Boston Combined Residency Program in Pediatrics, Harvard Medical School, Boston University School of Medicine, Boston, MA.
Children's Hospital Association, Lenexa, KS.
J Pediatr. 2018 Aug;199:223-230.e2. doi: 10.1016/j.jpeds.2018.04.003. Epub 2018 May 8.
Well-child visits (WCVs) help optimize children's health. We measured annual WCVs for children with medical complexity (CMC) and correlated WCVs with hospitalizations.
This was a retrospective analysis of 93 121 CMC aged 1-18 years continuously enrolled in 10 state Medicaid programs in the Truven MarketScan Database between 2010 and 2014. CMC had a complex chronic condition or 3 or more chronic conditions of any complexity identified from International Classification of Diseases, Ninth Revision codes, and the use of 1 or more chronic medications. We measured the number of years with 1 or more WCVs. The χ test and logistic regression were used to assess the relationships of WCV-years with the children's characteristics and hospitalization.
Over 5 years, 13.4% of CMC had 0 WCVs; 17.3% had WCVs in 1 year, 40.8% had WCVs in 2-3 years, and 28.5% had WCVs in 4-5 years. Fewer children received WCVs in 4-5 years when enrolled in Medicaid fee-for-service compared with managed care (20.9% vs 31.5%; P < .001) and when enrolled due to a disability compared with another reason (18.2% vs 32.2%; P < .001). The percentage of CMC hospitalized decreased as the number of years receiving WCV increased (21.5% at 0 years vs 16.9% at 5 years; P < .001). The adjusted odds of hospitalization were higher in CMC with WCVs in 0-4 years compared with CMC with WCVs in all 5 years (OR range across years, 1.1 [95% CI, 1.0-1.2] to 1.3 [95% CI, 1.3-1.4]).
Most Medicaid-insured CMC do not receive annual WCVs consistently over time. Children with fewer annual WCVs have a higher likelihood of hospitalization. Further investigation is needed to improve the use of WCVs in CMC.
定期儿童健康检查（Well-child visits，WCV）有助于优化儿童健康。本研究旨在评估患有复杂疾病的儿童（children with medical complexity，CMC）的年度 WCV 就诊情况，并分析 WCV 与住院之间的相关性。
本研究为回顾性分析，纳入 2010 年至 2014 年期间，10 个州的 Medicaid 计划中的 93121 例 1 至 18 岁的 CMC 患者，这些患者均连续入组 Truven MarketScan 数据库。符合纳入标准的 CMC 患者需满足以下条件：患有复杂的慢性疾病或 3 种或以上任何复杂程度的慢性疾病，这些疾病均根据国际疾病分类第 9 版代码进行诊断，且使用 1 种或以上慢性药物。我们测量了每年进行 WCV 就诊的年数。采用卡方检验和逻辑回归评估 WCV 年数与患儿特征和住院之间的关系。
5 年内，13.4%的 CMC 患儿未进行任何 WCV 就诊；17.3%的患儿进行了 1 次 WCV 就诊，40.8%的患儿进行了 2-3 次，28.5%的患儿进行了 4-5 次 WCV 就诊。与管理式医疗相比，接受费用报销型 Medicaid 服务的患儿（20.9%比 31.5%；P < .001）和因残疾而接受 Medicaid 服务的患儿（18.2%比 32.2%；P < .001）在 4-5 年内接受 WCV 就诊的比例更少。随着接受 WCV 就诊年数的增加，住院患儿的比例逐渐降低（0 年就诊率为 21.5%，5 年就诊率为 16.9%；P < .001）。与在所有 5 年内均进行 WCV 就诊的患儿相比，0-4 年内仅进行 WCV 就诊的 CMC 患儿的住院风险更高（就诊年数不同的患儿，其住院风险的比值比范围为 1.1[95%置信区间，1.0-1.2]至 1.3[95%置信区间，1.3-1.4]）。
大多数接受 Medicaid 保险的 CMC 患儿无法持续、定期进行年度 WCV 就诊。进行 WCV 就诊较少的患儿，其住院的可能性更高。需要进一步研究来提高 CMC 患儿 WCV 的利用率。
