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Complexity in pediatric primary care

  • Arwa Nasir (a1), Laeth Nasir (a2), Ariel Tarrell (a1), David Finken (a1), Amy Lacroix (a1), Swetha Pinninti (a1), Sheryl Pitner (a1) and Molly McCarthy (a3)...

The management of patients in primary care is often complicated by the presence of multiple chronic conditions and psychosocial issues that increase the complexity of the encounter and have important impacts on care. There is a paucity of literature on this subject in the pediatric population.


The aim of this study was to quantify the burden of chronic conditions in pediatric primary care.


The problem lists of 3995 randomly selected patients from a community pediatric clinic and an academic hospital-based pediatric clinic in the same metropolitan area were analyzed for the presence and number of any chronic condition.


In total, 53% of patients suffered from at least one chronic problem, 25% had two or more chronic conditions and 5.1% had four or more conditions. Compared with the community clinic, the academic clinic had significantly more children with catastrophic complex conditions (P<0.001). A regression analysis showed a significant positive correlation between the number of chronic medical conditions and mental health diagnoses.


The burden of chronic disease in the pediatric primary care setting may be significantly higher than has been previously suggested. To ensure optimal quality of care, health planners should take into account the high burden of chronic illness, psychosocial issues and multimorbidity among patients in the pediatric primary care setting, as well as the higher complexity profile of patients attending academic clinics.

