Published online February 29, 2008
PEDIATRICS Vol. 121 No. 3 March 2008, pp. e399-e406 (doi:10.1542/peds.2007-1497)
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ARTICLE

Effects of Continuity of Care in Infancy on Receipt of Lead, Anemia, and Tuberculosis Screening

Ana I. Flores, BSa, Warren B. Bilker, PhDb and Evaline A. Alessandrini, MD, MSCEa,b

a Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
b Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVES. The goals were (1) to examine the influence of continuity of care on delivery of lead, anemia, and tuberculosis screening in a cohort of Medicaid-enrolled children, (2) to determine whether well-child care continuity had a greater effect than continuity for all ambulatory visits, and (3) to investigate which aspects of continuity were most associated with receipt of these screening services.

METHODS. A prospective birth cohort of 1564 Medicaid-enrolled infants was studied. Continuity of care scores for the first 6 months of life were calculated for total ambulatory visits and well-child care visits. Outcomes of interest were performance of ≥1 screening for lead toxicity, anemia, and tuberculosis during the first 24 months of life.

RESULTS. For total ambulatory visits, children with complete continuity of care (the same practitioner seen for every visit) were more than twice as likely to receive lead screening, compared with children who saw a different practitioner for every visit, irrespective of the measurement technique used. Similarly, children with complete continuity were 1.5 to 2 times more likely to have been screened for tuberculosis. Continuity showed a lesser, but still significant, effect on anemia screening. Well-child care visit continuity of care had less impact on screening performance than did total visit continuity of care.

CONCLUSIONS. In this study, greater continuity of care in infancy was associated with increased likelihood of receiving screening for lead toxicity, anemia, and tuberculosis in the first 24 months of life. The dimension of continuity of care that was most influential in this population was dispersion of visits among different practitioners.

Key Words: continuity of care • Medicaid • screening • early childhood • urban

Abbreviations: COC—continuity of care • WCC—well-child care • UPC—usual provider of care • B&B—Bice and Boxerman • SECON—sequence continuity • CI—confidence interval • IQR—interquartile range • OR—odds ratio

Preventive health care is essential to promoting the health and development of children. Screening is available for potentially dangerous health problems in young children, including lead toxicity, iron-deficiency anemia, and tuberculosis. Lead toxicity in early life has been shown to be associated with decreased IQ later in childhood.1,2 The potential adverse effects of iron-deficiency anemia in infancy include problems with psychomotor development and damage to the visual and auditory systems.3,4 Although the incidence of tuberculosis in the United States is decreasing, tuberculosis remains significant for children because it is more likely to progress from latent to active disease and can lead to serious complications such as tuberculosis meningitis.5 Despite these known negative effects, many children are not receiving proper screening,6–9 particularly children shown to be at increased risk, such as those from urban low-income families.5,9–17 Attempts to improve preventive care services that have shown some success include patient education, practice-level interventions, reminder systems for patients and practices, and implementation of new office systems.18–22 However, few studies have looked specifically at increasing rates of lead, anemia, and tuberculosis screening.23–25 Additional methods for improving receipt of these screening services are needed, and continuity of care (COC) with a primary practitioner may play an important role.

COC has long been viewed as a fundamental part of the definition of primary care by the Institute of Medicine26 and is essential for providing quality health care. Studies have shown consistently that COC improves patient satisfaction,27,28 receipt of preventive care,29 and utilization of health care services.30,31 COC is perhaps most important in the pediatric population, because of the greater frequency of health care visits and the need to establish a foundation for future health care use. In the pediatric population, high COC has been shown to be associated with parental reports of high quality of care,32 fewer emergency department visits33 and hospitalizations,34 timely measles-mumps-rubella vaccination,35 and up-to-date immunizations at 2 years of age.36 These outcomes are clearly essential to providing quality health care, and COC is a key component in ensuring they are accomplished.

Many methods of quantifying COC have been developed, with little agreement regarding which is the most appropriate measure. Each available technique emphasizes different aspects of COC, and scores for the same pattern of health care visits vary depending on the measurement index used. Jee and Cabana37 suggested classifying COC indices into 5 categories, that is, (1) duration of the practitioner-patient relationship, (2) density of visits to a single practitioner, (3) dispersion of visits among practitioners, (4) sequence of practitioners seen, and (5) subjective estimates. Studies typically examine only 1 dimension of COC, with density being the most frequently studied measure. In determining the influence of COC, it is important to examine multiple measures, to account for the varying dimensions of COC and to determine the best approach to improving COC delivery. In addition, it has been suggested that, in evaluating COC in pediatric populations, separate analyses of COC for well-child care (WCC) visits alone, rather than for all visits combined, may be important,37 although this is rarely found in literature reports.

