In a retrospective cohort study of 93,121 medicaid-enrolled CMC identified from a database, CMC were found to not regularly attend well child visits (WCV). This is not surprising as half of all children with insurance (including healthy kids) do not receive all recommended WCV by AAP. This study, whose cohort included children who used at least 1 chronic medication with either a complex chronic condition (CCC) (predefined, Feudtner) or 3 or more chronic conditions of any complexity, found 13.4% had no well child visit (WCV) over a 4 year period and the majority had less than one a year. This lack of WCV was higher in teenagers, patients with fee-for-service medicaid (28% of the population, as compared to managed care), and patients qualifying for medicaid due to disability (26% of the population, as compared to other reasons). CCC (which was 62% of population) with transplants, neuromuscular conditions, and technology use were less likely to have regular WCV (~ 1 WCV/yr) than CCC with genetic, hematological/oncological, or prematurity.
CMC Do Not Regularly Attend Well Child Visits (and what we can do about it).
The less well child visits, the higher likelihood of acute, unplanned hospitalization.
More important, this study found that the less well child visits attended by CMC, the higher likelihood of an acute, unplanned hospitalization. 20% of study population had an acute unplanned hospitalization with median length of stay of 5 days during the 5 year study period. Odds of hospitalization was higher in kids with less than 1 WCV/yr. Of all other patient characteristics, highest odds of hospitalizations associated with kids with most non-WCV outpatient visits (primary or speciality, visits in time proximity to hospitalization were not included in this study).
It is not surprising to see CMC have low attendance of an annual WCV. This can be compounded by the facts that attempts to attend a WCV may turn into a sick visit, something I feel I see regularly, but does not give excuse to this low attendance. The fact that low WCV attendance is associated with increased risk of hospitalization brings this finding into a call for action. The authors have given suggestions to ameliorate this including having AAP survey PCPs to understand their willingness and ability to provide WCV to CMC, having insurance develop programs to encourage and enhance WCV services, but most importantly to have PCP realize the lack of WCV by CMC and proactively promote and enable CMC to come in for WCV.
In a population who perceives their care is uncoordinated and crisis-driven, we as PCPs need to promote WCV to CMC as a time to make a comprehensive plan. I have seen the effects of low WCV attendance in my own patient population and realize sometimes families do not see the benefit amongst all their other visits so we need to explain to families the benefits of this type of visits compared to other visits. In addition, not all CMC have complex care providers and thus I think our community needs to help all pediatricians realize the importance of WCV in CMC. We need to be able to offer local support to PCPs more than assuming or consulting their patients such as providing educational opportunities and sharing of resources but also a more global help in the ways of guidelines on care coordination methods (such as published HEADS AT tool) or topics to screen for at WCV for CMC (such as AAP provides for Trisomy 21 and other common genetic conditions).
Kristina Malik, MD