Young Children Who Miss Well-Child Visits Are More Likely to Be Hospitalized

Young children who missed more than half of recommended well-child visits had up to twice the risk of hospitalization compared to children who attended most of their visits, according to a study published today in the American Journal of Managed Care. The study included more than 20,000 children enrolled at Group Health Cooperative.

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, M.D., 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 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, M.D., 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. Visit

Study Finds Disagreement On The Role Of Primary Care Nurse Practitioners

Primary care physicians and nurse practitioners significantly disagree on some proposed changes to the scope of nurse practitioners' responsibilities, according to a New England Journal of Medicine study released today.

The study, led by investigators from the Vanderbilt University School of Nursing, Vanderbilt Institute for Medicine and Public Health and Massachusetts General Hospital, comes at a time when the U.S. health system is facing both an increasing demand for primary care services and a worsening shortage of primary care physicians.

One broadly recommended strategy to combat the problem has been to increase the number and the responsibilities of nurse practitioners.
"It is unsettling that primary care physicians and nurse practitioners, who have been practicing together for several decades, seem so far apart in their perceptions of each other's contributions," said co-author Peter Buerhaus, Ph.D., R.N., director of the Center for

Interdisciplinary Health Workforce Studies and the Valere Potter Professor of Nursing at VUSN.

"I am concerned that these large gaps in perceptions will inhibit efforts to redesign care delivery and to improve the productivity and configuration of the primary care workforce," he said.

The study survey was mailed to a national random sample of nearly 2,000 primary care clinicians — evenly divided between physicians and nurse practitioners — and responses were received from 467 nurse practitioners and 505 physicians.

The majority of both groups — 96 percent of nurse practitioners and 76 percent of physicians — agreed with the Institute of Medicine recommendation that nurse practitioners "be able to practice to the full extent of their education and training."

The two groups disagreed significantly on whether an increase in the supply of nurse practitioners would improve patient safety and the effectiveness of care and health costs. One-third of physicians responded that such an increase might have a negative effect on safety and effectiveness.

"We were surprised by the level of disagreement reported between these two groups of professionals," said Karen Donelan, Sc.D., Ed.M., of the Mongan Institute for Health at MGH, lead author of the report.

"We had hypothesized that, since primary care physicians and nurse practitioners had been working together for many years, collaboration would lead to more common views about their roles in clinical practice. The data reveal disagreements about fundamental questions of professional roles that need to be resolved for teams to function effectively," she said.

A strong majority (82 percent) of nurse practitioners believed they should be able to lead medical homes — practices using a team-based model to deliver coordinated patient care — but only 17 percent of physicians agreed.

Additionally, 64 percent of nurse practitioners agreed they should be paid equally for providing the same services, compared with only 4 percent of physicians.

Sixty percent of nurse practitioners in collaborative practices indicated they provided services to complex patients with multiple conditions, but only 23 percent of physician in such practices responded that those services were provided by nurse practitioners.

Study co-author Robert Dittus, M.D., Albert and Bernard Werthan Professor of Medicine, associate vice-chancellor for Public Health and Health Care and director of the Institute for Medicine and Public Health, said he hopes the study will provide information needed for thoughtful discussion among nurse practitioners and physicians and encourage a focus on working more closely together in both training and practice to understand each provider's capabilities and roles.

"Such roles are likely to evolve over time as primary care is practiced more in a team concept than a one-on-one provider to patient-only model," Dittus said. "The roles for many of the team providers, including nurse practitioners, are likely to change as such providers gain expertise and experience over time, and thus the confidence and trust of the entire provider team."

The two groups did agree that increasing the supply of primary care nurse practitioners would improve the timeliness of and access to care, and respondents working in collaborative practices indicated that both professions provide a wide range of services in their practices.
The study was supported by grants from the Gordon and Betty Moore Foundation, the Johnson & Johnson Campaign for Nursing's Future, and the Robert Wood Johnson Foundation.