Caregiver and Clinician Perspectives on Missed Well-Child Visits

A Pilot Randomized Controlled Trial of Text Messages to Improve Well-Child Visit Attendance After No-Show

OBJECTIVE

Evaluate the effectiveness of text messages to systematically engage parents/guardians ("caregivers") to reschedule a well-child visit (WCV) that was missed ("no-show") and attend that rescheduled WCV visits.

METHODS

Patients <18 years in one of five pediatrics or family medicine clinics, in one health system in the Southeast US, were eligible. Patients without a rescheduled WCV after a no-show were randomized into intervention (text messages) or care-as-usual comparison, stratified by language (English/Spanish). Enrollment occurred May-July 2022. Up to three text messages were sent to caregivers one week apart via REDCap and Twilio, advising how to reschedule the missed appointment by phone or health portal. Primary outcomes were 1) rescheduling a WCV within 6 weeks of no-show and 2) completing a rescheduled WCV within 6 weeks. Risk differences (RD) and odds ratios (OR) were used to evaluate the effect of text messages.

RESULTS

Seven hundred and twenty patients were randomized and analyzed (texts: 361, comparison: 359). The proportion rescheduling WCV after text versus usual care was English: 18.85% versus 15.02%, respectively, and Spanish: 5.94% versus 8.14%, with overall RD+ 1.98% (95% CI: -1.85, 5.81) and OR 1.21 (95% CI: 0.79, 1.84; P-value .38). Completed WCV rates in text or usual care were English: 13.08% versus 6.59%, and Spanish: 5.81% versus 5.94% with texts associated with RD+ 2.83% (95% CI: 1.66, 4.00) and OR 1.86 (95% CI: 1.09, 3.19).

CONCLUSION

Text message follow-up after a no-show WCV may positively impact attendance at WCVs rescheduled in the subsequent 6 weeks.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05086237.

Effectiveness of text message reminders on paediatric appointment adherence: a systematic review and meta-analysis

Attending health appointments is important for the paediatric population, as it allows for earlier detection of health issues and subsequent necessary treatments. It also ensures timely immunisations while also allowing patients or their parents to raise health concerns. Hence, it is crucial to take steps to ensure that such medical appointments are attended. To evaluate the effectiveness of text message reminders (TMRs) in improving paediatric patients' adherence to their appointments. A systematic review and meta-analysis were conducted. The search spanned across eight online databases from their inception dates to January 2024. The random-effects model was utilised to conduct the meta-analysis, where risk ratio was used as the effect measure. Subgroup analyses were conducted for age, number of TMRs sent, and type of appointments attended. In total, 13 studies were included. Compared to standard care (involving non-text message reminders or no reminders), TMRs were significantly more effective in improving appointment attendance among the paediatric population. Significant subgroup differences were found in the type of appointments attended, where TMRs were more effective for medical appointments compared to vaccination appointments. No differences in adherence to appointments were found across age groups or the number of TMRs sent.   Conclusion: Sending TMRs can be a potentially cost-effective way to improve the attendance rate of paediatric medical appointments, given the ease of implementation and the extensive mobile phone usage globally. Future studies should compare TMRs to other modes of automated reminders such as telephone messages or emails, to identify the most optimal method of delivery.   Trial registration: PROSPERO (CRD42023464893).

Place-Based Opportunity and Well Child Visit Attendance in Early Childhood

BACKGROUND

Lower neighborhood opportunity, measured by the Child Opportunity Index [COI], is associated with increased pediatric morbidity, but is less frequently used to examine longitudinal well child care. We aimed to evaluate associations between the COI and well child visit [WCV] attendance from birth - <36 months of age.

METHODS

The Upstate KIDS population-based birth cohort includes children born 2008-2010 in New York state. The exposure, 2010 census tract COI (very low [VL] to very high [VH]), was linked to children's geocoded residential address at birth. The outcome was attended WCVs from birth - <36 months of age. Parents reported WCVs and their child's corresponding age on questionnaires every 4-6 months. These data were applied to appropriate age ranges for recommended WCVs to determine attendance. Associations were modeled longitudinally as odds of attending visits and as mean differences in proportions of WCVs by COI.