In this study, we examined the influence of COC on delivery of lead, anemia, and tuberculosis screening in Medicaid-enrolled children. We hypothesized that increased COC would be associated with increased screening, with WCC COC having a greater influence. Finally, we investigated the different dimensions of COC, to determine whether any are more important for this population and therefore should be targeted for intervention strategies.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Study Population
We conducted a prospective birth cohort study of 1564 Medicaid-enrolled infants born between July 1999 and March 2001, at 2 urban teaching hospitals and 1 suburban community hospital in the Philadelphia area. Eligibility criteria for infants included birth weight of ≥2 kg, gestational age of ≥34 weeks, and nursery stay of ≤10 days. Families that did not have an English- or Spanish-speaking person in the home were excluded.

We collected data on maternal, infant, and household characteristics through hospital chart reviews and maternal interviews during the postpartum period. We made calls to study families at 2, 4, 6, 12, and 24 months and asked mothers to report all sites where their child had received care during that time. We reviewed charts in all primary care offices where care was received. In this chart review, we obtained ambulatory visit data (including the name of the practitioner seen) for the first 6 months and screening data for the first 24 months of life. Information on primary care practice characteristics, including number of full-time practitioners, hours of operation, and percentage of Medicaid-enrolled patients served, were collected through surveys sent to each infant's primary care practice.

Predictor
Our primary predictor of interest was COC during the first 6 months of life for (1) total ambulatory visits and (2) WCC visits. Health care visits from all ambulatory sites were reviewed by a trained research assistant, who abstracted the visit date and the name of the treating practitioner. Visits were categorized as WCC or non-WCC on the basis of abstracted diagnoses. Ambulatory visits included visits to primary practices for either WCC or sick visits and excluded visits to the emergency department or specialists. Because COC cannot exist for only 1 visit, total ambulatory COC scores were calculated for infants with ≥2 ambulatory visits and WCC COC scores were determined for infants with ≥2 WCC visits. For comprehensive assessment of COC, we used measurement techniques from 3 of the 5 identified COC categories, namely, density, dispersion, and sequence. We chose the usual provider of care (UPC) method38 as our density measure because it is the most frequently used method in the literature. Many measures of dispersion are used in the literature, including the method described by Bice and Boxerman (B&B),39 the modified continuity index,40 the modified modified continuity index,41 and the index described by Ejlertsson.42 We used each of these methods to calculate COC for our population, and we obtained similar results with all methods. Here we report only the results for the B&B method. Sequence continuity (SECON) is currently the only index of continuity for an individual patient that accounts for the sequence of visits.43 Table 1 describes each COC measure and provides the formula to calculate it.


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  		TABLE 1 COC Measures

 
Categorizing COC
No consistent definitions of what constitutes high and low COC have been used in the literature. Some studies divided populations into tertiles to define high, medium, and low COC,32,34,35 whereas others defined high and low COC with specific numerical COC scores. When tertiles are used in a population that may have inherently lower COC, some infants who are in the high COC category may not have COC that would be considered high COC by clinical standards. In addition, the numerical values for COC are not consistent between measurement techniques. Therefore, we chose to divide each COC measure into 4 groups on the basis of the scores for specific visit patterns, that is, (1) no continuity (different practitioner seen for every visit), (2) low continuity, (3) medium continuity, and (4) complete continuity (same practitioner seen for every visit) (Tables1 and 2). For B&B and SECON, all infants with scores of 0 had no continuity, those with scores of 1 had complete continuity, and the cutoff points for the low and medium continuity groups were chosen on the basis of scores corresponding to visit patterns considered clinically important. Because a score of 0 is not possible when using UPC, the no, low, and medium continuity groups were based on clinically significant visit patterns. Scores of 1 for UPC were considered to indicate complete continuity.


