In a recently released article in Pediatrics, Dr. Elizabeth Wolf and colleagues (10.1542/peds.2017-4019) examine the interesting question of which AAP-recommended well care visits are most likely to be missed by children ages birth to 6 years. They were able to include over 150,000 children, 77% of whom were publicly insured, from a consortium including 581 clinics in 19 states, with a rich diversity of races and ethnicities. The authors used clear measures to define attendance and non-attendance at each visit, and considered the possibility that families could have taken their children outside the multiple practice catchment area of the study for visits that appeared to be missing. Each well care visit was defined by a unique age range, and the first recorded visit was considered the first well care visit. To account for potential visits outside the consortium, the authors defined an upper and lower range of attendance possibilities: the upper range assumed that all recommended well care took place outside the consortium and the lower range assumed the reverse, i.e. that no other well care visits took place. This approach is creative, pragmatic and easily understood, and does a beautiful job of capturing the uncertainties of well care visit attendance in a mobile population. Dr. Wolf and colleagues further used a multivariate regression analysis to try to understand if any child characteristics (race/ethnicity, gender, specific practice, age at entry to the study) were associated with adherence.
The bottom line is easy to see, but I hope my summary invites you to read the full article! The 15- and 18-month visits, and the 4-year-old visit were “most missed,” i.e. had the lowest attendance rates. These specific visits are not only important for vaccinations, but are meaningful touch points for developmental progress related to speech, self-care and autism screening. The authors discuss potential reasons for lower adherence at these time points, as well as strategies such as value-based payments, that could incentivize practices to increase visit-specific attendance.
However, regarding the 15 and 18 month visits, I wonder if parents are voting with their feet, and are actually letting us know they need a “break” from well care visit frequency. Earlier work that included parental focus groups related to well care visits tells us that listening to parental concerns and issues about well care is a meaningful way to meet parents’ needs and improve preventive health care for younger and older children.1 I believe we should consider the possibility that a “new” 16 month visit could encompass what the 15 and 18 month visits do, both regarding vaccinations and developmental screening, and lessen the burden of visits for families. It is possible that with some flexibility that includes, for example, different formal screening tools or focused developmental surveillance, and putting off the second hepatitis A vaccine till the (better attended) 2-year-old visit, we could make this work. In fact, this is often the de facto approach when catching up from missed well care visits. It’s also possible that this modification would be a great mistake! But certainly we should avoid putting on blinders and insisting that our way is the only way, and that the current set of well child care recommendations is inviolable. Additional research that ideally includes all stakeholders, from parents to providers to insurance companies (particularly public insurance providers), would be needed. I personally feel less enthusiastic about taking this approach to the 4-year-old visit, but perhaps a 4-5-year-old visit that serves as an all-important pre-kindergarten touch point would be more economical and less burdensome while still providing needed care. Before you begin to shout and scream at me (and I welcome your comments), let’s thank Dr. Wolf and colleagues for a unique, important and well-designed study that asks as many questions as it answers!
References
Radecki L, Olson LM, Frintner MP, Tanner JL, Stein MT. What do families want from well-child care? Including parents in the rethinking discussion. Pediatr 2009 Sep;124:858-65.