Corresponding author
Author for correspondence: Arwa Nasir, Department of Pediatrics, 982167 Nebraska Medical Center, University of Nebraska Medical Center, Omaha, NE 68198-2167, USA. E-mail:
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Barnett, K, Mercer, SW, Norbury, M, Watt, G, Wyke, S Guthrie, B (2012) Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet 380, 3743.
Branum, AM Lukacs, SL (2009) Food allergy among children in the United States. Pediatrics 124, 15491555.
Brett, T, Arnold-Reed, DE, Popescu, A, Soliman, B, Bulsara, MK, Fine, H, Bovell, G Moorhead, RG (2013) Multimorbidity in patients attending 2 Australian primary care practices. Annals of Family Medicine 11, 535542.
Britt, HC, Harrison, CM, Miller, GC Knox, SA (2008) Prevalence and patterns of multimorbidity in Australia. Medical Journal of Australia 189, 7277.
Campo, JV, Jansen-McWilliams, L, Comer, DM Kelleher, KJ (1999) Somatization in pediatric primary care: association with psychopathology, functional impairment, and use of services. Journal of the American Academy of Child and Adolescent Psychiatry 38, 10931101.
Cederna-Meko, CL, Ellens, REH, Burrell, KM, Perry, DS Rafiq, F (2016) An exploration of behavioral health productivity and billing practices within pediatric primary care. Journal of Pediatric Psychology 41, 11331143.
Fortin, M, Stewart, M, Poitras, M-E, Almirall, J Maddocks, H (2012) A systematic review of prevalence studies on multimorbidity: toward a more uniform methodology. Annals of Family Medicine 10, 142151.
Foster, CC, Mangione-Smith, R Simon, TD (2017) Caring for children with medical complexity: perspectives of primary care providers. Journal of Pediatrics 182, 275282.e4.
Grant, RW, Ashburner, JM, Hong, CS, Chang, Y, Barry, MJ Atlas, SJ (2011) Defining patient complexity from the primary care physician’s perspective: a cohort study. Annals of Internal Medicine 155, 797804.
Horner, RD, Paris, JA, Purvis, JR Lawler, FH (1991) Accuracy of patient encounter and billing information in ambulatory care. Journal of Family Practice 33, 593598.
Huntley, AL, Johnson, R, Purdy, S, Valderas, JM Salisbury, C (2012) Measures of multimorbidity and morbidity burden for use in primary care and community settings: a systematic review and guide. Annals of Family Medicine 10, 134141.
Hwang, AS, Atlas, SJ, Hong, J, Ashburner, JM, Zai, AH, Grant, RW Hong, CS (2017) Defining team effort involved in patient care from the primary care physician’s perspective. Journal of General Internal Medicine 32, 269276.
Kellogg, ND, Hoffman, TJ Taylor, ER (1999) Early sexual experiences among pregnant and parenting adolescents. Adolescence 34, 293303.
McLean, G, Gunn, J, Wyke, S, Guthrie, B, Watt, GCM, Blane, DN Mercer, SW (2014) The influence of socioeconomic deprivation on multimorbidity at different ages: a cross-sectional study. British Journal of General Practice: The Journal of the Royal College of General. Practitioners 64, e440e447.
Moffat, K Mercer, SW (2015) Challenges of managing people with multimorbidity in today’s healthcare systems. BMC Family Practice 16, 129.
Pefoyo, AJK, Bronskill, SE, Gruneir, A, Calzavara, A, Thavorn, K, Petrosyan, Y, Maxwell, CJ, Bai, Y Wodchis, WP (2015) The increasing burden and complexity of multimorbidity. BMC Public Health 15, 415.
Perou, R, Bitsko, RH, Blumberg, SJ, Pastor, P, Ghandour, RM, Gfroerer, JC, Hedden, SL, Crosby, AE, Visser, SN, Schieve, LA, Parks, SE, Hall, JE, Brody, D, Simile, CM, Thompson, WW, Baio, J, Avenevoli, S, Kogan, MD Huang, LN (2013) Mental health surveillance among children--United States, 2005-2011. MMWR Supplements 62, 135.
Pulcini, CD, Zima, BT, Kelleher, KJ Houtrow, AJ (2017) Poverty and Trends in Three Common Chronic Disorders. Pediatrics 139, e20162539.
Radovic, A, Reynolds, K, McCauley, HL, Sucato, GS, Stein, BD Miller, E (2015) Parents’ role in adolescent depression care: primary care provider perspectives. Journal of Pediatrics 167, 911918.
Schellevis, FG, van der Velden, J, van de Lisdonk, E, van Eijk, JT van Weel, C (1993) Comorbidity of chronic diseases in general practice. Journal of Clinical Epidemiology 46, 469473.
Sondergaard, E, Willadsen, TG, Guassora, AD, Vestergaard, M, Tomasdottir, MO, Borgquist, L, Holmberg-Marttila, D, Olivarius, N, de, F Reventlow, S (2015) Problems and challenges in relation to the treatment of patients with multimorbidity: general practitioners’ views and attitudes. Scandinavian Journal of Primary Health Care 33, 121126.
Stein, RE Silver, EJ (1999) Operationalizing a conceptually based noncategorical definition: a first look at US children with chronic conditions. Archives of Pediatrics & Adolescent Medicine 153, 6874.
Sussman, AL, Williams, RL, Leverence, R, Gloyd, PWJ Crabtree, BF (2006) The art and complexity of primary care clinicians’ preventive counseling decisions: obesity as a case study. Annals of Family Medicine 4, 327333.
Uijen, AA van de Lisdonk, EH (2008) Multimorbidity in primary care: prevalence and trend over the last 20 years. European Journal of General Practice 14 (Suppl 1), 2832.
van den Akker, M, Buntinx, F, Metsemakers, JF, Roos, S Knottnerus, JA (1998) Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. Journal of Clinical Epidemiology 51, 367375.
van der Lee, JH, Mokkink, LB, Grootenhuis, MA, Heymans, HS Offringa, M (2007) Definitions and measurement of chronic health conditions in childhood: a systematic review. JAMA 297, 27412751.
van Oostrom, SH, Picavet, HSJ, van Gelder, BM, Lemmens, LC, Hoeymans, N, van Dijk, CE, Verheij, RA, Schellevis, FG Baan, CA (2012) Multimorbidity and comorbidity in the Dutch population – data from general practices. BMC Public Health 12, 715.
Violan, C, Foguet-Boreu, Q, Flores-Mateo, G, Salisbury, C, Blom, J, Freitag, M, Glynn, L, Muth, C Valderas, JM (2014) Prevalence, determinants and patterns of multimorbidity in primary care: a systematic review of observational studies. PloS One 9, e102149.
Woodward, CA, Hutchison, B, Norman, GR, Brown, JA Abelson, J (1998) What factors influence primary care physicians’ charges for their services? An exploratory study using standardized patients. Canadian Medical Association 158, 197202.
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Primary Health Care Research & Development
  • ISSN: 1463-4236
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