Missing Well Visits Results in Preventive Care Gaps for Preterm Infants

Newborns’ first big journeys into the world often are to well-baby exams at pediatricians offices. These checkups usually are scheduled within the first days or weeks after discharge from the hospital, followed by exams every few months during their first year of life. Well visits give parents important opportunities for their babies to receive routine vaccinations, to have their growth and development monitored, and to participate in health screenings.

While well visits, also known as health supervision visits, have become a mainstay of pediatric care and are recommended by the American Academy of Pediatrics’ Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, until now researchers have not gathered much data to demonstrate these exams’ value.

In an article published in the journal Pediatrics, a study team at The Children’s Hospital of Philadelphia looked at outpatient data from a retrospective cohort of 1,854 preterm infants born between 2005 and 2009 who received care at CHOP’s primary care network. Adherence to a well-visit schedule especially is a priority for preterm infants because they are at increased risk for medical complications and lifelong health problems.

The study results were disconcerting to lead investigator Scott Lorch, MD, MSCE, an attending neonatologist at CHOP and an associate professor of pediatrics at the Perelman School of Medicine at the University of Pennsylvania: Only 43 percent received all expected health supervision visits during the first 18 months of life.

“All it took was one missed visit, and we saw some fairly substantial differences in their health outcomes,” Dr. Lorch said. “The most telling finding was that missing one visit meant that the likelihood that a patient received all shots on time went down fairly dramatically, with a 64 percent drop in the likelihood of being up to date by 18 months.”

Families missed the well visits for two primary reasons. Sometimes they showed up for a well visit, but baby was not feeling well that day, so it became a sick visit. Other times they came in for a sick visit and then cancelled their next well visit. In both scenarios, the well visits were never rescheduled, and families did not receive the preventive care that normally would have occurred during those sessions. In addition to not getting vaccinations, the babies were less likely to receive screening tests and developmental assessments on time.

“We found that some groups of the smallest babies were being seen on average every week by the healthcare system, so that is a lot of competition for well visits,” Dr. Lorch said. “When children are showing up for sick issues, like chronic lung disease from prematurity, the things that physicians do or focus on during well visits seemed to get crowded out.”

Some of the other risk factors that the researchers associated with missed well visits were families who had public health insurance or no health insurance. On the flip side, continuity of care was linked to families being more likely to attend well visits. Having the same provider for sick and well visits keeps everyone in the loop, Dr. Lorch suggested, which may allow more time for them to concentrate on the real purpose of each visit.

In future research, Dr. Lorch and his study team will take a closer look at some of the potential barriers to families’ attendance at well visits. They also will investigate factors that could improve continuity of care and determine ways to avoid delays in immunizations and help close gaps in health monitoring. Already, they have shared insights from the current study with staff on the logistical side of scheduling outpatient visits to figure out strategies for handling no-shows.

“This is one of the first studies to provide documented evidence that there are health consequences for missing well visits,” Dr. Lorch said. “It shows how difficult it is for providers to get caught up with the services that these visits provide to patients.”