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  		TABLE 2 Examples of Visit Patterns for 3 and 5 Visits, With Corresponding COC Scores and Categories

 
Outcomes
The outcomes of interest were receipt of screening tests for lead, anemia, and tuberculosis at least once during the first 24 months of life. The Advisory Committee on Childhood Lead Poisoning Prevention issued recommendations in December 2000, stating that all children enrolled in Medicaid should receive blood lead screening at 12 and 24 months.44 In 1998, the Centers for Disease Control and Prevention published a recommendation that infants at high risk for iron-deficiency anemia, including those from low-income families, should receive universal screening between 9 and 12 months of age, 6 months later, and annually from 2 to 5 years of age.45 During the time of this study, accepted practice in Philadelphia was to screen for tuberculosis at 1, 3, 5, and 11 years of age. On the basis of these standards, our outcomes of interest were ≥1 screen for lead, 1 screen for anemia with a complete blood count, and 1 screen for tuberculosis with a purified protein derivative skin test.

Covariates
Infant, maternal, and health care characteristics collected via medical chart reviews, maternal interviews, and practice surveys were included in our analyses. These variables were chosen because of their association with either COC or receipt of preventive screening tests in the medical literature. These covariates are listed in Table 3.


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  		TABLE 3 Characteristics of Participants

 
Statistical Analyses
In the first stage of our analysis, categorical variables were described by using proportions with 95% confidence intervals (CIs), continuous variables with ranges, means with SDs, and medians with interquartile ranges (IQRs). The 4-level COC variable was described as the proportion of patients within each category (with 95% CI). Our outcomes for screening were dichotomized with respect to whether the infant was screened and are presented as proportions (with 95% CIs). In the second stage, we examined associations between levels of COC and screening, depicting the proportion of children screened within each COC level for each dimension. We used logistic regression models to assess the relationship between COC and receipt of lead, anemia, and tuberculosis screening. In the third stage, we investigated possible confounders of the relationship between COC and screening. We added relevant maternal, infant, and practice characteristics and visit frequency to our regression models. Variables that changed the coefficient for COC by ≥15% were considered confounders and were included in our final models. We tested adequate WCC for possible effect modification with COC. At the time of the study, the American Academy of Pediatrics recommended 4 WCC visits in the first 6 months of life.46,47 Because data collection ended when each infant was exactly 6 months of age, which might not have allowed time for the 6-month visit, we defined adequate WCC as ≥3 WCC visits. We dichotomized COC by comparing no COC (COC = 0) with all others, no COC with complete COC (COC = 1), and complete COC with all others. We then compared the odds ratios (ORs) for children with adequate and inadequate WCC for each of the screening tests. If a statistically significant difference in the ORs was seen, then an interaction term was added to the model and the P value was examined for the significance of this term. Final models included a test for trend, to determine whether increasing levels of COC were associated with increased likelihood of screening.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Study Population
Of the 1564 infants enrolled in the study, 1356 (87%) completed follow-up evaluation and had ≥2 ambulatory visits and 1286 (82%) had ≥2 WCC visits in the first 6 months of life. Infant, maternal, and practice characteristics for the participants with ≥2 total ambulatory visits and ≥2 WCC visits are summarized in Table 3.

Study infants were seen at 117 different health care practices. The median number of full-time practitioners at each practice was 9 (IQR: 0–18). The median number of ambulatory visits in the first 6 months was 5 (IQR: 3–7), and the median number of WCC visits was 3 (IQR: 2–4). The median number of practitioners seen was 3 (IQR: 1–5) for all ambulatory visits and 2 (IQR: 0–4) for WCC visits. A total of 723 infants (53%; 95% CI: 51%–56%) were screened for lead, 818 (60%; 95% CI: 58%–63%) for anemia, 451 (33%; 95% CI: 31%–36%) for tuberculosis, and 285 (21%; 95% CI: 19%–23%) for all 3 conditions.

COC
The distributions of COC for each measure are shown in Figs 1 to 3. The mean ± SD scores for UPC, B&B, and SECON were 0.61 ± 0.26, 0.40 ± 0.35, and 0.43 ± 0.36, respectively.


Figure 1
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  		FIGURE 1 Distribution of total visit COC scores with the UPC (density) measure.

 

Figure 2
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  		FIGURE 2 Distribution of total visit COC scores with the B&B (dispersion) measure.

 

Figure 3
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  		FIGURE 3 Distribution of total visit COC scores with the SECON (sequence) measure.

