Preventable pediatric hospitalizations and suboptimal use of health services despite universal coverage

Objectives: To report instances of preventable morbidity and suboptimal use of available health services in a universal coverage health care system. Design: Review of all pediatric hospital admissions during a recent one-year interval (October, 1991 - September, 1992). Setting: Hospital for the Indian Health Service, a universal coverage system in which all members are guaranteed appropriate health care free of charge. Results: Among 405 pediatric admissions during the one-year study, the following forms of preventable morbidity were identified: motor vehicle accidents in which seatbelts were not worn comprised 29% (7/24) of trauma admissions; shigellosis caused 35% (12/34) of gastroenteritis admissions; heavy alcohol consumption during pregnancy and its consequences was noted in 11% (9/82) hospital births; child abuse or neglect, 9% of all admissions; and possibly preventable high-risk behaviors resulted in 17 of the 31 adolescent admissions. Suboptimal use of readily-available health services was manifested by 1) poor prenatal care in 22% (18/82) of hospital births, and 2) inadequate prior tuberculosis screening in 2 of 4 tuberculosis admissions. Nevertheless, the success of universal coverage in this population is reflected in the absence of vaccine-preventable illness and of admissions for MVA trauma in infants not restrained in the appropriate car seat. The latter achievement may be due to an aggressive outreach/prevention program, in which car seats are loaned to all new mothers. Conclusion: Preventable morbidity and under-utilization of health services can persist in high-risk populations despite universal coverage. Sociocultural barriers such as poverty, cultural differences, and geographic obstacles appear to be responsible. Until these barriers to access are removed, intensive preventive education, counseling, and outreach may be the most effective approaches to these problems.