RESULTS

Among 4650 children, 21% (n = 977) experienced VL or low COI. Children experiencing VL (adjusted OR [aOR] 0.68, 95% CI 0.61, 0.76), low (aOR 0.81, 95% CI 0.73, 0.90), and moderate COI (aOR 0.88, 95% CI 0.81, 0.96), compared to VH COI, had decreased odds of attending any WCV. The estimated, adjusted mean proportions of WCV attendance were lower among children experiencing VL (0.45, P < .01), low (0.53, P = .02), moderate (0.53, P = .05), and high (0.54, P = .03) compared to VH COI (0.56).

CONCLUSIONS

Lower COI at birth was associated with decreased WCV attendance throughout early childhood. Reducing barriers to health care access for children experiencing lower COI may advance equitable well child care.

Understanding barriers to well-child visit attendance among racial and ethnic minority parents

OBJECTIVES

To assess racial and ethnic minority parents' perceptions about barriers to well-child visit attendance.

METHODS

For this cross-sectional qualitative study, we recruited parents of pediatric primary care patients who were overdue for a well-child visit from the largest safety net healthcare organization in central Massachusetts to participate in semi-structured interviews. The interviews focused on understanding potential knowledge, structural, and experiential barriers for well-child visit attendance. Interview content was inductively coded and directed content analysis was performed to identify themes.

RESULTS

Twenty-five racial and ethnic minority parents participated; 17 (68%) of whom identified Spanish as a primary language spoken at home. Nearly all participants identified the purpose, significance, and value of well-child visits. Structural barriers were most cited as challenges to attending well-child visits, including parking, transportation, language, appointment availability, and work/other competing priorities. While language emerged as a distinct barrier, it also exacerbated some of the structural barriers identified. Experiential barriers were cited less commonly than structural barriers and included interactions with office staff, racial/ethnic discrimination, appointment reminders, methods of communication, wait time, and interactions with providers.

CONCLUSIONS

Racial and ethnic minority parents recognize the value of well-child visits; however, they commonly encounter structural barriers that limit access to care. Furthermore, a non-English primary language compounds the impact of these structural barriers. Understanding these barriers is important to inform health system policies to enhance access and delivery of pediatric care with a lens toward reducing racial and ethnic-based inequities.

Head Injuries Among Children Treated in US Emergency Departments, 2015-2019

This study evaluates the epidemiology of nonfatal head injuries among children aged 1 to 4 years associated with consumer products and identifies the specific consumer products associated with these injuries. Data for children aged 1 to 4 years who presented to emergency departments (EDs) from 2015 to 2019 for a nonfatal head injury were extracted from the National Electronic Injury Surveillance System. An estimated 1 032 429 (95% confidence interval [CI]: 675 822-1 389 063) children presented to US EDs for head injuries, averaging 566 injuries daily. The average rate of head injury did not change over the 5-year study period (slope = -0.003; P = .852); it was highest among children aged 1 year (2.06 per 100 children aged 1 year), which was nearly 3 times that of children aged 4 years (rate ratio = 2.75; 95% CI: 2.73-2.77). Most injuries occurred at home (80.4%) and occurred from interacting with home furnishings (45.1%). This study underscores the need for increased head injury mitigation efforts among young children.

Caregiver Perspectives on Barriers and Facilitators to Timely Well-Child Visits for Black Infants

OBJECTIVES

Missed infant well-child visits (WCV) result in lost opportunities for critical preventive care. Black infants consistently receive less WCV care than other racial groups. We sought to understand barriers and facilitators to timely infant WCV for Black families in the context of COVID-19.

METHODS

We conducted 21 semi-structured interviews with caregivers of Medicaid-insured Black children aged 15- to 24-months who attended six or fewer of eight recommended well-child visits within the first 15 months of life. Interviews focused on WCV value, barriers, and facilitators. After developing our initial coding structure through rapid qualitative analysis, we inductively derived the final codebook and themes through line-by-line content analysis.

