomenological methodology. The parents were self-identified as the child's primary care-taker and the main parent that accompanies the child to health care appointments. The inquiry consisted of recorded, semi-structured interviews that were transcribed. Colaizzi's (1978) seven-step method and NVivo software were used to extract overall themes that describe the phenomenon. The sample consisted of 10 parents who have a school-aged child with DS between the ages of 6-11 years. The following nine parental themes emerged: (1) the need for their children with DS to be viewed and treated as individuals; (2) personal hopes and dreams for their children; (3) the need for respectful empathetic communication; (4) a PPHCP that is knowledgeable about DS; (5) acknowledgment that the parent is an expert regarding their child and is a partner in care; (6) PPHCP collaboration with specialists and navigation of care; (7) a desire for a trusting relationship with the PPHCP ensuring the child and parental needs will be met; (8) anticipatory guidance about their child's individual growth and development; (9) reliance upon the DS community for recommendations on resources for their child. This study provided insight on communication and interactions between parents of school-aged children with DS and their PPHCPs. Parental needs are an important consideration in this setting. PPHCPs interactions with parents on condition-specific health education and anticipatory guidance can direct relationship-based care necessary to optimize outcomes of the child with DS.

Primary Care Provider and Child Characteristics Associated with Age of Diagnosis of Autism Spectrum Disorder: A Population-Based Cohort Study.

In a cohort of kindergarten children in Ontario, Canada with Autism Spectrum Disorder (ASD) (n = 1522), we tested the association of age at ASD diagnosis and characteristics of (1) the child's primary care provider and, (2) the childusing health administrative databases. We tested the association of primary care practice model and time from developmental delay identification to age at ASD diagnosis. Older age of diagnosis was associated with provider foreign training (vs. domestic) (adjusted Hazard Ratio [aHR] 1.17, 95% CI 1.03, 1.33) but not sex, care model, and years of practice. After developmental delay identification, children with paediatricians had longer time to diagnosis than children with providers in care models (aHR 0.68, 95% CI 0.54, 0.86). Findings can be used to inform primary care provider ASD training.

Engaging and supporting families in the Neonatal intensive care unit with telehealth platforms

The utilization of telehealth in the Neonatal Intensive Care Unit (NICU) has the potential to better support families during their infant's time in the hospital. Due to the stressful nature of a NICU admission, parents are at increased risk for anxiety. The expanding use of web camera and videoconferencing technologies will allow families to bond and connect with their infant through remote baby viewing. These technologies are also in place during their hospitalization and allow families the opportunity to connect directly with their care team to build trusting relationships and work on a mutual care plan. Telehealth platforms can continue to aid families post discharge to ensure that transition of care to their child's primary care provider is seamless. With telehealth programs taking root in multiple, longitudinal aspects of NICU care, the hope is to promote the foundations of patient and family-centered care and provide our families with the support they deserve.

Childhood Adversity and Health After Physical Abuse.

Involvement with Child Protective Services (CPS) provides an opportunity to recognize those children at risk for ongoing adverse childhood experiences (ACEs). The relationship between ACEs and child health among CPS-involved children and the role of primary care providers (PCPs) in moderating this relationship is unknown. We conducted a convergent mixed-methods study of caregivers of children age 2 to 12 years with a CPS finding of physical abuse, modeling the association between cumulative ACEs and child health-related quality of life (HRQoL) using the PedsQL4.0, a validated 23-item survey of multidimensional health, with and without the moderator of a patient-centered medical home. Interviews elicited descriptions of a child's experience with ACEs, the impact of ACEs on child health, and the role of a PCP in this context. One hundred seventy-eight surveyed caregivers reported a mean of 5.5 (±3.3) ACE exposures per child. In a fully adjusted model, each ACE resulted in a 1.3-point (95% confidence interval: 0.7-2.0) reduction in HRQoL, a clinically important difference in HRQoL associated with ACE exposures. This association was explained by reduced psychosocial HRQoL and was not moderated by a patient-centered medical home. Twenty-seven interviewed caregivers described the influence of ACEs on a child's health. Many felt that a trusted PCP could support a child's well-being after such experiences. Children with CPS involvement have ACE exposures that are associated with reduced HRQoL. Although PCPs are often unaware of CPS involvement or other ACEs, many caregivers welcome the support of a child's PCP in improving child well-being after adversity.

