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Effect of Compliance With Health Supervision Guidelines Among US Infants on Emergency Department Visits
Rosemarie B. Hakim, PhD;
Donna S. Ronsaville, PhD
Arch Pediatr Adolesc Med. 2002;156:1015-1020.
ABSTRACT
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Background There are few studies that demonstrate the health benefit of compliance
with early periodic health supervision.
Objective To examine the association between emergency department (ED) use and
compliance with prevailing guidelines for periodic health supervision for
conditions that potentially could be avoided among a national cohort of US
children.
Design This was a historic cohort study that combined maternal and primary
care physician reports of the use of preventive care services for infants
during the first 7 months of life from the 1988 National Maternal and Infant
Health Survey and its 1991 Longitudinal Follow-up study. A preventive care
scale used in Cox proportional hazards survival regression predicted the time
to the first ED visit for selected diagnoses and all-cause visits controlling
for illness severity.
Results Among children with incomplete well-child care in the first 6 months
of life, there was an increased risk of having an ED visit for an upper respiratory
tract infection (hazard ratio, 2.3; 95% confidence interval, 1.6-3.2), gastroenteritis
(hazard ratio, 1.8; 95% confidence interval, 1.0-3.0), asthma (hazard ratio,
2.1; 95% confidence interval, 1.0-4.3), and all-cause ED visits (hazard ratio,
1.6; 95% confidence interval, 1.4-1.98).
Conclusions Because of the positive effect compliance with national guidelines for
early well-child care has on lowering the risk of experiencing ED use, national
efforts to improve the quality of child health services for young children
should focus on increasing compliance with periodic preventive care for young
children.
INTRODUCTION
THE SCHEDULE of early pediatric well-child care visits was designed
to accommodate the immunization schedule, monitor early development, and provide
guidance and counseling to parents about child care.1-5
Other than the proven effectiveness of immunizations, efforts to show a direct
health benefit to the schedule of well-child care visits have largely been
unsuccessful.6 The conviction that these visits
are themselves beneficial is reinforced by research that has correlated poor
access to ambulatory services among low-income children with more severe childhood
illnesses,7 higher avoidable hospitalizations
rates,8-9 and more frequent use
of the emergency department (ED).10 Because
of this lack of evidence, we embarked on a study to examine the relationship
of compliance with the schedule of visits recommended by the American Academy
of Pediatrics on ED visits.
In an earlier analysis of Medicaid claims data, we found that compliance
with the American Academy of Pediatrics recommended series of well-child care
visits during the first 2 years of life among a large cohort of children enrolled
in Medicaid from birth was related to fewer avoidable hospitalizations.11 Only limited information is available in the Medicaid
claims about ED visits. To examine the relation between compliance and ED
visits, we used longitudinal data from the 1988 National Maternal and Infant
Health Survey (NMIHS) and its 1991 Longitudinal Follow up (LF).
PARTICIPANTS AND METHODS
The NMIHS is a representative sample of live births and late fetal and
infant deaths that occurred in the United States in 1988.12
The purpose of the survey was to examine factors related to poor pregnancy
outcomes. The infants were sampled by birth weight (<1500 g, 1500-2499
g, and >2499 g) and race (African American and all others) strata, oversampling
low-birth-weight and African American children. Seven months after the infants
were born, the mothers were interviewed about health habits, socioeconomic
characteristics, use of health care services, and the child's health and medical
care up until that time. Of the 13 417 mothers selected for the live birth
survey, 9953 (74%) responded. The mothers were asked extensive questions about
their pregnancy and pregnancy history, behavioral risk factors, prenatal care,
infant feeding, socioeconomic level, and use of pediatric health care services.
The 1991 LF interviewed the mothers of the live born infants from the
1988 NMIHS to obtain longitudinal data on child development, effects of low-birth-weight,
child care, and pediatric health care services use since the earlier survey.