RESULTS

Caregivers attended a mean of 3.53 of eight infant visits. Structural (e.g., transportation) and psychological (e.g., maternal depression) barriers delayed Black infant WCV. Families most frequently valued monitoring development and addressing concerns. Caregivers perceived visits as less urgent when infants seemed healthy or more recently avoided visits due to fears around COVID-19. Long waits and feeling rushed/dismissed were linked to WCV delays; positive provider relationships encouraged WCV attendance. Most caregivers reported reluctance to vaccinate. Vaccine hesitancy contributed to delayed infant WCV.

CONCLUSIONS

Caregivers described several factors that impacted WCV attendance for Black infants. Persistent structural and psychological barriers are compounded by perceptions that caregiver time is not respected and by notable vaccine hesitancy. To address these barriers, well-care can meet Black families in their communities, better address caregiver wellbeing, more efficiently use caregiver and provider time, and cultivate partnerships with Black caregivers.

"When You Look at This Chart, That Is Not My Whole Life": Caregiver Perspectives to Inform Improved Primary Care Practice and Outcomes

OBJECTIVE

Worsening rates of infant and maternal mortality in the United States serve as an urgent call for multi-modal intervention. Infant Well Child Visits (WCVs) provide an opportunity for prevention, however not all infants receive the recommended schedule of visits, with infants of low-income and Black families missing a higher portion of WCVs. Due to diverse experiences and needs of under-resourced communities throughout the United States, caregiver voice is essential when designing improvement efforts.

METHODS

Purposeful sampling and interviewing of 10 caregivers in Cincinnati, OH was performed by community peer researchers. Interview transcripts were evaluated by the research team, with identification of several important themes.

RESULTS

Nine out of 10 caregivers self-identified as Black. All young children of the interviewed caregivers had Medicaid as their insurance provider. All interviews highlighted rich perspectives on caregiver hopes for their child, family, and selves. Establishing trust through empathy, shared decision making, and the nurturing of interpersonal patient-practitioner relationships is crucial for fostering a positive healthcare experience. Levels of mistrust was perceptibly high across several interviews, with lack of racial concordance between medical provider and family exacerbating the issue for some caregivers. Caregivers voiced a tendency to rely on family and community members for when to seek out health care for their children, and additionally cited racism and perceptions of being rushed or judged as barriers to seeking further care.

CONCLUSION

This study emphasizes the importance of being community-informed when considering interventions. Prior research on the topic of missed WCV's often focused on material resource availability and limitations. While that was commented on by caregivers in this study as well, equal-if not more-attention was directed toward interpersonal relationship formation, the presence or absence of trust between practitioner and caregiver, and the importance of social-emotional support for caregivers. We highlight several opportunities for systemic improvements as well as future directions for research.

Factors associated with unmet pediatric health care needs during the coronavirus pandemic

PURPOSE

To examine risk factors for unmet pediatric health care needs during the coronavirus pandemic in a national sample of US children under 17 years of age.

DESIGN AND METHODS

In this cross-sectional study, we used data from the 2021 National Survey of Children's Health (n = 50,892). Unmet pediatric health care needs were assessed as follows: "during the past 12 months, was there any time when this child needed health care but it was not received?". Logistic regression with multiple imputations was used to evaluate bivariate and multivariable associations between predisposing, enabling, and need factors of health care services use and unmet pediatric health care needs.

RESULTS

Approximately 3.6% of children had unmet health care needs, with significant differences by sample characteristics. Unmet health care needs were notably prevalent among select groups, including children with difficulty covering basic needs (10.6%) and those with ≥2 health conditions (8.9%). In multivariable analyses, factors associated with unmet pediatric health care needs included predisposing factors such as older age, ≥2 children with special health care needs in the household, primary language other than English or Spanish, and poor caregiver health; enabling factors such as difficulty covering basic needs, no insurance, and no personal doctor or nurse; and need factors such as poor perceived or evaluated child health. Reasons for unmet needs included financial, nonfinancial, and accessibility barriers.