 
Lead Screening
Lead screening increased significantly with increasing COC in all 3 dimensions examined (Table 4), although the dispersion (B&B) measure had a greater effect than the density (UPC) and sequence (SECON) measures. The WCC COC showed a similar trend, with slightly less of an effect. These models are adjusted for 2 confounders, namely, urban residence and receiving care at a practice with more than one half of patients enrolled in Medicaid.


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  		TABLE 4 Adjusted ORs for Lead Screening According to COC Category

 
Anemia Screening
Compared with lead screening, total visit COC had a lower, but still significant, association with receiving anemia screening. The dispersion and sequence measures, but not the density measure, of COC showed significant associations (Table 5). WCC COC did not have a significant effect on anemia screening for any of the 3 measures.


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  		TABLE 5 Adjusted ORs for Anemia Screening According to COC Category

 
Tuberculosis Screening
With increasing total visit COC, the likelihood of receiving tuberculosis screening improved for all 3 COC measures (Table 6). In this case, density and dispersion measures had greater effects than did the sequence measure. Unlike with lead and anemia screening, WCC continuity had a greater effect than did total visit COC.


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  		TABLE 6 Adjusted ORs for Tuberculosis Screening According to COC Category

 
Visit Frequency and Adequate WCC
The total number of ambulatory visits did not have a significant independent effect on screening for lead (OR: 1.0; 95% CI: 0.9–1.0), anemia (OR: 1.1; 95% CI: 1.0–1.1), or tuberculosis (OR: 0.9; 95% CI: 0.9–1.0). The number of WCC visits also did not independently influence the receipt of screening for lead (OR: 1.0; 95% CI: 0.9–1.1), anemia (OR: 1.1; 95% CI: 1.0–1.2), or tuberculosis (OR: 0.9; 95% CI: 0.8–1.0). Finally, adequacy of WCC did not modify the effect of any measure of COC on receipt of screening tests.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Low rates of preventive screening services for lead toxicity, anemia, and tuberculosis continue to be a significant problem. Children from low-income families are at higher risk of suffering from these conditions and are less likely to receive screening. Wide ranges of preventive service delivery rates have been reported for different populations.17 In our cohort of Medicaid-enrolled children, 53% were up to date for lead testing at 24 months of age, 60% for anemia, and 38% for tuberculosis. Methods of increasing screening rates in this population need to be identified, to improve the health and development of these children. Various studies have suggested that practice education interventions and implementation of new office systems can improve preventive care delivery.18–25 In this study, we showed that higher COC was associated with increased likelihood of receiving screening; therefore, efforts to improve continuity should be pursued.

Many studies have demonstrated the importance of COC in improving health care outcomes.27–36 Higher COC has been shown to be associated with timely and up-to-date immunizations in children.35,36 To date, no studies have examined quantitatively the influence of COC on other preventive care measures in a pediatric population. The goal of this study was to determine whether children who receive high COC are more likely to receive recommended screening for lead, anemia, and tuberculosis. Our results indicated that high COC during infancy was associated with increased performance of these tests in the first 24 months of life. Children with complete COC (the same practitioner seen for every visit) were >2 times more likely to receive lead screening than were children who saw a different practitioner for every visit, irrespective of the measurement technique used. Similarly, when complete COC was compared with no COC for tuberculosis screening, children with complete COC were 1.5 to 2 times more likely to have been screened. Continuity showed a lower, but still significant, effect on anemia screening.

Because preventive care is traditionally delivered during WCC visits, we hypothesized that COC for these visits would be more important than total visit COC in influencing health screening. Our results, however, indicated that WCC COC did not influence up-to-date lead screening as much as did total visit COC and the relationship between WCC COC and anemia screening was not significant. For tuberculosis screening, increased total COC and WCC COC were associated with increased screening. This indicates that all visits, not just WCC visits, are important in establishing relationships with patients and families and meeting their health care needs, including preventive health care. Furthermore, familiarity between patients and clinicians may facilitate performance of health screening even at sick visits, because the patient's personal history, risk factors, and history of screening are better known.

Previous analysis of this cohort found that up-to-date immunization status was associated with the number of health care visits the infant made in the first 6 months, rather than COC.48 This is likely attributable to the attention that immunization status receives as a quality indicator for pediatric health care, which results in a focus on receipt of immunizations at every visit, regardless of the physician seen. In contrast, we found that screening tests were associated positively with COC in this population but were not associated with a greater number of health care visits.