Parent-reported toilet training practices and the role of pediatric primary care providers.

Toilet training is a universal developmental milestone and a stressful period for families with few empirically based guidelines. This study identified currently used methods of toilet training and sources used for parental guidance. A descriptive, qualitative design was used. Participants included 479 parents of children aged 2-6 years. Parents described diverse toilet training strategies, most of which were behavioral and inconsistent with recommendations of the American Academy of Pediatrics. Most children were toilet trained between 24 and 36 months within 5 weeks. Forty-one percent of parents relied on the Internet for toilet training information, and fewer than half reported involvement of their child's primary care provider. Parents in the community would likely benefit from additional education and anticipatory guidance from primary care providers about normative toilet training. Further work is needed to understand the effectiveness of different methods of training and improve adherence to AAP recommendations.

What is Newborn Screening?

Newborn screening is a system that provides early identification and treatment of infants with disorders prior to permanent disability or death. A successful newborn screening program requires skilled effort, understanding, and collaboration by many individuals, from those collecting the blood spots to the child's primary care provider and family.

Use of the Delphi Technique to Obtain Community Input on Leading Contributors to Early Childhood Obesity in Latino Communities.

In the United States, Latino children are disproportionately affected by childhood obesity and related comorbidities. Stakeholder engagement has the potential to heighten the efficacy of interventions, thereby reducing the disparate prevalence of obesity among Latino children. The objective of this study was to identify stakeholders' opinions on factors influencing early childhood obesity in Latino children aged 0 to 5 years. This study used the Delphi technique to gather and prioritize stakeholders' opinions about the factors and barriers considered most influential in early (age 0-5 years) childhood obesity intervention or prevention within the Latino community. Three sequential phases were used. Participants included Latina women as well as staff from community organizations serving Denver metropolitan's Latino population. Study results revealed that stakeholders value the role of the child's primary care provider in the identification of overweight children and desire more educational support to reduce intake of nonnutritious foods. Participants further determined that obesity-related knowledge gaps and affordability of healthy foods and activities were the largest barriers to helping Latino children maintain healthy weights. Use of this stakeholder-informed data could assist in the development of future culturally tailored interventions aimed at reducing the rates of early childhood obesity in the Latino population.

When Pediatric Primary Care Providers Prescribe Nature Engagement at a State Park, Do Children “Fill” the Prescription?

Abstract The use of a written nature prescription (Park Rx) written by a child's primary care provider (PCP), physician, or nurse practitioner, is one hypothesized approach to encouraging children to participate in free, unstructured play in nature. PCPs recruited through the local chapter of the American Academy of Pediatrics were provided Park Rxs to write for children aged 6–10 attending a well-child visit. The written prescription was a tool for the PCP to use to start a conversation on the value of nature for physical and mental health. In addition, the Park Rx could be redeemed as a free day pass to any state park. The prescribing and redemption patterns for the Park Rxs were studied over the 15-week summer season in a rural state in the Northeast. The nature relatedness (NR) of PCPs and their likelihood to prescribe nature with a Park Rx prior to, during, and after the project were also examined. Eleven PCP offices in six counties participated in the pilot study and wrote a combined 1,935 park pres...

Increased identification of the primary care provider as the main source of asthma care among urban minority children

Objective: Urban, minority, and disadvantaged youth with asthma frequently use emergency departments (EDs) for episodic asthma care instead of their primary care providers (PCPs). We sought to increase the rate of guardians' identification of the PCP as the source of asthma care for their children through integrated electronic health records and care coordination. Methods: In this prospective cohort study, we implemented an electronic communication process between an asthma specialty clinic and PCPs coupled with short-term care coordination in sample of youth aged 2–12 years with asthma and surveyed their guardians at baseline and 3 and 6 months after the intervention. Results: Guardians of 50 children (median age 5.8 years, 64% male, 98% African American, 94% public insurance) were enrolled. Compared to baseline, at 3 and 6 months after the intervention, significantly more guardians reported that the PCP was their child's primary asthma health care provider [70% at baseline, 85% at 3 months, 83% at 6 months (time averaged adjusted OR 77.4, 95% CI 3.0, 2027.1]. Further, significantly more guardians reported that they took their child to the PCP when the child experienced problems with his/her asthma [16% at baseline, 35% at 3 months, 41% at 6 months (time averaged adjusted odds ratio (OR) 10.6, 95% CI 2.7, 41.7]. Conclusion: Care in a subspecialty asthma clinic augmented by electronic communication with PCPs and short term care coordination was associated with significantly improved identification of PCPs as the primary source of asthma care in a cohort of urban minority youth.

