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

Objective. This study examines coverage levels for immunization, misse d opportunities to immunize, and extent of lead and tuberculosis scree ning in inner-city storefront physician offices and then relates child , visit, and physician characteristics to missed opportunities. Method ology. With the use of a nested sampling strategy, 232 charts were sel ected for review in 31 physicians' offices. Charts selected were for c hildren 0 to 35 months of age who had three or more visits in more tha n 3 months. Physicians were selected from those in specific low-income New York inner-city neighborhoods who submitted large volumes of Medi caid billing claims. Variables examined were missed opportunities to i mmunize, immunization coverage levels, lead, and tuberculosis screenin g. 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, mump s, rubella (MMR) compared with a city-wide coverage level of 49%. Chil dren who were not up to date for immunization coverage were more likel y not to be up to date for lead (RR = 1.24, CI 0.96 to 1.60) or tuberc ulosis (RR = 1.54, CI 1.14 to 2.08) screening. Physicians miss opportu nities to immunize in 84% of the eligible visits. Opportunities to imm unize are missed more frequently at sick care or follow-up visits (95% and 98% missed opportunities) than at well care visits (41% missed op portunities). Conclusions. The quality of pediatric primary care given by these inner-city storefront physicians is suboptimal. Sick and fol low-up visits predominate; well care visits are infrequent. If care is to be improved, Medicaid reimbursement polities, which make delivery of well care unprofitable, will need to be changed. In addition, monit oring 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 c are. If reimbursement and monitoring policies that provide incentives for delivering pediatric primary care are to be in place, it will be t he managed care plans that implement this.