Factors related to receipt of well-child visits in insured children

Association of Parent Preventive Care with their Child's Recommended Well-Child Visits

BACKGROUND

Receipt of recommended well-child care is lowest for children without insurance, many of whom receive care in community health centers (CHCs).

OBJECTIVE

To understand if there is an association between parent preventive care and their children's well-child visits.

METHODS

We used electronic health record data to identify children and link them to parents both seen in an OCHIN network (CHC; n = 363 clinics from 17 states), randomly selected a child aged 3 to 17 with ≥1 ambulatory visit between 2015 and 2018. We employed a retrospective, cohort study design and used general estimating equations Poisson regression to estimate yearly rates of well-child visits based on parent preventive care adjusted for relevant covariates and stratified by child age for 3 linked samples: mother only, father only, and two parents.

RESULTS

We included 75,398 linked mother only pairs, 12,438 in our father only, and 4,156 in our 2-parent sample. Children in the mother only sample had a 6% greater rate of yearly well-child visits when their mother received preventive care (adjusted rate ratio [ARR] = 1.06; 95% CI = 1.03-1.08) compared to no preventive care. Children in the father only sample had a 7% greater rate of yearly well-child visits when their father received preventive care (ARR = 1.07; 95% CI = 1.04-1.11) versus no preventive care. Children in the two parent sample had an 11% greater rate of yearly well-child visits when both parents received preventive care (ARR = 1.11; 95% CI = 1.03-1.19) compared to neither receiving preventive care.

CONCLUSIONS

These findings suggest focusing on receipt of healthcare for the whole family may improve well-child visit rates.

Timing and Persistence of Material Hardship Among Children in the United States

Objective

Screening for social determinants of health (SDH) has been widely adopted to identify child health risks associated with exposure to material hardship. Whereas SDH screening typically addresses a 12-month span, we sought to compare the prevalence of exposure to present (within the past year) as compared to recent (2–4 years ago) hardship among children in the United States.

Methods

We analyzed the 2014 Survey of Income and Program Participation, a nationally representative survey that interviewed participating households annually between 2014 and 2017. We included data from households with children in all waves. As of 2017, households were categorized as (1) experiencing present hardship (within the last year); (2) experiencing recent but not present hardship (any year between 2014 and 2016); and (3) experiencing no hardship over the 4-year period.

Results

Of 2422 households, 27% experienced present hardship and 29% experienced recent but not present hardship. Households presently experiencing hardship were more likely to have Medicaid insurance, less likely to be married, and had more children than families who had experienced recent hardship. However, these groups were similar on caregivers’ educational attainment, race/ethnicity, language spoken in the home, and age of the youngest child.

Conclusions

Our results suggest that clinical screening tools for SDH that use a 12-month time frame risk missing many children who have recently (within the past 4 years) experienced material hardship and may benefit from interventions to improve social support; a longer time frame could provide clinicians with valuable information for understanding social factors that impact child health and development.

Community Healthy Workers Fill in the Gaps for Participants Who Became Lost to Follow-up in a Healthy Start Program

The purpose of this mixed methods study was to solicit information from Community Health Workers (CHWs) in order to further understand reasons for Healthy Start participants becoming lost to follow-up after delivery. Four CHWs from a local Healthy Start Program completed questionnaires for participants in their caseloads who had become lost to follow-up from the program (n = 146) between Sep 2018 and Jan 2020. The questionnaire included open ended items about ease of contact before and after delivery, changes in contact information, compliance with prenatal care visits, other life challenges (such as housing, legal, transportation, and family support), family size, living arrangements, working/student status, and substance use. Participants were categorized by ease of contact throughout participation into Easy (28.8%), Easy then Difficult (11%) and Difficult (60.3%). Responses to questions were reviewed and coded to identify common themes. Groups differed on: having a change in contact information, having challenges with transportation, having lots of help, having other children between 6 and 10 years old, compliance with prenatal care, and race being non-Black. Areas where groups differed may indicate possible reasons for participants becoming lost to follow up after delivery. The descriptive results from this study can help CHWs address these issues with participants during prenatal care, when they are easier to contact, to develop contingency plans for remaining in contact after delivery.

