OBJECTIVE This study aimed to examine factors associated with adherence to recommended treatment among pediatric patients with positional skull
deformity by reviewing a single-institution experience (2007-2014) with the treatment of
positional plagiocephaly. METHODS A retrospective chart review was conducted. Risk factors, treatment for positional head shape
deformity, and parent-reported adherence were recorded. Univariate and multivariate analyses were used to assess the impact of patient clinical and demographic characteristics on adherence. RESULTS A total of 991 patients under age 12 months were evaluated for positional skull
deformity at the Texas Children's Hospital Cranial
Deformity Clinic between 2007 and 2014. According to an age- and risk factor-based treatment algorithm, patients were recommended for repositioning,
physical therapy, or cranial
orthosis therapy or crossover from repositioning/
physical therapy into cranial
orthosis therapy. The patients' average chronological age at presentation was 6.2 months; 69.3% were male. The majority were white (40.7%) or Hispanic (32.6%); 38.7% had commercial insurance and 37.9% had Medicaid. The most common initial recommended treatment was repositioning or
physical therapy; 85.7% of patients were adherent to the initial recommended treatment. Univariate analysis showed differences in adherence rates among subgroups. Children's families with Medicaid were less likely to be adherent to treatment recommendations (adherence rate, 80.2%). Families with commercial insurance were more likely to be adherent to the recommended treatment (89.6%). Multivariate logistic regression confirmed that factors associated with parent-reported adherence to recommended treatment included primary insurance payer, diagnosis (
plagiocephaly vs
brachycephaly), and the nature of the recommended treatment. Families were less likely to be adherent if they had Medicaid, a child with a diagnosis of
brachycephaly, or were initially recommended for cranial
orthosis therapy than families with commercial insurance, a child with a diagnosis of
plagiocephaly, or an initial recommendation for repositioning or
physical therapy. Factors associated with treatment completion included corrected age, insurance, diagnosis, recommended treatment, and distance to provider from patient's residence. Patients with commercial insurance (OR 1.49, 95% CI 1.10-2.02, p = 0.009), those diagnosed with both
brachycephaly and
plagiocephaly (OR 2.26, 95% CI 1.31-3.90, p = 0.003), those recommended for treatment with cranial
orthosis (OR 4.55, 95% CI = 3.24-6.38, p < 0.001), and those living in proximity to the provider (OR 1.40, 95% CI 1.00-1.96, p = 0.047) were more likely to complete treatment. CONCLUSIONS Insurance type, degree of head shape
deformity, and types of recommended treatment appear to affect rates of adherence to recommended treatments for positional skull deformation.