MISSED OPPORTUNITIES FOR ANTICIPATORY GUIDANCE IN PEDIATRIC HEALTH SERVICES FOR YOUNG CHILDREN Neal Halfon, Ritesh Mistry, Moira Inkelas, Gregory D. Stevens, Lynn M. Olson. Center for Healthier Children, Families, and Communities, UCLA, Los Angeles, CA; American Academy of Pediatrics, Elk Road Village, IL.

BACKGROUND: A key component of pediatric primary care is anticipatory guidance (AG), which optimally is responsive to the individual needs of children and parents. The notion of missed opportunities (MO) has been used as a measure of sub-optimal care, but the criteria to judge MOs are usually based on professional guidelines (eg. immunization schedule), rather than the parent?s perspective.

OBJECTIVE: Using parent reports of unmet need to define MOs, we describe frequency of MOs for AG and how MOs vary according to child, family and health care (structure and process) factors.

DESIGN/METHODS: Data were analyzed from the 2000 National Survey of Early Childhood Health (NSECH), which used a stratified random-digit-dial sampling design to achieve a nationally representative cross-sectional sample of children age 4 to 35 months. Thirty-minute structured telephone interviews were conducted in English or Spanish with the primary caregiver for the index child, who were asked about the provision of AG across a range of age-specific topics (eg. food and feeding, discipline, injury prevention, reading). MO occurs when a parent reports that a particular AG topic was not discussed, and that discussion would have been helpful.

RESULTS: No MOs for AG are reported for 44.6% of children, while 1 or 2 (out of 12) MOs are reported for 31.3%, and 3 to 6 MOs for 19.2%. MOs are most frequently reported for toilet training (28.7%), guidance and discipline (24.3%), child care (17.2%) and reading (13.8%). Multivariate logistic regression indicates MOs are more likely to be reported for children in the older age-groups (referent 4-9mos;10-18mos: OR=4.70, 95% CI=3.01-7.34; 19-35mos: OR=2.71, 1.81-4.04) and for parents who have inadequate emotional support. Children with longer well child check-ups (in minutes) are less likely to have MOs (OR=0.98, 95% CI=.97-.99), as are children whose parent reports more family-centered care (OR=0.97, 95% CI=0.96-0.98) on a FACCT composite scale.

CONCLUSIONS: The topics that most frequently result in MOs (eg. toilet training, discipline, child care), the higher rate of MOs for children at age 10-18 months, and the relationship of MOs to parental emotional support and length of office visits, together suggest that longer well child visits at 12 and 18 months and greater focus on these topics could reduce MOs for needed AG.