Rural Disparities in Early Childhood Well Child Visit Attendance

PURPOSE

Children should attend well child visits (WCVs) during early childhood so that developmental disorders may be identified as early as possible, so treatment can begin. The aim of this research was to determine if rurality impacts access to WCV during early childhood, and if altering rurality measurement methods impacts outcomes.

DESIGN AND METHODS

We utilized a longitudinal correlational design with early childhood data gathered from the Virginia All Payer Claims Database, which contains claims data from Medicaid and the majority of Virginia commercial insurance payers (n = 6349). WCV attendance was evaluated against three rurality metrics: a traditional metric using Rural-Urban Commuting Area codes, a developed land variable, and a distance to care variable, at a zip code level.

RESULTS

Two of the rurality methods revealed that rural children attend fewer WCVs than their urban counterparts, (67% vs. 50% respectively, using a traditional metric; and a 0.035 increase in WCV attendance for every percent increase in developed land). Differences were attenuated by insurance payer; children with Medicaid attend fewer WCVs than those with private insurance.

CONCLUSIONS

Young children in rural Virginia attend fewer WCVs than their non-rural counterparts, placing them at higher risk for missing timely developmental disorder screenings. The coronavirus disease pandemic has been associated with an abrupt and significant reduction in vaccination rates, which likely indicates fewer WCVs and concomitant developmental screenings. Pediatric nurses should encourage families of young children to develop a plan for continued WCVs, so that early identification of developmental disorders can be achieved.

The Impact of Sickle Cell Anemia and Mental Health Diagnoses on Healthcare Use and Preventive Care among Children Enrolled in Medicaid, 2005-2012

OBJECTIVE

To examine mental health diagnoses, healthcare use, and receipt of age-appropriate preventive care, including antibiotic prophylaxis, hydroxyurea therapy, and transcranial Doppler screenings, among children with sickle cell anemia (SCA).

STUDY DESIGN

Children aged 1-17 years with SCA from 6 states having 3 or more Medicaid claims with a SCA diagnosis within a year (2005-2012) were included. Children with mental health diagnoses were identified with 1 or more mental health encounters. Poisson and logistic regression models with general estimating equations assessed the relationship between mental health diagnoses, healthcare use, and receipt of age-appropriate preventive care.

RESULTS

In total, 7963 children with SCA were identified (22 424 person-years); 1593 person-years (7.1%) included 1 or more mental health diagnoses. Children with a mental health diagnosis were more likely to have inpatient admissions (incidence rate ratio [IRR] 1.46, 95% CI 1.36-1.56) and outpatient (IRR 1.27, 95% CI 1.21-1.34), emergency department (IRR 1.39, 95% CI 1.30-1.48), and well-child visits (IRR 1.19, 95% CI 1.11-1.29). Those with a mental health diagnosis were more likely to receive hydroxyurea therapy (odds ration [OR] 1.17, 95% CI 1.03-1.33) and less likely to receive transcranial Doppler screenings (OR 0.79, 95% CI 0.68-0.93).

CONCLUSIONS

Children with SCA do not receive adequate age-appropriate preventive care. Further research is necessary to identify key points of coordination between mental health and SCA services throughout the life course. This approach may help to increase receipt of age-appropriate preventive care and decrease reliance on acute care.

Don't hesitate, vaccinate! An influenza vaccine education program

The State of Connecticut mandates that prekindergarten children be vaccinated against the influenza virus each year by December 31st. Annually, prekindergarten students in urban schools in Connecticut are not compliant with this statute due to many factors such as parents' lack of education. The purpose of an educational intervention project (EIP) is to provide urban prekindergarten parents/caregivers with education about the influenza virus, influenza vaccine, the community resources, and Connecticut mandates. An influenza vaccine educational intervention was provided to parents and caregivers of prekindergarten students in one urban elementary school in Connecticut. Parents were educated during an open house at the school and then 4 weeks later at a Meet and Greet with prekindergarten parents. Information regarding influenza virus, vaccine, and state regulations was provided along with Pre- and post-questionnaires to assess the level of knowledge. The goal of this EIP is increased knowledge of the influenza virus, the vaccine, community resources, and state regulations. The success of this educational intervention can be shared and implemented in other licensed prekindergarten programs to increase parents' knowledge and it would lead to increased rates of district-wide compliance and decreased student absences. Most importantly, implications point to the potential protection of the public from an illness stemming from the influenza virus.

