Early Parental Satisfaction with Pediatric Care: Does it Improve Immunization of Young Children? Ashley Schempf BS, Cynthia Minkovitz MD MPP Donna Strobino PhD, Bernard Guyer MD MPH Department of Population and Family Health Sciences Johns Hopkins Bloomberg School of Public Health

Background Parental satisfaction is an important indicator of pediatric care quality Satisfaction has been linked to patient compliance decreased provider/plan disenrollment reduced malpractice litigation Despite frequent assessment, it is rarely examined in relation to receipt of services

Background cont’d Childhood immunizations are among the most valuable preventive services available Considerable delays in vaccination have been documented Only 42% of children complete 4:3:1 series at all recommended ages Bates and Wolinsky (1998), observed an association between parental satisfaction and up- to-date immunization at 24 months

Objectives To prospectively evaluate the impact of early parental satisfaction with care on timely vaccination of young children To determine whether the potential effect of satisfaction on immunization is mediated by enhanced utilization of well-child care To determine whether improved satisfaction is responsible for the positive effects of HS intervention on immunization

Design Data from the National Evaluation of the Healthy Steps for Young Children Program Enhanced developmental services in first three years of life 5565 children 15 sites: 6 randomization, 9 quasi- experimental

Data Sources Newborn Enrollment Questionnaire 2-4 month Interview Medical Records

Sample 4756 children with data from 2-4 month interview and abstracted medical records 4896/5565 (88%) responded to 2-4 month interview 4756/4896 (97%) with abstracted medical records Overall response rate of 85%

Satisfaction with Care Global Measure of Satisfaction Parents asked to rate doctors and nurses in “providing good health care since [their] baby left the hospital after birth” Excellent, Good, Fair, Poor

Immunization Outcomes Age-appropriate DTP1, DTP3, MMR Up-to-Date 4:3:1 at 24 months According to minimum age and spacing guidelines of AAP Red Book Denominators based on ‘time in practice’

Analyses Bivariate χ 2 Tests Satisfaction and Covariates Satisfaction and Immunization Immunization and Covariates Multivariate Logistic Regression Adjusted for sociodemographic characteristics, maternal health care utilization, provider site, HS intervention

Sample Characteristics Representative of diversity in nation 13% Teenage Mothers 16% Mothers Education < 12 th Grade 47% Minority Race/Ethnicity 33% Unmarried Satisfaction with Care 69% Excellent 27% Good 4% Fair/Poor

Sociodemographic Characteristics by Satisfaction with Care All p<.05 %

Health Care Utilization by Satisfaction All p<.05

Immunization by Covariates Positively related Maternal Age Maternal Education Income Home ownership Postpartum visit Early Prenatal Care 2 mo well-child visit HS Intervention Negatively related Unmarried Mother Black race/ethnicity Medicaid/Uninsured Birth Order

Immunization by Satisfaction * *.99.59*.96.65* Odds Ratios % * p<.05

Mean Age-Appropriate Visits by Satisfaction

HS Effect on Immunization Adjusted ORs for HS intervention ranged from 1.68 to 1.83 for the vaccine outcomes Little change in ORs after adjusting for satisfaction Improved satisfaction was not responsible for the effect of HS intervention

Limitations Only 4% of parents were dissatisfied Other measures may yield more variability New ‘time in practice’ denominator Sensitivity analysis using children who had a visit during or after previous well-child interval showed no difference from original findings

Conclusions Satisfaction was predictive of both age- appropriate and up-to-date immunization A single global measure of satisfaction may be efficient and helpful in identifying children who are less likely to receive preventive services

Public Health Implications Increasing parental satisfaction may have an additional benefit of improving timely childhood vaccination Providers should be encouraged to measure and improve parental satisfaction as part of a quality improvement strategy