Preterm Infant Attendance at Health Supervision Visits

The Utilization of Early Outpatient Care for Infants Following NICU Discharge among a National Sample

Outpatient care following discharge from a neonatal intensive care unit (NICU) is critical for streamlined transfer of care. Yet, information is lacking about the characteristics of early outpatient care. The objective of this secondary data analysis is to describe outpatient encounters (OPEs) within the first three months following the discharge of commercially insured infants admitted to NICUs in the MarketScan Research Database nationally from 2015 to 2017. Data were analyzed using descriptive statistics and logistic regression. A total of 22,214 NICU survivors were included, of whom half had an OPE within two days following discharge (quartiles 1, 3) and 90% within five days. The median number of OPEs in the first three months was five (quartiles 4, 7). A majority of first physician visits were with pediatricians (81.5%). A minority of infants with chronic conditions saw subspecialists. Term infants with delayed care had a lower risk of readmission. Spending was higher for preterm infants and those with chronic conditions. We conclude that most patients are seen shortly after discharge and by pediatricians; however, there is room for improvement. Frequent encounters and spending afflict high-risk groups with chronic conditions. Future work should examine the associations of early outpatient care with social determinants of health and other outcomes such as immunizations.

Racial and ethnic disparities in outcomes after NICU discharge: An equity-focused model

Significant racial and ethnic disparities exist in birth outcomes and complications related to prematurity. However, little is known about racial and ethnic variations in health outcomes after premature infants are discharged from the neonatal intensive care unit (NICU). We propose a novel, equity-focused conceptual model to guide future evaluations of post-discharge outcomes that centers on a multi-dimensional, comprehensive view of health, which we call thriving. We then apply this model to existing literature on post-discharge inequities, revealing a need for rigorous analysis of drivers and strength-based, longitudinal outcomes.

Patient-reported outcome measures can advance population health, but is access to instruments and use equitable?

Patient reported outcome measures (PROM) can engage patients and clinicians to improve health outcomes. Their population health impact may be limited by systematic barriers inhibiting access to completion. In this analysis we evaluated the association between individual parent/child characteristics and clinic factors with parental completion of a locally developed PROM, the Early Healthy Lifestyles (EHL) questionnaire. Participants included parent-child dyads who presented at 14 pediatric clinics for regularly scheduled well-child visits (WCV) prior to age 26 months. EHL items include feeding practices, diet, play time, screen exposure, and sleep. Completion was categorized at patient- (i.e., parent-child dyad) and clinic-levels. Parents completed the 15-item EHL in the patient portal before arrival or in the clinic; ninety-three percent of EHL questionnaires were completed in the clinic vs. 7% in the patient portal. High-completers completed EHL for half of WCVs; low-completers completed at least once; and non-completers never completed. Clinics were classified by EHL adoption level (% high completion): High-adoption: >50%; Moderate-adoption: 10%-50%; and Low-adoption: <10%. Individual-level factors had negligible impact on EHL completion within moderate/low EHL adoption sites; high-adoption sites were used to evaluate infant and maternal factors in association with EHL completion using hierarchical logistic regression. Noncompletion of EHL was significantly associated (p < 0.05) with infant use of public insurance (OR = 1.92 [1.42, 2.59]), >1 clinic site for WCV (OR = 1.83 [1.34, 2.50]), non-White birth mother (OR = 1.78 [1.28, 2.47]), and body weight <2,500 grams or gestational age <34 weeks (OR = 1.74 [1.05, 2.90]). The number of WCVs, a proxy for clinic size, was evaluated but was not associated with completion. Findings indicate potential disparities between populations exposed to, completing, and benefitting from these tools.

Facilitators and Barriers to Access to Pediatric Medical Services in a Community Hospital

Background: Missed medical appointments decrease continuity of medical care, waste resources, and may affect health outcomes. We examined the factors associated with missed children's supervision visits in Eastern Brooklyn, NY, USA. Methods: We surveyed guardians whose children received routine medical care at four pediatric clinics. Participants filled out a questionnaire that queried: demographics, food security, recent relocation, parental support of healthy behaviors, and length of knowing provider. Preexisting disease(s) and missed visits were retrieved from medical records. Regression analyses were used to determine factors that were associated with missing medical appointments. Results: Among 213 families, 33% faced food insecurity and 16.4% reported moving within the past 12 months. Forty percent of children missed at least 1 visit. Food insecurity (adjusted odds ratio [aOR] 2.3, 95% confidence interval [CI 1.0% to 5.2%) and recent relocation (aOR 1.8, 95% CI 1.1-3.4 were associated with missed health supervision visits, whereas greater parental healthy behaviors (aOR 0.5, 95% CI 0.3-0.9) and longer length of knowing provider (aOR 0.8, 95% CI 0.7-1.0) were associated with fewer missed appointments. Conclusion: This study indicates that social inequity may contribute to poor adherence to medical appointments through multiple mechanisms, including food insecurity, lack of social stability, and parental health behaviors. Multidimensional proactive prevention, and reactive tolerance should be considered as opportunities to mitigate the impact of social inequity on health outcomes.