We used 3 measurement techniques for determining COC in 3 (density, dispersion, and sequence) of the 5 dimensions of COC suggested by Jee and Cabana.37 Previous studies focused on only 1 measurement technique and therefore do not provide information on what aspect of COC should be the focus of attempts to improve health care outcomes. Our goal was to determine whether particular components of COC are more strongly associated with receipt of preventive care services. Analysis of total ambulatory visit COC showed that the dispersion measure (B&B) had a greater effect than density (UPC) and sequence (SECON). Dispersion methods differ from density measures in that they add the components of the number of practitioners seen and the number of visits to each practitioner, rather than simply the number of visits to a single practitioner, compared with all other visits. This suggests that, in attempts to maximize COC to improve health outcomes, the focus should be not only on increasing the number of visits to the primary provider but also on decreasing the number of practitioners from whom a patient seeks care. A possible way to accomplish this in larger practices would be to assign each patient to a smaller cluster of 2 or 3 practitioners within the practice. SECON examines the order in which the practitioners are seen. Higher SECON scores were associated with up-to-date screening but were less important than dispersion. These results indicate that less emphasis can be placed on ensuring that the same practitioner is seen for consecutive visits when seeking to improve preventive care; however, this may not be true when outcomes for a series of visits for a specific illness are examined.

In this study, we examined COC only in the first 6 months of life, when health care visits are most frequent. However, COC beyond this early infant time frame is also likely to be associated with optimal use of health services. To obtain more information about how COC changes over time and how this affects the relationship between COC and receipt of screening tests, future studies that monitor patients over a longer period of time are needed. We did not account for emergency department visits or specialist visits when calculating COC. Including these visits in the calculations would have decreased the COC scores for a subset of patients. Because screening tests are not typically performed in these settings, we thought that inclusion of these visits was not indicated. We looked at only 3 of the 5 dimensions of COC and did not include the duration of the practitioner-patient relationship or subjective estimates. Because the time period over which the study was conducted was short and fixed, durations of care were similar for all patients and would not have provided additional information for this group. Subjective estimates were not obtained at the time of the study because we sought to focus on quantifiable methods of determining COC, although parent perception is important and may be a valuable component to consider in future studies.

Our study group consisted of Medicaid-enrolled infants in the Philadelphia area, and results may not be generalizable to other populations. Because this is an urban low-income population, the patients are at higher risk of not receiving proper screening, and targeting this vulnerable group is important. Our data on specific practice characteristics was somewhat limited. For instance, we did not have information regarding whether the practices had electronic records or office systems to alert providers when it was time for screening. Studies have shown the benefits of these methods in improving vaccination rates and delivery of other preventive services,18–25 and they might have been an important predictor in this population as well. We also did not have information on whether the practices had the resources to perform blood tests on site, which could play an important role in determining whether children receive screening.

Our results suggest that COC is an important part of ensuring adequate preventive service delivery to a vulnerable population. The next step is to identify ways to improve COC and to predict which children are at risk of not receiving it. Increasing COC is difficult in the pediatric population because of the frequency of acute visits, for which families may prefer to see the first physician available, rather than waiting to see their regular physician. Targeting improvement of COC for WCC visits, which typically are scheduled in advance, may be the most feasible first step in increasing overall continuity. Although the association between WCC COC and preventive service delivery was less clear than that for total visit continuity, enhancing WCC COC could establish a pattern that would lead to improved overall COC.


   ACKNOWLEDGMENTS
 
Dr Alessandrini was supported by a career development award from the National Institute of Child Health and Human Development (grant K23HD001320) and Ms Flores by a clinical research fellowship from the Doris Duke Charitable Foundation.

We thank Colleen Brensinger and the Biostatistics Analysis Center at the University of Pennsylvania for help with the data analysis for this study. In addition, we thank Dr Michael Cabana for encouraging us to explore the various dimensions of COC.


   FOOTNOTES
 
Accepted Jul 20, 2007.

Address correspondence to Evaline A. Alessandrini, MD, MSCE, Children's Hospital of Philadelphia, 3535 Market St, Room 1542, Philadelphia, PA 19104. E-mail: alessandrini{at}email.chop.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


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 METHODS
 RESULTS
 DISCUSSION
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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics




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