It resurveyed 8285 (88%) of the mothers interviewed in the 1988 NMIHS when
the surviving children were 3 years old.13-14
When merged, 1991 LF and the 1988 NMIHS data provided a rich longitudinal
database for our analysis of the relationship of ED visits and compliance
with recommended well-child care visits. Mothers were asked to provide the
names of all medical providers and hospitals where the child's condition was
diagnosed, treated, and/or where the child was admitted. Each health care
provider was asked to supply information about the type of service provided
and diagnosis for each visit and/or hospitalization. Specific information
about ED visits came from the hospitals that responded to the survey. Responses
were received from 6606 primary care physicians (73% of those contacted) and
3183 hospitals (89% of those contacted). The 1991 LF sample was then reweighted
to be representative of all children aged 3 years in the United States. Emergency
department visits were ascertained from the hospitals that responded to the
1991 LF.
LEVEL OF WELL-CHILD CARE COMPLIANCE WITH RECOMMENDED GUIDELINES
The goal of the analysis was to examine the effect of compliance with
accepted guidelines for well-child care on use of emergency services adjusting
for elements that could also be related to use of the ED. To do this, we created
a variable to represent compliance with the 1988 American Academy of Pediatrics
schedule of well-child care visits and immunizations during the first 7 months
of an infant's life, which was the period about which mothers were asked to
recall their child's physician visits and immunizations during the 1988 NMIHS.
In that year, the American Academy of Pediatrics recommended 4 well-child
care visits for that age group (1 soon after birth, then every 2 months thereafter)
and 5 immunizations (3 diphtheria and tetanus toxoids and pertussis vaccines
and 2 oral polio vaccines).15 To improve the
responses of the mothers during the 1988 NMIHS, we combined the information
provided by the mothers during the earlier survey with that supplied by the
health care providers from the 1991 LF. We restricted the health care provider
information to the first 7 months of the child's life, which was the period
reported on by the mothers.
We classified sick visits during which an immunization or screening
was given as well-care visits to capture opportunistic well care. The 1988
NMIHS contained the month but not day of birth to protect respondent confidentiality,
limiting our ability to determine the exact timing of child well-care visits
in relation to the date of birth. Instead, we arbitrarily assigned age to
be the 15th day of the birth month. Because we did not know the date of the
first well-child care visit relative to the child's age, we set a lenient
deadline of 2 months for the first visit to occur and required only 3 total
visits in 7 months instead of the recommended 4 for an child to be categorized
as having complete well-child care visits. We totaled maternal and primary
care physician counts of child well-care visits and immunizations separately,
using the greater of the 2 to determine the number of visits and immunizations
during the first 7 months of the child's life. We excluded cases with no information
from either source. A thorough explanation of the combination of these 2 sources
is given in a previous article.16
We categorized the variable that indicated compliance into 3 levels
based on the relative completeness of well-child care visits and immunizations.
Compliance was complete if there were maternal or primary care physician reports
of 3 or more well-child care visits with the first occurring by age 2 months,
with the requisite number of immunizations (3 diphtheria and tetanus toxoids
and pertussis vaccines and 2 oral polio vaccines) by age 7 months. The intermediate
level, which we termed "adequate," was defined as 3 or more well-child care
visits that began by age 2 months but with fewer than the above-mentioned
immunizations. This situation suggested that while well-child care visits
appeared up-to-date, there were missed opportunities to immunize the child.
Inadequate compliance was no well-child care visit in the first 2 months or
fewer than 3 visits by age 7 months, regardless of the number of immunizations,
implying that there were barriers to accessing preventive care visits that
could potentially affect the child's health.
ED VISITS
Previous studies have used the concept of avoidable hospitalizations
as an indication of adequate well-child care.9, 17
The concept of having an avoidable ED visit has not been used as an indicator
of quality pediatric preventive care, to our knowledge, with the exception
of a study that found that a higher level of ED use to be related to poor
continuity of care.18 Because of this, we hypothesized
that ED use would be related to compliance with well-child care visits. We
selected 3 diagnoses from those commonly used to indicate a hospital admission
is potentially avoidable and that would be common reasons for visiting an
ED: upper respiratory tract infection, gastroenteritis, and asthma.9 We also examined the effect of compliance with early
well-child care on ED visits for all diagnoses.
To maintain a temporal chain of events, we defined our outcome to be
an ED visit that occurred after the first 7 months of each child's life, which
was the period about which we had maternal information about well-child care.
Emergency department visits that occurred before the age of 7 months were
excluded from the analysis.
STATISTICAL ANALYSIS
We used SUDAAN statistical software for the analysis to consider the
sampling framework when computing national estimates and SEs in regression
models.19 Survival time in days until the first
ED visit after the seventh month of life was the outcome variable in a Cox
proportional hazards model for acute upper respiratory tract disease and for
all-cause ED visits. The major independent variable was the level of well-child
care compliance in the first 7 months of life. To account for general health,
we counted the number of ambulatory visits for sick care using the maximum
number of sick care visits reported by the mother or primary care physician
and categorized them into 3 levels ( 1, 2-6, and  7). We computed separate
Cox proportional hazards models for upper respiratory tract infections, gastroenteritis,
asthma, and all diagnoses.