Urban-rural disparity of preventive healthcare utilisation among children under the universal health insurance coverage in Taiwan: a national birth cohort analysis

OBJECTIVE

In the context of universal health insurance coverage, this study aimed to determine whether urban-rural inequality still exists in preventive health care (PHC) amongst children in Taiwan.

STUDY DESIGN

Prospective cohort study.

METHODS

A total of 184,117 mothers and their children born in 2009 were identified as the study cohort. The number of children born in urban, satellite and rural areas was 40,176, 57,565 and 86,805, respectively. All children were followed for 7 years, before which a total of seven times PHC were provided by Taiwan's National Health Insurance (NHI) programme. Ordinal logistic regression models were used to associate urbanisation level with the frequency of PHC utilisation. Stratified analyses were further performed in accordance with the children's birth weight and the mothers' birthplace.

RESULTS

Children from satellite areas had higher utilisation for the first four scheduled PHC visits. Children living in urban areas received more PHC for the fifth and sixth scheduled visits. Compared with those from rural areas, children in satellite areas exhibited a small but significant increase in odds in PHC utilisation, with a covariate-adjusted odds ratio (aOR) of 1.04 and 95% confidence interval (CI) of 1.02-1.06. By contrast, no significant difference was observed between rural and urban areas (aOR = 1.01). Further stratified analyses suggest more evident urban-rural difference in PHC utilisation amongst children with low birth weight and foreign-born mothers.

CONCLUSIONS

Given a universal health insurance coverage and embedded mechanisms in increasing the availability of healthcare resources in Taiwan, a slight urban-rural difference is observed in PHC utilisation amongst children. Hence, sociodemographic inequality in utilisation of PHC still exists. This issue should be addressed through policy intervention.

The impact of driving time on pediatric TBI follow-up visit attendance

Objective: Examine the effect of driving time on follow-up visit attendance for children hospitalized with a traumatic brain injury (TBI). We hypothesized that families who lived further from the hospital would show poorer follow-up attendance.Participants: 368 children admitted to the hospital with TBI.Design & Outcome Measures: Using a retrospective chart review, we calculated driving time from patients' homes. The primary outcome was attendance at the first appointment post-discharge. We used logistic regression to examine the effect of driving time on attendance, including an analysis of the effects of injury and sociodemographic covariates on the model.Results: Majority of children attended their first appointment. Patients living 30-60 min from the hospital were most likely to attend, and those living 15 min away were least likely to attend. After adjusting for patient characteristics, families with driving time of 30-60 min had significantly higher odds of returning for follow-up than those with driving time <15 min, though the significance of this relationship disappeared after specific socioeconomic (SES) factors were included.Conclusions: Distance plays a significant role on follow-up attendance for pediatric patients with TBI. However, neighborhood SES may be an additional factor that influences the significance of the distance effect.Abbreviations: TBI: Traumatic brain injury; SES: socioeconomic status; ISS: Injury severity scale; AIS: Abbreviated injury scale.

Early Childhood Vaccination Status of Preterm Infants

BACKGROUND

Preterm infants are at increased risk for vaccine-preventable infections and associated complications. Limited studies describe timely vaccination of these vulnerable infants.

METHODS

This retrospective cohort study included Washington State infants with birth hospitalizations at an urban academic medical center between 2008 and 2013. Demographic, clinical, and visit data from electronic health records were linked to vaccine data from the Washington State Immunization Information System. Completion of the recommended 7-vaccine series by 19 months of age was compared between preterm infants (born at <37 weeks' gestation) and term/postterm infants (born at 37-43 weeks' gestation) by using Pearson's χ² test and multivariable logistic regression. Secondary outcomes included 7-vaccine series completion by 36 months of age and receipt of individual vaccines in the series. Rotavirus, hepatitis A, and influenza vaccination was also assessed.

