PolicyLab

Brian Lefchak is a graduate of Drexel University in Philadelphia and the MD/MPH program at Drexel University College of Medicine. He completed pediatric residency at NewYork-Presbyterian Weill Cornell Medical Center and is currently a fellow in pediatric emergency medicine at Children's Minnesota.

Approximately 28 million children in the United States live in families with low incomes, many of whom experience other challenges such as food insecurity, housing instability and neighborhood violence. Here in Philadelphia, as many as 2 in 5 children live in poverty.

As health care providers, we realize behind these statistics are the individual stories of children entrusted to us for their care. Whether it be the valuable role of a partnership during office visits or amidst the trying moments of an unexpected emergency, we strive to meet families where they are, helping children realize their full potential.

Unfortunately, despite the crucial role of regular check-ups for vaccinations, screening and guidance, many children face delays in care or are lost to care entirely. Missed appointments are a widespread issue for health care organizations with negative consequences on patient health outcomes, medical costs, office productivity, patient-physician partnerships, and preventative services.

While it is known that families with low incomes often experience social risks that can affect appointment attendance, predicting appointment attendance for comparable families with young infants has not been explored as much. So, our team conducted a study to characterize social risks present at first newborn visits that were predictive of missing future appointments during the subsequent 6 months of life. Our hope was that understanding trends among newborn-caregiver pairs could assist clinical practices in tailoring upstream resources for patients at highest risk for missing appointments.

Understanding Why Families May Miss Appointments

Dr. Katie McPeak, who now supports health equity work in Children’s Hospital of Philadelphia’s (CHOP) vast primary care network, was previously the primary care medical director at St. Christopher’s Hospital for Children. While there, she and colleagues were very interested in supporting families through universal social needs screening and developed a newborn-specific family screener. This screener was utilized at families’ first newborn visits at St. Christopher’s as part of routine clinical care. Dr. Brian Lefchak, now a pediatric emergency medicine fellow at Children’s Minnesota, collaborated as a medical student with Dr. McPeak and colleagues to design a study matching 720 screener responses between December 2016 and June 2017 with electronic health record-derived sociodemographic and appointment attendance data.

These families demonstrated high rates of social needs, particularly maternal mental health diagnoses, lack of child care support and food insecurity. Many were also missing appointments—approximately 74% of caregivers overall—with a significant number missing or canceling one-quarter or more of their appointments.

In the end, we uncovered two major patterns that we’ll delve into below: both younger, single caregivers who had other children, and caregivers with the combination of mental health diagnoses and multiple stressors were at higher risk for missing appointments.

Young, Single Mothers

Lack of child care support was not only a prevalent concern in our study, it may have increased the risk of missing appointments specifically for younger caregivers. Despite the historic decline in teen pregnancy rates, many still occur. Young teenage caregivers stand to benefit from approaches that validate their experiences as outlined by the American College of Obstetricians and Gynecology recommendations. Additionally, our study suggests having another caregiver at home for these younger caregivers may buffer specifically against future missed appointments to some small effect.

These findings support programs such as postnatal home visiting and are in line with another study showing appointment adherence can be predicted by maternal marital status. As we strive to support young families, we have learned that finding and paying for high-quality child care is one of the most common unmet social needs among families with lower incomes. Health care systems should consider screening for this unmet need and partnering with child care systems to increase enrollment and access to these vital services.

Mental Health

Caregivers with mental health diagnoses did not report additional risk factors on average in our study, but those who did were at higher risk of missing appointments. Maternal mental health has been known to impact many pediatric outcomes and could exhaust caregivers’ abilities to attend appointments while contending with multiple other stressors.

Pediatric health care providers should consider screening for perinatal depression and other related mood disorders. Recognizing families with ongoing mental health stress and supporting them could potentially reduce missed appointments, though this would need further study.

Supports That Meet Families Where They Are

Much of our work informed later perspectives on social care interventions that we are now working on at CHOP, as highlighted by PolicyLab’s 2021 brief, “Screening for Social Needs in Pediatrics: How Can We Ensure it is Family-centered and Effective?” Future study of this issue could expand on effects of social risks including mental health, variation in attendance across appointment types and interventions to address reported caregiver needs at additional points in their lives.

Although we identified many social risk factors in this newborn population, several surprisingly did not predict missed appointments. These included factors that had been associated with missing pediatric appointments elsewhere, such as insurance type, transportation difficulties and various socioeconomic metrics.

This particular finding may in fact reflect a positive note; namely, the degree to which the newborn clinic wraparound services do address identified unmet social needs may encourage attendance at subsequent appointments. In other words, ‘‘co-located nonmedical services’’ such as connecting families to food insecurity resources, parenting support and eligibility for other assets could promote appointment attendance—a finding that has been suggested by other studies.

As we work to understand family perspectives on social care integration in pediatrics, we know that several things are true: much of a child’s health outcomes are influenced by the external, wider-context social determinants of health, and the conditions in which they are born, raised and learn. While health care systems cannot control those facets of a child’s life, we can work with families to understand potential barriers to flourishing and explore solutions in a way that is family-centered, trauma-informed and compassionate.