We tested many potential variables that have been found to be related
to use of infant services by other researchers including maternal depression,
number of children in the family, use of prenatal care,20
whether the mother wanted the pregnancy, alcohol consumption, where the infant's
care was obtained, race, marital status, parental educational level, maternal
age, number of children in the household, and household income. We also adjusted
for maternal smoking and infant's birth weight.
RESULTS
Beginning with the sample of 8285 mothers who responded to both the
1988 NMIHS and the 1991 LF, we excluded 241 (2.9%) who were not white, African
American, or Hispanic, leaving a total of 7904 mothers. We excluded 609 respondents
(7.3%) who did not name a health care provider or refused permission to contact
their health care providers. Since hospitals were the only source of information
about ED visits, we excluded 1250 cases (15.1%) that either did not name a
hospital or for whom the hospital did not respond to the survey, leaving a
sample of 6045 cases.
The characteristics of the analytic sample differed somewhat from the
subsample not selected for analysis (Table
1). The mothers in the analytic sample were more likely to be white
(72.7% vs 62.1%) and less likely to be Hispanic (11.1% vs 15.5%). They were
more likely to be married (71.4% vs 68.7%), less likely to have a household
income less than the federal poverty level (28.7% vs 33.3%), and more likely
to be privately insured (52.8% vs 49.5%).
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Table 1. Characteristics of Children Selected or Not Selected for Analysis
of the Effect of Well-Child Care on Emergency Room Visits*
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More than half (55.5%) the children in the sample experienced complete
early well-child care visits (3 well-child care visits, the first occurring
by age 2 months, and 3 diphtheria and tetanus toxoids and pertussis vaccines
and 2 oral polio vaccines) by age 6 months; 26.7% had adequate well-child
care visits (3 well-child care visits and <5 immunizations) and 17.8% of
the children had inadequate early well-child care visits (no well-child care
visit in the first 2 months or <3 well-child care visits by age 7 months)
(Table 2). Approximately 30% of
the children had 0 or 1 sick visit by age 7 months, and 53.6% had 2 to 6 sick
visits during that time. Infants with a birth weight less that 1500 g (n =
864) had a different pattern of compliance: 36.6% had complete compliance,
38.2% had adequate compliance, and 25.2% had incomplete compliance. For this
reason we conducted separate analyses for the infants who weighted less than
1500 g and those who weighted 1500 g and more.
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Table 2. Level of Compliance With the American Academy of Pediatrics
Guidelines for Well-Child Care Visits and the Number of Sick Visits During
the First 6 Months of Life*
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Emergency department visits were common among children between the ages
of 7 months and 3 years (Table 3).
Emergency department visits were even more common for children born with a
birth weight less than 1500 g. Rates of ED visits for upper respiratory tract
infection, asthma, and all-causes diagnoses were associated with level of
well-child care compliance, increasing as compliance became poorer. For example,
those children with a birth weight of 1500 g or more with complete well-child
care compliance had 40.0 of 1000 ED visits for upper respiratory tract infection
compared with 87.0 of 1000 among those with an inadequate level of compliance.
The rate of ED visits for asthma among the larger-birth-weight infants rose
from 6.4 per 1000 among those with complete care to 13 per 1000 for those
with inadequate care. The very low-birth-weight children with inadequate compliance
experienced 551.7 per 1000 ED visits for any diagnosis compared with 339 per
1000 among those with complete care and 76.5 per 1000 ED visits for asthma
among those with inadequate care compared with 36.0 of 1000 among those with
complete compliance. For ED visits for gastroenteritis, the pattern was less
clear. Among infants weighting more than 1500 g at birth, ED visits rose from
17.5 per 1000 for those with complete well-child care to 30.5 per 1000 and
30 per 1000 for those with adequate and inadequate well-child care.