RESULTS

Of study infants (n = 10 367), 19.3% were born prematurely. Preterm infants had lower 7-vaccine series completion compared with term/postterm infants by 19 months (47.5% vs 54.0%; adjusted odds ratio 0.77 [95% confidence interval 0.65-0.90]) and 36 months (63.6% vs 71.3%; adjusted odds ratio 0.73 [95% confidence interval 0.61-0.87]). Early preterm (23-33 weeks' gestation) and late preterm (34-36 weeks' gestation) infants had a lower rate of 7-vaccine series completion compared with term/postterm infants. Full influenza vaccination coverage by 19 months also differed between groups (early preterm: 47.7%; late preterm: 41.5%; term/postterm: 44.7%; P = .02).

CONCLUSIONS

Over half of preterm infants were undervaccinated at 19 months; one-third failed to catch up by 36 months. Strategies to improve vaccination of these high-risk infants are needed.

Immunization Completion in Infants Born at Low Birth Weight

BACKGROUND

Low birth weight (LBW) has been associated with underimmunization. We sought to understand the effect of LBW on immunization completion after controlling for previously hypothesized mediators, including prematurity, neonatal illness, well-child care, non-well-child visits, and provider consistency.

METHODS

We formed a retrospective cohort of infants born between 2008 and 2011 with ≥2 years of military healthcare follow-up. International Classification of Diseases, Ninth Revision codes were used to identify LBW, preterm birth, neonatal illnesses, well-child visits, non-well-child visits, provider consistency, and parental rank in the inpatient and outpatient records. Immunization records were extracted from both records. Logistic regression determined the odds of immunization completion and well-child care completion (ie, having had ≥6 WCC visits by 15 months of age).

RESULTS

Of 135964 included infants, 116521 (85.7%) were completely immunized at the age of 2 years. In adjusted analysis, the odds of immunization completion were significantly decreased in infants born at LBW (odds ratio [OR], 0.88 [95% confidence interval (CI), 0.79-0.97]), very LBW (OR, 0.61 [95% CI, 0.48-0.77]), or extremely LBW (OR, 0.45 [95% CI, 0.33-0.63]) or at ≤32 weeks' gestation (OR, 0.76 [95% CI, 0.63-0.92]), infants with chronic lung disease (OR, 0.63 [95% CI, 0.45-0.88]), male infants (OR, 0.96 [95% CI, 0.93-0.99]), and infants who experienced decreased provider consistency (OR, 0.92 [95% CI, 0.91-0.92]). The rate of immunization completion increased with the overall number of healthcare visits (OR, 1.02 [95% CI, 1.02-1.02]) and complete well-child care (OR, 1.80 [95% CI, 1.75-1.86]). However, children born LBW or preterm were significantly less likely to have complete well-child care.

CONCLUSIONS

After adjustment for preterm birth, comorbid neonatal conditions, and early childhood patterns of healthcare use, LBW was significantly associated with immunization noncompletion in a universal healthcare system. Provider consistency and well-child care seem important for increasing immunization completion in LBW infants.

Continuity of Care in Infancy and Early Childhood Health Outcomes

BACKGROUND AND OBJECTIVES

Continuity of care is a key aspect of the patient-centered medical home and improves pediatric outcomes. Health care reform requires high-quality data to demonstrate its continued value. We hypothesized that increased provider continuity in infancy will reduce urgent health care use and increase receipt of preventive services in early childhood.

METHODS

Continuity, using the Usual Provider of Care measure, was calculated across all primary care encounters during the first year of life in a prospectively-constructed cohort of 17 773 infants receiving primary care from birth through 3 years at 30 clinics. Health care utilization and preventive care outcomes were measured from ages 1 to 3 years. Confounders, including chronic conditions, number of sick visits in the first year, socioeconomic status, and site, were addressed by using multivariable regression models incorporating a propensity score.

RESULTS

Demographics associated with the lowest continuity quartile included white race (adjusted odds ratio [aOR] 1.43; 95% confidence interval [CI] 1.25-1.64), Medicaid insurance (aOR 1.41; 95% CI 1.23-1.61), and asthma (aOR 1.59; 95% CI 1.30-1.93). Lower continuity was associated with more ambulatory care-sensitive hospitalizations (adjusted incidence rate ratio 2.74; 95% CI 1.49-5.03), ambulatory sick visits (adjusted incidence rate ratio 1.08; 95% CI 1.05-1.11), and lower odds of lead screening (aOR 0.61; 95% CI 0.46-0.79). These associations were stronger for children with chronic conditions. Continuity measured during well visits was not associated with outcomes.

