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The association of health insurance and continuous primary care in the medical home on vaccination coverage for 19- to 35-month-old children.

Article Excerpt
ISSUES AFFECTING PEDIATRIC access to health care have been studied extensively, and one concept that has been a priority for researchers is that of the medical home. In 1992, the American Academy of Pediatrics issued its first policy statement, which provided a definition of the medical home: "that medical care of infants, children and adolescents should be accessible, continuous, comprehensive, family-centered, coordinated and compassionate. It should be delivered or directed by well-trained physicians who are able to manage or facilitate essentially all aspects of medical care. The physician should be known to the child and family and should be able to develop a partnership of mutual responsibility and trust with them." The medical home should provide preventive services, such as well-child care and immunization delivery, and these services should be provided over an extended period of time to enhance continuity of care. (1) However, costs related to obtaining ongoing primary care, as well as vaccinations in the medical home, have posed a barrier for children who are uninsured or underinsured. (2)

In 1994, the Vaccines for Children (VFC) program was instituted to assist children in remaining in their medical home for vaccinations. (3) VFC reduced the cost of obtaining childhood vaccinations by providing publicly purchased vaccines at no charge to enrolled health care providers. Before VFC implementation, private providers would often refer parents who could not afford vaccines to health departments, thus fragmenting medical care. (4) The effect of VFC has been to minimize that practice, the outcome being a greater percentage of children obtaining vaccinations in their medical home (3,5-7) and a resultant rise in vaccination rates over the years since its implementation.

Several studies have examined the association between having regular preventive care visits and vaccination coverage for young children. (8-10) However, only a few have created a definition of the medical home to examine how this factor influences vaccination coverage. (8,11,12) The association between type of health insurance and continuity of insurance coverage with vaccination coverage have also been evaluated. (13-17) However, most of the studies examining health insurance coverage have looked at how the presence or absence of insurance affected vaccination coverage but were not able to take into account the effect of insurance lapses on vaccination rates.

We used a nationally representative sample to examine how up-to-date (UTD) vaccination coverage for 19- to 35-month-old children was associated with continuous primary care in a medical home, type of health insurance, and lapses in health insurance coverage. As additional childhood vaccines are added to the schedule, understanding the impact of these factors on vaccine delivery becomes more important.

METHODS

The National Survey of Children's Health (NSCH) was a module of the State and Local Area Integrated Telephone Survey, which is a broad-based, ongoing surveillance system that uses the sampling frame of the National Immunization Survey (NIS), conducted jointly by the Centers for Disease Control and Prevention's (CDC's) National Center for Health Statistics and the National Immunization Program. The survey design is described briefly in the article by Kogan and Newacheck (18); more in-depth information can be found elsewhere. (19) The NIS is a random-digit dialed telephone survey conducted annually by the CDC to obtain national, state, and selected urban-area estimates of vaccination coverage for US children aged 19 to 35 months at the time of the interview. (20) It includes household- and child-specific information from the most knowledgeable respondent concerning the child's vaccination history followed by a mail survey to vaccination providers to verify vaccination information. Human subjects review was not required for this study.

NSCH-NIS Linkage

The NSCH questionnaire was designed to follow a completed NIS interview in households with an NIS-eligible child or the NIS screener in households without an NIS-eligible child. The NSCH responses were weighted to estimate the US population of children, age-adjusted for nonresponse and unequal probability of selection. Of the 102 353 NSCH children in the study, 6976 were 19 to 35 months of age. Of these, 420 NSCH records were unable to be linked to NIS records, leaving 6556 subjects who had completed interviews from both NSCH and NIS surveys. Ninety-seven percent of these records were linked across surveys via a unique household identifier; the remaining 3% were linked by a combination of household identifier and demographic characteristics or assigned randomly within the household when it was impossible to determine which twin or triplet was the child who had been selected randomly...