Markers for primary care: missed opportunities to immunize and screen for lead and tuberculosis by private physicians serving large numbers of inner-city Medicaid-eligible children

Abstract

Objective: This study examines coverage levels for immunization, missed opportunities to immunize, and extent of lead and tuberculosis screening in inner-city storefront physician offices and then relates child, visit, and physician characteristics to missed opportunities.

Methodology: With the use of a nested sampling strategy, 232 charts were selected for review in 31 physicians' offices. Charts selected were for children 0 to 35 months of age who had three or more visits in more than 3 months. Physicians were selected from those in specific low-income New York inner-city neighborhoods who submitted large volumes of Medicaid billing claims. Variables examined were missed opportunities to immunize, immunization coverage levels, lead, and tuberculosis screening. The outcome measure was missed opportunities to immunize.

Results: Only 26% of the children were up to date for their age for diphtheria, tetanus, pertussis (DTP), oral polio vaccine (OPV), and measles, mumps, rubella (MMR) compared with a city-wide coverage level of 49%. Children who were not up to date for immunization coverage were more likely not to be up to date for lead (RR = 1.24, CI 0.96 to 1.60) or tuberculosis (RR = 1.54, CI 1.14 to 2.08) screening. Physicians miss opportunities to immunize in 84% of the eligible visits. Opportunities to immunize are missed more frequently at sick care or follow-up visits (95% and 91% missed opportunities) than at well care visits (41% missed opportunities).

Conclusions: The quality of pediatric primary care given by these inner-city storefront physicians is suboptimal. Sick and follow-up visits predominate; well care visits are infrequent. If care is to be improved, Medicaid reimbursement policies, which make delivery of well care unprofitable, will need to be changed. In addition, monitoring the quality of care will need to be more aggressive. In the near future children who receive Medicaid in New York will be in managed care. If reimbursement and monitoring policies that provide incentives for delivering pediatric primary care are to be in place, it will be the managed care plans that implement this.