CONCLUSIONS

Several factors were associated with unmet health care needs.

PRACTICE IMPLICATIONS

We identified children who would benefit from targeted interventions aimed at promoting health care services use.

Association between maternal prenatal cannabis use and missed child preventive care visits in an integrated health care delivery system in Northern California

The periodicity of well-child visits recommended by the American Academy of Pediatrics emphasizes the importance of continuity of care in health management. Exposure to cannabis in utero has been associated with adverse development, and adherence to well-child visits is critical for earlier detection and intervention. To assess whether maternal prenatal cannabis use was associated with missed well-child visits in the first three years after birth we conducted a longitudinal cohort study in Kaiser Permanente Northern California of pregnant individuals and their children born between January 1, 2011 and December 31, 2018. Maternal prenatal cannabis use was defined as any self-reported cannabis use since becoming pregnant and/or a positive urine toxicology test for cannabis during pregnancy. Well-child visits were defined as an encounter for a well-child visit or physical exam and categorized into seven time periods from birth to 36 months. Modified Poisson regression models were conducted. Of the 168,589 eligible pregnancies, 3.4% screened positive for maternal prenatal cannabis use. Compared to no use, maternal prenatal cannabis use was associated with more missed well-child visits at every time period; (missed 12-month visit: adjusted relative risk (aRR): 1.43, 95%CI: 1.32-1.54; missed 3-year visit: aRR: 1.15, 95%CI: 1.11-1.20). Maternal prenatal cannabis use was also associated with missing two or more well-child visits through 36 months of age (35.8% among cannabis users vs. 23.0% among non-users, Χ2p < .001). Educating pregnant individuals who use cannabis on the importance of well-child visits may benefit children's health and development.

Previous missed visits and independent risk of loss to follow-up in the high-risk neonatal follow-up clinic

BACKGROUND

Neonatal intensive care unit (NICU) patients are at high risk for developmental delays. As a result, many are seen in neonatal follow-up (NFU) clinics. Disparities in NFU follow-up rates by social determinants of health exist.

AIMS

Determine how the number of missed visits (composed of patient-canceled visits and no-show visits) relates to risk of loss to follow-up in the NFU clinic.

STUDY DESIGN

Retrospective cohort study at a regional specialty center in the United States.

SUBJECTS

262 patients born between January 1, 2014, and December 31, 2017, who were referred to the NFU clinic.

OUTCOME MEASURES

Logistic binomial regression was used to model risk ratio of loss to follow-up over two years, defined as not attending a recommended follow-up visit and not informing the clinic of a reason for discontinued care.

RESULTS

Of 262 infants, 220 patients (84 %) were seen for at least one visit and 143 (65 %) completed follow-up. Younger maternal age, maternal smoking during pregnancy, maternal drug use during pregnancy, and public insurance were all associated with missing more visits. For each additional missed visit, the risk of loss to follow-up was 1.73 times higher unadjusted (95 % CI: 1.33, 2.26) and 1.81 times higher (95 % CI: 1.36, 2.40) after adjusting for confounders. The risk ratio of loss to follow-up for no-show visits was three times higher than that for patient-canceled visits.

CONCLUSIONS

Each missed visit was independently associated with higher risk of loss to follow-up from NFU clinic, even after adjusting for other risk factors.

Prematurity, birth weight, and access to a medical home among school-aged children in the US: A cross-sectional survey

Introduction

Prematurity and low birth weight (LBW) are associated with higher health care needs and higher health care utilization in the first few years of life. The aim of this cross-sectional study was to determine how prematurity and LBW were correlated with access to a medical home later in childhood, at ages 6–17 years.

Methods

Data were analyzed from the 2016–2018 National Survey of Children's Health. Non-institutionalized US children 6–17 years of age who had been born preterm were classified as very low birth weight (VLBW, <1500 g), LBW (1500–2500 g), and normal weight (NBW, >2500 g). Term-born NBW children were included as a reference group. Medical home access was determined according to caregiver report.