CONCLUSIONS

Continuity may improve care quality and prevent high-cost health encounters, especially for children with chronic conditions. Novel solutions are needed to improve continuity in the medical home.

Care System Redesign for Preterm Children After Discharge From the NICU

Approximately 1 in 8 children in the United States are born preterm. Existing guidelines and research examine the cost of prematurity from the NICU stay and developmental surveillance and outcomes after discharge from the NICU. Preterm children are at greater risk for excess hospitalizations, outpatient visits, and societal costs after NICU discharge. Improved delivery of care and health promotion from the community setting, particularly from the patient-centered medical home, may result in improved growth, health, and development, with accompanying reduction of post-NICU discharge costs and encounters. There has been comparatively little focus on how to promote health and wellness for children born preterm, particularly for community-based providers and payers. Accordingly, health care delivery for NICU graduates is often fragmented, with little guidance on medical management beyond tertiary care follow-up. In this article, we use what is known about chronic care and practice transformation models to present a framework for health care system redesign for children born preterm. We discuss the rationale for NICU graduates as a priority population for health system redesign. Promotion of health and wellness for children born preterm who are discharged to the community setting entails population health management from the patient-centered medical home; comanagement, clinical care protocols, and clinical support from the tertiary care-based tertiary care-based center; and a favorable payer strategy that emphasizes support for chronic care management. Practical suggestions are provided for the practicing physician for the child born preterm as health care systems are redesigned.

Parent Language: A Predictor for Neurodevelopmental Follow-up Care Among Infants With Very Low Birth Weight

OBJECTIVE

Preterm/very low birth weight infants may suffer neurodevelopmental delays. Pediatricians should monitor neurodevelopment and pursue timely referrals. Yet parents who speak non-English primary languages (NEPL) report worse health care communication and fewer appropriate specialty referrals for their children. We sought to determine whether infants of NEPL parents receive recommended outpatient follow-up care for neurodevelopment. We hypothesized that these infants received less care than infants of English speakers.

METHODS

We linked paid claims from California Children's Services to clinical data from California Perinatal Quality Care Collaborative (58% linkage rate, 1541 subjects) for publicly insured infants with birth weight <1500 g or gestational age ≤32 weeks. Our primary outcomes were completion of 1) preventive visits and 2) ophthalmology visits; and receipt of 3) influenza vaccination and 4) palivizumab. To compare group differences, we also assessed 5) hospital length of stay and 6) readmissions. Analyses were adjusted for medical severity and sociodemographic characteristics.

RESULTS

A total of 433 infants (28%) had NEPL parents. Infants of NEPL parents had 38% higher odds of receiving influenza vaccination (95% confidence interval 9-75, P = .008) and completed 8% more preventive visits (95% confidence interval 1-64, P = .019) than infants of English speakers. Infants of NEPL parents did not have longer lengths of stay or more readmissions.

CONCLUSIONS

Infants of NEPL parents were more likely than infants of English speakers to receive some aspects of recommended outpatient follow-up care. Regardless of language, all infants received far lower rates of follow-up care than recommended by national guidelines. Future study should address the causes of these gaps.

Transition From Hospital to Home in Parents of Preterm Infants: A Literature Review

Transition from hospital to home is a complex and multidimensional phenomenon for parents of prematurely born infants (<37 weeks of gestation). The absence of a clear conceptualization of this particular transition coupled with the challenges parents have when they return home and higher costs of healthcare service usage postdischarge dictates the need for a better understanding of this phenomenon. A literature review was undertaken using Whittemore and Knafl's theoretical framework for integrative review as a guide. A systematic search of the electronic databases (PsycINFO, PubMed, Medline, Cumulative Index of Nursing and Allied Health Literature, EMBASE, Cochrane Database for Systematic Reviews, and EBSCO) was performed. Fifty selected reports of research conducted on parents of preterm infants during 1980-2014 are included in this article. Five themes emerged from the review-disruption of parental role development, distorted development of parent-infant relationships, psychological consequences of a preterm birth and infant hospitalization, learning caregiving and parenting, and need for social and professional supports-which appear to reflect parental challenges during transition from hospital to home after discharge. Several inconsistencies in results of the studies dictate the need for further research in this vulnerable population; the better conceptualization and measurement of transitional challenges are warranted.