Parent Perceptions of Care Received by Children With an Autism Spectrum Disorder

Research in the post-genomic era has provided substantial contributions toward identification of medical, genetic and environmental heritability factors associated with autism spectrum disorder (ASD). A specific etiology related to the diagnosis remains unclear, although prevalence statistics continue to rise with profound impact on families and their primary care providers (PCPs). Support professionals encounter significant challenges delivering comprehensive management for this complex neurobehavioral and developmental disorder. Children with ASD experience significantly higher risk for unmet healthcare needs, and parents report less satisfaction with their care although current literature does not fully explain why this issue persists. This study sought parent insight for the missing answers needed to inform practice. Eleven parents of children with an ASD participated in the study. Parent perceptions of care were examined utilizing Interpretive Phenomenological Analysis (IPA) and the Measure of Process of Care (MPOC-20) to illuminate and describe their lived experiences raising children with ASD, and interactions with their PCPs. Most parents utilized their child's PCP for general health maintenance, and many felt their PCP was unable to manage issues specifically related to their child's ASD. Most did not have an expectation for support with behavioral management in the home and school setting or identification of community and mental health resources, although many struggled with unaddressed needs in both of these realms. Utilizing parent perceptions to highlight practice deficiencies can build a foundation for care models that are more comprehensive and family centered.

A cluster-randomized trial shows telephone peer coaching for parents reduces children's asthma morbidity

Childhood asthma morbidity remains significant, especially in low-income children. Most often, asthma management is provided by the child's primary care provider. We sought to evaluate whether enhancing primary care management for persistent asthma with telephone-based peer coaching for parents reduced asthma impairment and risk in children 3 to 12 years old. Over 12 months, peer trainers provided parents with asthma management training by telephone (median, 18 calls) and encouraged physician partnership. The intervention was evaluated in a cluster-randomized trial of 11 intervention and 11 usual care pediatric practices (462 and 486 families, respectively). Patient outcomes were assessed by means of telephone interviews at 12 and 24 months conducted by observers blinded to intervention assignment and compared by using mixed-effects models, controlling for baseline values and clustering within practices. In a planned subgroup analysis we examined the heterogeneity of the intervention effect by insurance type (Medicaid vs other). After 12 months, intervention participation resulted in 20.9 (95% CI, 9.1-32.7) more symptom-free days per child than in the control group, and there was no difference in emergency department (ED) visits. After 24 months, ED visits were reduced (difference in mean visits/child, -0.28; 95% CI, -0.5 to -0.02), indicating a delayed intervention effect. In the Medicaid subgroup, after 12 months, intervention participation resulted in 42% fewer ED visits (difference in mean visits/child, -0.50; 95% CI, -0.81 to -0.18) and 62% fewer hospitalizations (difference in mean hospitalizations/child, -0.16; 95% CI, -0.30 to -0.014). Reductions in health care use endured through 24 months. This pragmatic telephone-based peer-training intervention reduced asthma impairment. Asthma risk was reduced in children with Medicaid insurance.

Randomized trial of a health communication intervention for parents of children with asthma