Adolescents' and Young Adults' Routine Care Use: The Role of Their Mothers' Care Use Behaviors

PURPOSE

Little is known whether mothers' own care use is differentially associated with their adolescents' routine care use by gender. The main purpose of this study is to examine whether mothers' healthcare use prospectively predicts their adolescents' routine care use stratified by gender, after controlling for predisposing (child's age, race/ethnicity, region of residence, urbanicity, and mother's age at child's birth), enabling (mother's education, adolescent and mother health insurance), and need (child health status) factors.

METHODS

In 2018, a prospective analysis was conducted using data from 5,040 adolescents aged 9-24 and their mothers who completed the two-generation National Longitudinal Survey of Youth in 2006 (first interview) and 2008 (second interview). Findings include percentages and adjusted odds ratios of the factors that predict adolescents' self-report of routine care use in the past year measured at the second interview.

RESULTS

In 2008, over half of participants reported a routine doctor visit during the prior 12 months and this varied by gender; more females (68.7%) had a visit than males (53.5%). Factors that independently predicted a greater odds of adolescents' routine doctor visits included mothers with routine doctor visits at both interviews or the second interview only, and adolescents' health insurance and past routine visit, regardless of gender. Males aged 18-20 and 21-24 years had lower odds of having a routine doctor visit than males aged 9-11 years.

CONCLUSIONS

This study provides evidence for the potential role that mothers' care use can play in their adolescents' routine care use, especially for their sons, independent of insurance status.

Gaps in Well-Child Care Attendance Among Primary Care Clinics Serving Low-Income Families

BACKGROUND AND OBJECTIVES

It is unclear which specific well-child visits (WCVs) are most frequently missed and whether age-specific patterns of attendance differ by race or insurance type.

METHODS

We conducted a retrospective cohort study of children 0 to 6 years old between 2011 and 2016 within 2 health networks spanning 20 states. WCVs were identified by using International Classification of Diseases, Ninth and 10th Revisions and Current Procedural Terminology codes. We calculated adherence to the 13 American Academy of Pediatrics-recommended WCVs from birth to age 6 years. To address data completeness, we made 2 adherence calculations after a child's last recorded WCV: 1 in which we assumed all subsequent WCVs were attended outside the network and 1 in which we assumed none were.

RESULTS

We included 152 418 children in our analysis. Most children were either publicly insured (77%) or uninsured (14%). The 2-, 4-, and 6-month visits were the most frequently attended (63% [assuming no outside care after the last recorded WCV] to 90% [assuming outside care]), whereas the 15- and 18-months visits (41%-75%) and 4-year visit (19%-49%) were the least frequently attended. Patients who were publicly insured and uninsured (versus privately insured) had higher odds of missing WCVs. Hispanic and Asian American (versus non-Hispanic white) patients had higher odds of attending WCVs.

DISCUSSION

The 15- and 18-month WCVs as well as the 4-year WCV are the least frequently attended WCVs. The former represent opportunities to identify developmental delays, and the latter represents an opportunity to assess school readiness.

Well-Child Visits of Medicaid-Insured Children with Medical Complexity

OBJECTIVE

Well-child visits (WCVs) help optimize children's health. We measured annual WCVs for children with medical complexity (CMC) and correlated WCVs with hospitalizations.