Results

The analysis included 64,597 infants (preterm VLBW n  =  737; preterm LBW n  =  2869; preterm NBW n  =  3942; and term NBW n  =  57,049). Based on this sample, 44% of children ages 6–17 years were estimated to receive care meeting the criteria of a medical home. On multivariable analysis, none of the preterm groups had higher likelihood of receiving care in a medical home compared to children born at term and NBW (odds ratios ranging from 0.75 to 0.95).

Conclusions

School-aged children born preterm and LBW were equally or less likely to receive care meeting the criteria of a medical home than children born at term and NBW. Although prematurity and LBW are associated with increased health care use early in the life course, this does not appear sufficient to help children establish and maintain access to a medical home.

A Qualitative Study of Two Oregon Family Medicine Clinics to Explain Parent and Child Healthcare Initiation and Engagement

Background: Parental factors are associated with children's receipt of recommended care but not adequately described. Methods: We conducted a qualitative study of patients with at least two visits who were a primary caregiver for a child who also had at least two visits at the same clinic in 1/2018-12/2019 from two Oregon family medicine clinics. We stratified patients by child age and number of caregiver visits and randomly selected caregivers. Participants were interviewed in accordance with approval by our Institutional Review Board between 12/2020 and 4/2021. The data were analyzed using a grounded theory approach. Results: 12 caregivers (termed parents) were interviewed; half were single parents and three-quarters had a history of substance use disorder and/or a mental health condition. Parents focused on the importance of keeping themselves healthy to keep their families healthy. They described similar reasons for choosing to initiate and continue care for themselves and their children at the same clinic, including: convenience, trust, relationships, and receiving whole-person and whole-family care. Many valued having a healthcare "home" for their entire family. We developed a figure that highlights three themes that capture the interrelated factors parents identified as supporting healthcare use for themselves and their families. These overarching themes included: healthcare initiation; healthcare engagement and continuity; and parent bringing child to the same clinic for healthcare. Conclusion: Our data suggests that long-standing patient-clinic relationships for parents and children can support family-focused healthcare.

Missed and Delayed Preventive Health Care Visits Among US Children Due to the COVID-19 Pandemic

OBJECTIVE

The COVID-19 pandemic led to a substantial drop in US children's preventive care, which had not fully rebounded by the end of 2020. We sought to estimate the overall prevalence of missed, skipped, or delayed preventive checkups among households with children in the last 12 months because of the pandemic.

METHODS

We used data from the US Census Bureau's Household Pulse Survey, Phase 3.1 (collected April-May 2021). The analytic sample included 48 824 households with ≥1 child or adolescent aged <18 years. We estimated both national and state-level prevalences, examined associations with sociodemographic and household characteristics, and described reasons for missed or delayed preventive visits.

RESULTS

Overall, 26.4% (95% CI, 25.5%-27.2%) of households reported that ≥1 child or adolescent had missed or delayed a preventive visit because of COVID-19; percentages varied by state, from 17.9% in Wyoming to 37.0% in Vermont. The prevalence of missed or delayed preventive visits was significantly higher among respondents who reported material hardships (ie, not caught up on rent/mortgage, difficulty paying usual household expenses, children not eating enough because of lack of affordability) than among respondents who did not report material hardships. The most common reasons for missing or delaying preventive visits were concern about visiting a health care provider, limited appointment availability, and the provider's location being closed.

CONCLUSIONS

Programs and policies could reduce gaps in children's preventive care caused by the pandemic, with a particular focus on addressing social determinants of health.

"First Five" Quality Improvement Program Increases Adherence and Continuity with Well-child Care

The American Academy of Pediatrics Bright Futures recommends routine well-child care as optimal care for children. This quality improvement project aimed to increase adherence to the "First Five" visits after newborn follow-up at 2, 4, 6, 9, and 12 months-by 25% (50% or higher) and continuity with providers by 20% (64% or higher) between 2013 and 2016.