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Table 3. Incidence Rates of Having an Emergency Department Visit for
Selected Conditions Between the Ages of 6 Months and 3 Years by Well-Child
Care in the First 6 Months*
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The results of the Cox proportional hazards regression analysis revealed
a 60% increase in risk of experiencing an ED visit for any reason among the
sample of children who weighed 1500 g (hazard ratio [HR], 1.6; 95% confidence
interval [CI], 1.4-1.9) when early well-child care was inadequate compared
with those with complete early well-child care after adjustment for sick visits
(Table 4). Similarly, the children
with inadequate well-child care had a 40% increase in risk of having an ED
visit (HR, 1.4; 95% CI, 1.2-1.6). This relationship between ED visits and
the level of well-child care compliance was similar for visits for upper respiratory
tract infections, gastroenteritis, and asthma, with an approximate doubling
in risk (HR, 2.3; 95% CI, 1.6-3.2; HR, 1.8; 95% CI, 1.0-3.0; and HR, 2.1;
95% CI, 1.0-4.3, respectively). With the exception of gastroenteritis, a similar
pattern of an approximate doubling of risk of experiencing an ED visit for
any reason or for upper respiratory tract infections or asthma was seen among
the very low-birth-weight children. Sick visits were related to ED visits
among the children with a birth weight greater than 1500 g, a relationship
that was less clear among the very low-birth-weight children.
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Table 4. Results of Cox Regression for Risk of an Emergency Department
Visit Between the Ages of 6 Months and 3 Years for Infants With a Birth Weight 1500
g*
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A second regression model that adjusted for race, marital status, parental
education, maternal age, number of children in the household, use of prenatal
care, maternal depression score, maternal smoking, whether the pregnancy was
wanted, household income, insurance, and birth weight in grams did not change
the relationship between well-child care compliance and ED visits. In this
model (not shown), there were few consistent relationship associations between
any of the variables and ED visits except for insurance status. Receiving
Medicaid was associated with a 60% increase in likelihood of having any ED
visit for children weighing more than 1500 g at birth (HR, 1.6; 95% CI, 1.1-2.3)
and a 30% increase among the very low-birth-weight children (HR, 1.3; 95%
CI, 1.1-1.6).
COMMENT
Since well-child care became institutionalized, pediatric policy-makers
have hypothesized that comprehensive primary care consisting of examination,
immunization, monitoring of growth and development, and anticipatory guidance
and counseling of parents reduces childhood morbidity and mortality. Indirect
evidence suggests that this is so. For example, during the first full decade
of Medicaid (1970-1980), which was associated with increased use of health
services, infant mortality dropped 35%, the most rapid decline of the century.
In addition, deaths in early childhood (ages 1-4 years) declined 24%; for
school-aged children (5-14 years), 26%; and for older adolescents and young
adults, 25%.21 Research shows that poor children
are less likely to use preventive services and that among poor children there
is a greater likelihood that they will use ED services for conditions that
could be treated in a physician's office.22-23
The results of this and other studies suggest that children in the United
States are underusing preventive care services.11, 16
But, there has been little direct evidence of a link between the level of
compliance with well-child care and ED visits.
Researchers have used the concept of avoidable hospitalizations and
nonurgent ED visits to measure access to and the quality of primary care.9, 24 The class of hospitalizations considered
by researchers to be potentially avoidable has been found to be associated
with indicators of poverty, such as minority status and low educational level.8 Similarly, ED visits for nonurgent reasons have been
found to be associated with the same factors.10, 25-26
A recent study found that among Medicaid-covered children, compliance with
recommended guidelines for well-child care was related to as much as a 50%
decrease in avoidable hospitalizations.11 Another
study of the relationship between continuity of care and ED use found that
with poor continuity of care there was more than a 50% increase in the risk
of an ED visit.18 Several studies have found
an association between more frequent primary care visits and fewer ED visits.10, 18, 27 However, using ED
use as a health outcome indicator is nonspecific—it includes many visits
that are unavoidable, such as acute illness that occurs after hours. The time
of the ED visit was unavailable to us.
Use of health care services is a multidimensional phenomenon. Individual
circumstances; family dynamics; social, cultural, political, and economic
factors; health care provider characteristics; and the characteristics of
health care systems may affect health care behaviors that might improve use
of pediatric child health care.6, 28-39
Because the 1988 NMIHS and its 1991 LF conducted a comprehensive survey that
included a large number of questions, a long list of potential risk factors
were tested in our regression models as independent risk factors for ED visits.
These included indicators of social status (marital status, income, and educational
level), family dynamics (whether the index pregnancy was wanted, number of
children, and birth order), health care access (prenatal care attendance and
usual source of care), and other indicators (ie, depression score, use of
alcohol, and others). None of these was consistently associated with the dependent
variables (with the exception of insurance status) suggesting that the notion
of compliance with well-child care and fewer ED visits is independent of race,
socioeconomic indicators, and other variables thought to be causally associated
with use of ED services.