STUDY DESIGN

This was a retrospective analysis of 93 121 CMC aged 1-18 years continuously enrolled in 10 state Medicaid programs in the Truven MarketScan Database between 2010 and 2014. CMC had a complex chronic condition or 3 or more chronic conditions of any complexity identified from International Classification of Diseases, Ninth Revision codes, and the use of 1 or more chronic medications. We measured the number of years with 1 or more WCVs. The χ² test and logistic regression were used to assess the relationships of WCV-years with the children's characteristics and hospitalization.

RESULTS

Over 5 years, 13.4% of CMC had 0 WCVs; 17.3% had WCVs in 1 year, 40.8% had WCVs in 2-3 years, and 28.5% had WCVs in 4-5 years. Fewer children received WCVs in 4-5 years when enrolled in Medicaid fee-for-service compared with managed care (20.9% vs 31.5%; P < .001) and when enrolled due to a disability compared with another reason (18.2% vs 32.2%; P < .001). The percentage of CMC hospitalized decreased as the number of years receiving WCV increased (21.5% at 0 years vs 16.9% at 5 years; P < .001). The adjusted odds of hospitalization were higher in CMC with WCVs in 0-4 years compared with CMC with WCVs in all 5 years (OR range across years, 1.1 [95% CI, 1.0-1.2] to 1.3 [95% CI, 1.3-1.4]).

CONCLUSIONS

Most Medicaid-insured CMC do not receive annual WCVs consistently over time. Children with fewer annual WCVs have a higher likelihood of hospitalization. Further investigation is needed to improve the use of WCVs in CMC.

Spillover Effects of Adult Medicaid Expansions on Children's Use of Preventive Services

BACKGROUND

Since the passage of the Affordable Care Act, Medicaid enrollment has increased by ∼17 million adults, including many low-income parents. One potentially important, but little studied, consequence of expanding health insurance for parents is its effect on children's receipt of preventive services.

METHODS

By using state Medicaid eligibility thresholds linked to the 2001-2013 Medical Expenditure Panel Surveys, we assessed the relationship between changes in adult Medicaid eligibility and children's likelihood of receiving annual well-child visits (WCVs). In instrumental variable analyses, we used these changes in Medicaid eligibility to estimate the relationship between parental enrollment in Medicaid and children's receipt of WCVs.

RESULTS

Our analytic sample consisted of 50 622 parent-child dyads in families with incomes <200% of the federal poverty level, surveyed from 2001 to 2013. On average, a 10-point increase in a state's parental Medicaid eligibility (measured relative to the federal poverty level) was associated with a 0.27 percentage point higher probability that a child received an annual WCV (95% confidence interval: 0.058 to 0.48 percentage points, P = .012). Instrumental variable analyses revealed that parental enrollment in Medicaid was associated with a 29 percentage point higher probability that their child received an annual WCV (95% confidence interval: 11 to 47 percentage points, P = .002).

CONCLUSIONS

In our study, we demonstrate that Medicaid expansions targeted at low-income adults are associated with increased receipt of recommended pediatric preventive care for their children. This finding reveals an important spillover effect of parental insurance coverage that should be considered in future policy decisions surrounding adult Medicaid eligibility.

Provider Visits for Asthma: Potential Barriers for Insured Children

OBJECTIVE

The barriers to provider visits for asthma in insured children are not well understood. Our objective was to examine the relationship between parent, family, and child attributes and asthma visits in insured children.

METHODS

This retrospective, cross-sectional analysis of 2007 Medical Expenditure Panel Survey-Household Component data included insured children 0-17 years old reported to have active asthma. We summed the number of provider visits during which asthma was treated or diagnosed to represent the frequency of asthma visits during the year. Probit models were used to estimate the relationship between parent, family, and child attributes and asthma visits.

RESULTS

Seventy percent of the 542 children did not have an asthma visit during the year. Children with parents employed full time were 16 percentage points less likely to have an asthma visit than children whose parents were not working (P=.01).

CONCLUSION

Many insured children go more than a year without seeing a provider for their asthma, signaling that insurance is not sufficient to guarantee children will receive asthma monitoring. The attributes related to asthma visits suggest potential barriers that providers might want to consider to increase participation in asthma visits.