Objective: To determine if a health communication intervention targeting parents of high-risk, urban, minority children with asthma could (i) improve parental perceptions of connectedness to and communication with their child's primary care providers (PCP) and (ii) decrease reliance on emergency departments (EDs) and other urgent care services for their child's asthma-related care. Methods: The design was a single blind, parallel groups, randomized controlled trial. Parents were recruited from an ED-based asthma clinic serving primarily low-income, minority children in Washington, DC. The intervention involved face-to-face education on effective communication followed by a single booster call. Standardized instruments were administered to assess primary care connectedness and healthcare utilization at baseline and 2- and 6-months post-enrollment. Results: A total of 150 parents of children 1–12 years old were randomized (77 intervention and 73 usual care), and 137 (91%) were successfully followed for six months. Only at the two-month follow-up time-point, parents in the intervention group were significantly more likely to identify a PCP as the main source of their child's asthma care (adjusted odds ratio: 12.6, 95% confidence interval: 1.1–142.1) and to report a significant reduction in ED visits for asthma care (adjusted incidence rate ratio: 0.3, 95% confidence interval: 0.1–0.8). There was no significant effect on parent communication self-efficacy or number of PCP visits. Conclusions: A brief, in-person health communication intervention for parents of high-risk children with asthma resulted in improved identification of PCPs as the usual source of asthma care and reduced reliance on EDs for asthma care, albeit only for two months post-intervention.

Preventing Dehydration-Related Hospitalizations: A Mixed-Methods Study of Parents, Inpatient Attendings, and Primary Care Physicians

The goal of this study was to identify the proportion of dehydration-related ambulatory care-sensitive condition hospitalizations, the reasons why these hospitalizations were preventable, and factors associated with preventability. A cross-sectional survey of primary care providers (PCPs), inpatient attending physicians, and parents was conducted in a consecutive series of children with ambulatory care-sensitive conditions admitted to an urban hospital over 14 months. Eighty-five children were diagnosed with dehydration. Their mean age was 1.6 years; most had public (74%) or no (17%) insurance, and were nonwhite (91%). The proportion of hospitalizations assessed as preventable varied from 12% for agreement among all 3 sources to 45% for any source. Parents identified inadequate prevention (50%), poor self-education (34%), and poor quality of care (38%) as key factors. PCPs identified parents providing insufficient home rehydration (33%), not visiting the clinic (25%), and not calling earlier (16%) as reasons. Inpatient attending physicians cited home rehydration (40%), delays in seeking care (40%), and lacking a PCP (20%) as contributors. Physicians (PCPs and inpatient attending physicians) were more likely than parents to describe the admission as inappropriate (75% vs 67% vs 0%; P < .01). Parental dissatisfaction with their child's PCP and a history of avoiding primary care due to costs or insurance problems were associated with significantly higher odds of preventable hospitalization. Up to 45% of dehydration-related hospitalizations may be preventable. Inadequate parental education by physicians, insufficient home rehydration, deferring clinic visits, insurance and cost barriers, inappropriate admissions, poor quality of care, and parental dissatisfaction with PCPs are the reasons that these hospitalizations might have been prevented.

Calling 911! What Role Does the Pediatrician Play?

The objective of this study was to compare admission rates and medical interventions among children whose caregivers called their child's primary care provider (PCP) before taking an ambulance to the pediatric emergency department (PED) versus those who did not. This was a prospective cohort study of patients brought to an urban, public hospital PED via emergency medical system (EMS). Children were included if the caregiver called 911 to have them transported via EMS and was present in the PED. The main variable was whether the child's PCP was called before EMS utilization. Study outcomes were medical interventions, such as intravenous line insertion or laboratory tests, and hospital admission. χ Test and logistic regression were used to evaluate the relationship of the main variable to the study outcomes. Six hundred fourteen patients met inclusion criteria and were enrolled. Five hundred eighty-five patients (95.3%) were reported to have a PCP. Seventy-four caregivers (12.1%) called their child's PCP before calling EMS. Two hundred seventy-seven patients (45.1%) had medical interventions performed; of these, 42 (15.2%) called their PCP (P = 0.03). Forty-two patients (6.8%) were admitted; among these, 14 (33.3%) called their PCP (P < 0.01). Adjusting for triage level, patients whose caregiver called the PCP before calling EMS were 3.2 times (95% confidence interval, 1.9-5.2 times) more likely to be admitted and 1.7 times (95% confidence interval, 1.1-2.9 times) more likely to have a medical intervention compared with patients whose caregivers did not call their child's PCP. Children were more likely to be admitted or require a medical intervention if their caregiver called their PCP before calling EMS. The availability of a PCP for telephone triage may help to optimize EMS utilization.

