Young children who miss well-child visits are more likely to be hospitalized

Children with chronic conditions like asthma and heart disease were even more likely to be hospitalized when they missed visits, according to the study. In fact, children with chronic conditions who missed more than half of the recommended well-child visits had more than three times the risk of being hospitalized compared to children with chronic conditions who attended most of their visits.

"Well-child visits are important because this is where children receive preventive immunizations and develop a relationship with their provider," says lead author Jeffrey Tom, MD, MS, an assistant investigator with the Kaiser Permanente Center for Health Research in Hawaii. "These visits allow providers to identify health problems early and help to manage those problems so the children are less likely to end up in the hospital."

When he conducted the study Dr. Tom was a senior fellow in the University of Washington Department of Pediatrics.

"Regular preventive care for children with special needs and chronic conditions is even more important, given the risk of possible complications for their conditions, often leading to hospitalizations," added coauthor David C. Grossman, MD, MPH, a senior investigator at Group Health Research Institute in Seattle.

The study included 20,065 children who were enrolled in Group Health from 1999 to 2006. Researchers followed the children from birth until age 3.5 years or until their first hospital stay, whichever came first.

During the study period, Group Health recommended nine well-child visits between birth and 3.5 years. The visits start at 3-5 days and continue at 1, 2, 4, 6, 10, and 15 months, and at 2 and 3.5 years.

Most children in the study (76 percent) attended at least three-quarters of the recommended visits, for which Group Health required no copayment. The authors say the lack of copayment is an important incentive and likely one reason for such good adherence to visits among the study population.

Overall, 4 percent of children in the study -- and 9 percent of children with chronic conditions -- were hospitalized. The two most common reasons for hospitalization in both groups were pneumonia and asthma.

Children who missed more than half of their visits had 1.4 to 2.0 times the risk of hospitalization compared to those who attended most of their visits. Children with chronic conditions who missed more than half of their visits had 1.9 to 3.2 times the risk of hospitalization compared to those who attended most of their visits.

Authors caution that their findings might not apply to all health systems because the study was conducted in an integrated health care system where the majority of children attend most of their well-child visits and tend to have families with higher-than-average income and education. The authors were unable to adjust for income, education, race, or ethnicity.

This study does not prove that missing well-child visits will increase the chance of hospitalization, although it does show an important association between these factors. The authors say one important reason for this link is that well-child visits allow for preventive care that keeps children from ending up in the hospital. An alternative explanation is that parents who miss well-child visits are also less likely to manage their kids' illnesses and follow treatment regimens which could result in higher rates of hospitalization for the children.

Some prior studies have found an association between missing well-child visits and increased hospitalization, but others reported no link. The authors of this study conducted another study with similar findings in a fee-for-service medical setting in Hawaii. That study was published in the Archives of Pediatrics and Adolescent Medicine (now JAMA Pediatrics) in November 2010.

Authors of the study include Jeffrey O. Tom, MD, MS, with the Kaiser Permanente Center for Health Research in Hawaii; Rita Mangione-Smith, MD, MPH, with the University of Washington and Seattle Children's Research Institute; David C. Grossman, MD, MPH, with Group Health Research Institute and the University of Washington in Seattle; Cam Solomon, PhD, with Seattle Children's Research Institute; and Chien-Wen Tseng, MD, MPH, with the University of Hawaii and Pacific Health Research and Education Institute in Hawaii.

This study was supported by the Health Resources and Services Administration (grant T32HP10002-21), an agency of the U.S. Department of Health and Human Services -- and by Group Health Cooperative and Group Health Research Institute.