METHODS

Retrospective data collection identified a quality gap, in which only 25% had the required well-child visits by the first year. We interviewed parents/caregivers of 12- to 15-month-old children for their perspectives on access to care, scheduling, and the medical home concept. Plan-Do-Study-Act cycles targeted modification of electronic medical record templates, scheduling, staff and parental education, standardization of work processes, and birth to 1-year age-specific incentives. We then piloted interventions in one of our clinic's pod/subgroup. Process and outcome measures were analyzed using descriptive statistics, a run chart, and a 2-sample % Defective Test.

RESULTS

Parent/caregiver interviews revealed that only 6% knew what a medical home was, and only 40% "almost always saw the same provider for care." At baseline in 2012, we documented completion of all 5 visits in only 25% of the children; <10% of those children had consecutive visits with the same provider. After multiple Plan-Do-Study-Act cycles and pilot, our "First Five" well-child care adherence rose to 78%, and continuity increased to 74% in 2018 (P < 0.001 for adherence, P < 0.001 for continuity).

CONCLUSION

A multifaceted, evidence-based approach improved both well-child care adherence and provider continuity.

Role of Occupational Therapy in Pediatric Primary Care: Promoting Childhood Development

Occupational therapy practitioners have the opportunity to promote development for all children as new service delivery models are established for pediatric primary care. Three action steps are identified: (1) advocacy for legislation that requires developmental screenings and surveillance, (2) support of culturally responsive developmental monitoring, and (3) building evidence for occupational therapy in primary care settings. This article describes the role of occupational therapy practitioners on pediatric interprofessional teams in encouraging family capacity within the scope of health promotion and universal developmental monitoring.

Cross-Sector Approach Expands Screening and Addresses Health-Related Social Needs in Primary Care

OBJECTIVES

During infancy, the American Academy of Pediatrics Bright Futures fourth edition health supervision guidelines recommend frequent well-child visits (WCVs) in which providers are expected to screen for and address maternal depression, intimate partner violence (IPV), and health-related social needs (HRSN). We spread an evidence-based approach that implements these recommendations (Developmental Understanding and Legal Collaboration for Everyone; DULCE) with 3 aims for 6-month-old infants and their families: 75% receive all WCVs on time, 95% are screened for 7 HRSNs, and 90% of families with concrete supports needs and 75% of families with maternal depression or IPV receive support.

METHODS

Between January 2017 and July 2018, five DULCE teams (including a community health worker, early childhood system representative, legal partner, clinic administrator, pediatric and behavioral health clinicians) from 3 communities in 2 states participated in a learning collaborative. Teams adapted DULCE using Plan-Do-Study-Act cycles, reported data, and shared learning monthly. Run charts were used to study measures. The main outcome was the percent of infants that received all WCVs on time.

RESULTS

The percentage of families who completed all WCVs on time increased from 46% to 65%. More than 95% of families were screened for HRSNs, 70% had ≥1 positive screen, and 86% and 71% of those received resource information for concrete supports and maternal depression and IPV, respectively.

CONCLUSIONS

Quality improvement-supported DULCE expansion increased by 50% the proportion of infants receiving all WCVs on time and reliably identified and addressed families' HRSNs, via integration of existing resources.

Pediatric Preventive Care: Population Health and Individualized Care

Well-child care is a near-universal service for young children toward which a great deal of time and professional resources are devoted but for which there is scant evidence of effectiveness in routine practice. It is composed of many components, the value of which likely varies with the quality of their provision and the needs and priorities of the children and families who receive them. Achieving more efficient and effective preventive care will require that pediatric practices segment the population they serve and design schedules and staffing to match patients' health, well-being, personal and social circumstances, and service needs. Care should be individualized and include essential screening, tests, procedures, and education on the basis of assessment of patients' and families' needs and priorities. The traditional schedule of individual, comprehensive preventive care visits should be reconsidered and replaced with a schedule that allows complete care to be provided over a series of visits, including those for acute and chronic care. Preventive pediatric care should be provided in family-centered, team-based practices with strong linkages to other providers in the community who serve and support children and families. Care should make use of the wide variety of modalities that exist, and face-to-face time should be reserved for those services that are both important and uniquely responsive to in-office intervention. This model of preventive care will require changes in training, responsibilities and reimbursement of health care team members, and enhanced communication and collaboration among all involved, especially with families.