African-American Parents' Trust in their Child's Primary Care Provider

ObjectivePatients' trust in their primary care providers has important implications in terms of health outcomes and, among minority patients, mitigating racial health disparities. This study aims to identify family, provider, and health care setting characteristics that predict African American parents' trust in their child's primary care provider and whether provider partnership-building communication style explains this association. MethodsData were collected via retrospective telephone interviews completed 2 weeks after a child's health care visit to 1 of 7 pediatric primary care clinics in Washington, DC (3 community health centers, 3 private practices, and 1 hospital-based clinic). Four hundred twenty-five self-identified African American parents of children 0 to 5 years of age participated. Parents completed several standard survey instruments about trust and provider communication style as well as demographic questionnaires about their family and their child's provider. ResultsA step-wise linear regression revealed significant independent effects of having a previous relationship with the provider and seeing a provider in a community health center (CHC) on higher trust. There was also evidence of mediation by provider communication style, suggesting that parents who take their child to a CHC report greater trust in their child's provider because they have higher perceptions of provider partnership building. ConclusionsAfrican American parents' trust in their child's provider may be enhanced by continuity of care and greater use of a partnership-building communication style by providers.

Vaccinating Adolescents—New Evidence of Challenges and Opportunities

Vaccinating Adolescents—New Evidence of Challenges and Opportunities

Revisiting Predictors of Parental Health Care-Seeking Behaviors for Nonurgent Conditions at One Inner-City Hospital

To determine important predictors of why parents seek care for their children at a pediatric emergency department (ED) compared to their child's primary care provider's (PCP's) walk-in clinic. Cross-sectional study. An inner-city hospital located in New York City, from April 2003 to January 2004. A convenience sample of 170 parents with children younger than 18 years, Medicaid beneficiaries, had a PCP, and presented with a nonurgent medical problem either at the pediatric ED or walk-in clinic. The main outcome measure was the setting in which parents sought care for their child; odds ratios (ORs) were calculated for parents seeking care in the pediatric ED compared to those seeking care at the walk-in clinic, adjusting for predisposing, enabling, and need-related factors. Of the 170 parent-child visits, 87 (51%) were seeking care at the ED and 83 (49%) at their child's walk-in clinic. In logistic regression, single parenting was the strongest predictor for seeking care in the ED (OR, 5.54; 95% confidence interval [CI], 1.4-26.9), followed by Hispanic ethnicity (OR, 4.96; 95% CI, 1.43-17.2), low parental perceptions of their child's physical health (OR, 0.90; 95% CI, 0.82-0.99), controlling for number of chronic conditions, parental working status, and satisfaction with their PCP. Single parenting, Hispanic ethnicity, and perceptions of health are associated with health care-seeking behaviors in high cost settings among Medicaid beneficiaries. Targeted education programs could be used to influence future site of care.

Does Quality of Primary Care Vary by Level of Training in Pediatric Resident Continuity Practices?

The aim of this study was to compare parental perception of quality of care provided by first- versus third-year pediatric residents who served as their children's primary care providers. The Parents' Perception of Primary Care (P3C) survey was administered to all parents who identified a pediatric resident as a primary care provider at 19 Continuity Research Network (CORNET) sites. Parent survey scores were compared between those identifying first-year pediatric residents (PL-1) versus third-year pediatric residents (PL-3) as care providers by using t tests and linear regression modeling, as well as item-specific chi-square analysis and logistic regression. Comparing the responses of the 347 parents who identified a PL-3 resident and the 360 parents who identified a PL-1 resident as their child's primary care provider, those who identified a PL-3 resident rated their childrens overall care higher, with a mean score of 79.2 (95% confidence interval [95% CI] 77.5-80.8) as compared to 75.9 (95% CI 74.4-77.3); P < .05. This disparity was primarily due to differences in the longitudinal continuity domain. Comparisons of the other domains of communication, comprehensiveness, access, contextual knowledge, and coordination showed no statistically significant differences between the 2 groups. Parents rated PL-3 residents as having greater knowledge in behavioral counseling and coordination with schools than PL-1 residents. Parents rated residents at both training levels very highly for the quality of care provided. PL-3 residents had higher longitudinal continuity scores and were perceived to have greater knowledge about behavioral counseling and coordination of care with schools. Further research will need to elucidate strategies to improve earlier resident acquisition of coordination and behavior management skills.