More than 56% of children do not receive an annual well-child visit

Well-child visit compliance was especially low among teenagers and uninsured children.

Issue: February 2007

Compliance rates for the well-child visit are not as high as they should be.

More than half of all children up to age 18 years did not visit the physician for a well-child visit in a 12-month period, according to data from the Medical Expenditure Panel Survey. Similarly, nearly 40% of children did not have a well-child visit in a two-year period.

“Although there remain unanswered questions regarding the exact value of well-child visits, it is a fact that many children have far fewer well-child visits than are recommended by the American Academy of Pediatrics,” said Thomas M. Selden, PhD.

Medical Expenditure Survey

The study goal was to examine well-child visit compliance based on data from the 2000 to 2002 Medical Expenditure Panel Survey, a household survey.

Selden, of the Center for Financing, Access and Cost Trends at the Agency for Health Care Research and Quality, in Rockville, Md., looked at data from 29,460 children.

Researchers defined the well-child visit as any visit to the physician office and/or hospital outpatient visits for general checkups and immunizations. Also examined were age, health status, insurance coverage, gender, race/ethnicity, family structure, citizenship, parent education and more.

Selden looked at three well-child visit measures: an indicator that the child had one or more visit in the past year, the number of visits, and a count of the visits expressed as a ratio of the age-specific number of visits the AAP recommends. The compliance ratio was calculated by merging the AAP guidelines and the age of the child in months at the end of the year.

Compliance rates

Overall, well-child visit compliance was low in children in the United States. Nearly 44% of all children had at least one or more well-child visits during the sample year, according to Selden’s results. He calculated the mean number of visits at 0.75 and the mean compliance ratio at 61.4%.

The highest rates of compliance were found in infants (83.2%), children with special health care needs (86.6%), children with college-educated parents (74.3%), and children in families with incomes more than four times the poverty level (71.6%). The lowest rates were observed in children without insurance (35.3%), teenagers (49.2%), and noncitizens of the United States (43.9%).

According to Selden, large differences in visit by age group were not surprising. Very young children, including infants, had the most visits, and children aged 6 to 12 years had the fewest.

Selden said the most significant finding was based on compliance and region. Children who live in New England had the highest compliance rate at 95%, followed by the Middle Atlantic region with 83.2%. The Mountain, East South Central and West South Central regions all had compliance rates lower than 50%.

The association between well-child visits and health insurance was strong, according to Selden. Children without health insurance for one year had a lower compliance ratio (35.3%) compared with children with private (64.1%) and public (63.1%) health insurance.

“Of course, having health insurance and having adequate well-child care may both be driven by other child or family characteristics,” Selden wrote. “Lacking coverage and low visit compliance may also reflect differences in child health and/or parent attitudes and abilities. Certainly the low compliance rates observed among eligible but uninsured children highlight the importance of outreach efforts seeking to increase enrollment in public coverage.” The lowest compliance rate in relation to health insurance was found in uninsured children who are eligible for public coverage (28.4%).

Significant increases in compliance were also noted in children whose parents received a high school or college degree vs. children whose parents did not receive a degree.

In the two-year study, Selden calculated the mean compliance ratio at 58.6%. The most important finding, he said, was that 39.4% of all children went two or more years without any well-child visit.

Children with health problems and concerns were more likely to have one or more well-child visits, and higher compliance ratios than children without health concerns, according to Selden. Children deemed in fair/poor health had a compliance ratio of 82% compared with 60.8% for children deemed in excellent/very good/good health. Those who require special health care needs had a higher compliance (86%) than those who do not (56.4%).

Why compliance is essential

“Of course, it should be noted that children who undercomply with well-child visit recommendations may be unaware of health problems, so that reported health status might well be a consequence of well-child care, rather than the reverse,” Selden wrote.

He continued, “Although well-child visit compliance seems to have risen slightly over time, the overall prevalence of well-child visits in the Medical Expenditure Panel Survey falls short of the AAP norms.” Selden questioned whether households could accurately report well-child visits.

For more information:

Selden T. Compliance with well-child visit recommendations: evidence from the Medical Expenditure Panel Survey, 2000-2002. Pediatrics. 2006;118:1766-1778.