Achieving Diagnostic Resolution in Young Children with Social Communication Concerns in a Predominantly Low-Income Population

Children in low-income families are at risk for delayed diagnosis of autism spectrum disorder (ASD). The cascade-of-care model, which examines steps of care for quality and efficacy, can identify lesions in the process for evaluation and diagnosis for children at risk for ASD. Little is known about predictors that influence key steps in this process. We performed a retrospective chart review of 110 children under age five years from an academic medical center with social communication concerns. We assessed predictors of age of referral for ASD diagnostic evaluation, time to diagnosis, and likelihood of diagnostic completion. Children with continuity of primary care were referred at an earlier age than those receiving primary care at multiple centers. Compared with children with missed visits, children attending all well-child visits had a shorter median time to diagnosis. These findings illustrate a need for primary medical homes to facilitate early and timely ASD evaluations.

Barriers to Attendance of Prenatal and Well-Child Visits

OBJECTIVE

Prenatal care (PNC) and well child visit (WCV) attendance are associated with improved health outcomes. We aimed to determine if the factors affecting maternal and child attendance are similar or different.

METHODS

We conducted a retrospective case control study at Virginia Commonwealth University Health System. We used the Adequacy of Prenatal Care Utilization Index and the American Academy of Pediatrics recommendations to assess the adequacy of PNC and WCV attendance, respectively. Mothers with less than 50% visit adherence or initiation after 5 months gestation were eligible as cases and those with 80% or more adherence and initiation before 5 months were eligible as controls. Children in the lowest quintile of adherence were eligible as cases and those with 80% or more adherence were eligible as controls. Cases and controls were randomly selected at a 1:2 ratio from the eligible subjects and frequency matched on birth month.

RESULTS

In adjusted analyses, mothers and children who were publicly insured or who were uninsured had higher odds of poor preventive visit attendance. Mothers who experienced intimate partner violence and had more living children were more likely to have poor attendance. Children whose mothers had younger age, greater number of pregnancies and transportation difficulties had poorer attendance.

CONCLUSIONS

While lack of insurance and public insurance remained significantly associated with both poor PNC and WCV attendance, other factors varied between groups. Expanding eligibility requirements and streamlining enrollment and renewal processes may improve two generations of preventive visit attendance.

Addressing logistical barriers to childhood vaccination using an automated reminder system and online resource intervention: A randomized controlled trial

BACKGROUND

As the rates of vaccination decline in children with logistical barriers to vaccination, new strategies to increase vaccination are needed. The goal of this study was to develop and evaluate the effectiveness of the Vaccines For Babies (VFB) intervention, an automated reminder system with online resources to address logistical barriers to vaccination in caregivers of children enrolled in an integrated healthcare system. Effectiveness was evaluated in a randomized controlled trial.

METHODS

Qualitative interviews were conducted with parents of children less than two years old to identify logistical barriers to vaccination that were used to develop the VFB intervention. VFB included automated reminders to schedule the 6- and 12-month vaccine visit linking caregivers to resources to address logistic barriers, sent to the preferred mode of outreach (text, email, and/or phone). Parents of children between 3 and 10 months of age with indicators of logistical barriers to vaccination were randomized to receive VFB or usual well child care (UC). The primary outcome was percentage of days undervaccinated at 2 years of life. A difference in differences analysis was conducted.

RESULTS

Qualitative interviews with 6 parents of children less than 2 years of age identified transportation, scheduling challenges, and knowledge of vaccine timing as logistical barriers to vaccination. We enrolled 250 participants in the trial, 45% were loss to follow-up. There were no significant differences in vaccination uptake between those enrolled in UC or the VFB intervention (0.51%, p = 0.86). In Medicaid enrolled participants, there was a modest decrease in percentage of days undervaccinated in the VFB intervention compared to UC (6.3%, p = 0.07).