A limitation of this study is that more than one quarter of the original
sample was eliminated because of incomplete survey information. Because the
excluded sample was more frequently of those in a lower socioeconomic level,
the analytic sample had a higher level of complete compliance compared with
the full sample analyzed in our previous study (55.5% vs 51.7%).16
Had we had ED visit information on the whole sample, the incidence rates given
in Table 3 may have been higher.
However, because our results remained robust after adjustment for socioeconomic
factors, they are generalizable to all US children.
Other limitations of this study include the potential for incomplete
or inaccurate data from the health care providers, discrepancies between maternal
and health care provider reports, or problems with maternal recall of use
of services. The fact that neither the maternal nor the health care provider
reports were complete suggests that our estimates of health services use may
have been low because of underreporting. Conversely, the estimated rates of
early well-child care may be inflated because mothers excluded from the study
were disproportionately from high-risk groups. Although mothers reported more
early well-child care than did their health care providers, the health care
providers reported more sick visits than mothers, suggesting that visits mothers
considered to be for well-child care may have been recorded as sick visits
by physicians. Counting well-child care visits and immunizations is only a
proxy for the concept of complete preventive care and does not provide a measure
of the quality of that care. However, with the exception of immunizations,
no study has yet found that any particular component of the well-child care
visit is effective.6 The results of this analysis
suggest that it is the act of compliance with a scheduled series of primary
care encounters that is related to the outcome. We speculate that once continuity
is established between the mother and physician, a mutually trusting relationship
forms that facilitates treatment.
Despite these limitations, the results of our study strongly suggest
that compliance with guidelines for care may establish a physician-family
relationship that may prevent the use of ED for nonurgent care. This suggests
that children with poor compliance should be targeted for intervention. Moreover,
children without adequate health coverage should by assured of adequate pediatric
care. Nationally, the Children's Health Insurance Program, enacted by the
1997 Balanced Budget Act, is improving coverage of children of the working-
and near-poor who have been ineligible for Medicaid.
| What This Paper Adds
Only a few studies have shown a correlation between well-child care
visits and indicators of health such as avoidable hospitalizations or ED use.
Even fewer studies have shown a positive health benefit of compliance with
the recommended pediatric guidelines for health supervision. This study provides
evidence that compliance with health supervision guidelines during infancy
is associated with a decrease in incidence of ED visits in general. The results
of this study provide further support of the role of early health supervision
in preventing unnecessary morbidity. The implication is that no child in the
United States should be without preventive care.
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AUTHOR INFORMATION
Accepted for publication May 9, 2002.
The views expressed in this study are those of the authors and do not
reflect those of the Department of Health and Human Services or the Centers
for Medicare & Medicaid Services.
Corresponding author: Rosemarie B. Hakim, PhD, CMS c3-19-07, 7500
Security Blvd, Baltimore, MD 21244 (e-mail: rhakim{at}CMS.hhs.gov).
From the Centers for Medicare & Medicaid Services, Baltimore, Md
(Drs Hakim and Ronsaville); and KEVRIC Company, Inc, Baltimore (Dr Ronsaville).
Dr Ronsaville is now with the National Institute of Mental Health, Bethesda,
Md.
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Physician Reimbursement Levels and Adherence to American Academy of Pediatrics Well-Visit and Immunization Recommendations
McInerny et al.
Pediatrics 2005;115:833-838.
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Cost-Effectiveness of Postnatal Home Nursing Visits for Prevention of Hospital Care for Jaundice and Dehydration
Paul et al.
Pediatrics 2004;114:1015-1022.
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Parents' Health and Demographic Characteristics Predict Noncompliance with Well-Child Visits
Jhanjee et al.
J Am Board Fam Med 2004;17:324-331.
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Access And Quality In Child Health Services: Voltage Drops
Chung and Schuster
Health Aff (Millwood) 2004;23:77-87.
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Placement Changes and Emergency Department Visits in the First Year of Foster Care
Rubin et al.
Pediatrics 2004;114:e354-e360.
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The Effects of Access to Pediatric Care and Insurance Coverage on Emergency Department Utilization
Johnson and Rimsza
Pediatrics 2004;113:483-487.
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A Practice-Based Intervention to Enhance Quality of Care in the First 3 Years of Life: The Healthy Steps for Young Children Program
Minkovitz et al.
JAMA 2003;290:3081-3091.
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