CONCLUSION

Automated Reminders and with links to heath system resources was not shown to increase infant vaccination uptake demonstrating additional resources are needed to address the needs of caregivers experiencing logistical barriers to vaccination.

Analysis of socioeconomic and demographic factors and imaging exam characteristics associated with missed appointments in pediatric radiology

BACKGROUND

Missed appointments can have an adverse impact on health outcomes by delaying appropriate imaging, which can be critical in influencing treatment decisions.

OBJECTIVE

To assess for socioeconomic and imaging exam factors associated with missed appointments among children scheduled for diagnostic imaging.

MATERIALS AND METHODS

We retrospectively analyzed children (<18 years) scheduled for outpatient diagnostic imaging during a 12-month period. In doing so, we obtained socioeconomic and radiology exam characteristics (modality, intravenous contrast administration, radiation and use of sedation) data from the electronic medical record. We employed multivariate logistic regression to assess the association of socioeconomic, demographic and imaging exam characteristics with imaging missed appointments.

RESULTS

In total, 7,275 children met inclusion criteria. The mean age was 8.8 years (standard deviation [SD] = 6.2 years) and the study population consisted of 52% female gender, 69% White race, 38% adolescent age group and 32% with a median household income by ZIP-code category of <$50,000. Logistic regression showed increased likelihood of missed appointments among children of Black/African-American race (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.4-2.5); with insurance categories including Medicaid (OR=2.0; 95% CI=1.6-2.4), self-pay (OR=2.1; 95% CI=1.3-3.6) and other (OR=2.7; 95% CI=1.3-5.4); with <$50,000 median household income by ZIP-code category (OR=1.7; 95% CI=1.4-2.0); and with examination wait time of 7-21 days (OR=2.7; 95% CI=2.1-3.5) and >21 days (OR=3.7; 95% CI=2.9-4.8). The use of radiation, intravenous contrast agent or sedation was not associated with increased likelihood of missed appointments.

CONCLUSION

Expanding our knowledge of how different socioeconomic and imaging-related factors influence missed appointments among children can serve as a foundational step to better understand existing and emerging disparities and inform strategies to advance health equity efforts in radiology.

Characteristics associated with pediatric growth measurement collection in electronic medical records: a retrospective observational study

Background

Complete growth measurements are an essential part of pediatric care providing a proxy for a child’s overall health. This study describes the frequency of well-child visits, documented growth measurements, and clinic and provider factors associated with measurement.

Methods

Retrospective cross-sectional study utilizing electronic medical records (EMRs) from primary care clinics between 2015 and 2017 in Manitoba, Canada. This study assessed the presence of recorded height, weight and head circumference among children (0–24 months) who visited one of 212 providers participating in the Manitoba Primary Care Research Network. Descriptive and multivariable logistic regression analyses assessed clinic, provider, and patient factors associated with children having complete growth measurements.

Results

Our sample included 4369 children. The most frequent growth measure recorded was weight (79.2% n = 3460) followed by height (70.8% n = 3093) and head circumference (51.4% n = 2246). 67.5% of children (n = 2947) had at least one complete growth measurement recorded (i.e. weight, height and head circumference) and 13.7% (n = 599) had complete growth measurements at all well-child intervals attended. Pediatricians had 2.7 higher odds of documenting complete growth measures within well-child intervals compared to family physicians (95% CI 1.8–3.8). Additionally, urban located clinics (OR 1.7, 95% CI 1.2–2.5), Canadian trained providers (OR 2.3, 95% CI 1.4–3.7), small practice size (OR 1.6, 95% CI 1.2–2.2) and salaried providers (OR 3.4, 95% CI 2.2–5.2) had higher odds of documented growth measures.

Conclusions

Growth measurements are recorded in EMRs but documentation is variable based on clinic and provider factors. Pediatric growth measures at primary care appointments can improve primary prevention and surveillance of child health outcomes.