for increased access to health care for teens.
There are however serious concerns about
confidentiality that must be address prior to
implementation.
Funding Source(s): Other, The Blue Shield
Foundation of California
Posters
™Teen Use of a Patient Portal: A Qualitative
Study of Parent, Teen & Provider Attitudes
David Bergman, M.D., Nancy Brown, Ph.D.,
Sandra Wilson, Ph.D.
™Iron Deficiency in Early Childhood: Risk
Presented By: David Bergman, M.D., Associate
Professor, Pediatrics, Stanford University School
of Medicine, Suite 325; 750 Welch Road, Palo
Alto, CA 93403 Phone: (650) 450-0071,
Fax: (650) 325-9070,
Email: david.bergman@stanford.edu
Factors & Racial/Ethnic Disparities
Jane M. Brotanek, M.D., M.P.H., Jacqueline
Gosz, M.S., Michael Weitzman, M.D., Glenn
Flores, M.D.
Presented By: Jane M. Brotanek, M.D., M.P.H.,
Assistant Professor, Pediatrics, Medical College
of Wisconsin, 8701 Watertown Plank Road, MS
756, Milwaukee, WI 53226 Phone: (414) 456-5778,
Fax: (414) 456-6385, Email: jbrotane@mcw.edu
Research Objective: To assess the attitudes of
teens, parents and providers toward the use of a
patient portal for health care services.
Study Design: Teens(11th and 12th grades) and
parents were randomly selected from clinician
practices for 2 teen and 2 parent focus groups
and 1 teen and 1 parent electronic bulletin board.
A volunteer sample was used for the provider
group. Videotapes from the focus groups and
transcripts from the bulletin boards were
independently analyzed by 2 reviewers for
significant themes which were then validated by
2 members of the research team.
Population Studied: 11th and 12th grade teens
drawn from a multi-specialty medical clinic
Principle Findings: Eleven teens and 13 parents
participated in the focus groups and 17 teens
and 19 parents participated in the electronic
bulletin boards. Significant themes included: 1)
parents and teens had mixed feeling about teens
taking control of their own health care. ) Both
parents and teens were enthusiastic about the
use of a patient portal to increase teen access to
care, 3) both parents and teens liked being able
to seek health information and make
appointments. but both groups expressed
concerns about secure messaging with teens
worried about confidentiality and parents
concerned about being out of the loop , 4) both
parents and teens felt that teen use of a patient
portal provided an opportunity to discuss and
negotiate issues of confidentiality, parent
notification and billing prior to use and 5)
providers were concerned about medical liability,
extra time burden and inappropriate use by teens
Conclusions: Our results showed that there was
positive support for teen use of a patient portal
and that the use of a portal provided an
important opportunity for teens and parents to
negotiate issues of confidentiality and parent
notification prior to implementation
Implications for Policy, Practice or Delivery:
Patient portal may provide an important avenue
Research Objective: Iron deficiency (ID) affects
2.4 million US children, and childhood irondeficiency anemia is associated with behavioral
and cognitive delays. Given the detrimental
longterm effects and high prevalence of ID, its
prevention in early childhood is an important
public health issue. The objective of this study
was to identify risk factors for ID among US
children 1-3 years old.
Study Design: Analyses of NHANES IV (19992002) were performed for a nationally
representative sample of US children 1-3 years
old. Iron status measures were transferrin
saturation, free erythrocyte protoporphyrin, and
serum ferritin. Independent variables included
age, gender, race/ethnicity, poverty status,
weight-for-height status, blood lead level,
birthweight, interview language, daycare
attendance, and food security. Bivariate and
multivariate analyses were performed to identify
factors associated with ID.
Population Studied: Nationally representative
sample of US children 1-3 years old
Principle Findings: Among 1,641 toddlers, 400
(42%) were Latino, 271 (28%) white, and 239
(25%) African-American. The ID prevalence was
12% among Latinos vs. 6% in whites and 6% in
African-Americans (p<.04). ID prevalence was
20% among those with overweight, 8% for those
at-risk for overweight, and 7% for normal-weight
toddlers (p=.02). 14% of toddlers with parents
interviewed in Spanish had ID vs. 7% of toddlers
with parents interviewed in English (p=.007). 5%
of toddlers in daycare and 10% of toddlers
without daycare had ID (p=.02). Latino toddlers
were significantly more likely than white/AfricanAmerican toddlers to be overweight (16% vs. 5%
vs. 4%) and without daycare (70% vs. 50% vs.
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43%). In multivariate analyses adjusting for
variables significant in bivariate analyses
(race/ethnicity, interview language, weight-forheight status, and preschool/daycare
attendance), overweight toddlers (OR, 3.5; 95%
CI, 1.1-10.6) and those without daycare (OR, 1.8;
95% CI, 1.01- 3.4) had higher odds of ID.
Conclusions: Toddlers who are overweight and
not in daycare are at high risk of ID. Latino
toddlers are more likely than white/AfricanAmerican toddlers to be overweight and not in
daycare. The higher prevalence of these risk
factors among Latino toddlers may account for
their increased risk of ID.
Implications for Policy, Practice or Delivery:
Screening practices and nutritional counseling
should be targeted at these high-risk groups.
Funding Source(s): Medical College of
Wisconsin
US toddlers. ID prevalence remained unchanged
in Latino (15%) and white (6%) toddlers but
decreased from 15% to 6% among AfricanAmerican toddlers (p=.006). For all 3 survey
waves, racial/ethnic disparities in ID persisted
between Latino and white toddlers with a
disparity ratio of at least 2 (p<.03). The ID
prevalence remained high (20-25%) in
overweight toddlers, significantly higher than in
at-risk for overweight (11%) and normal-weight
(8%) toddlers (p<.03). ID prevalence decreased
from 22% to 9% in toddlers in poor households
(p=.02), but remained unchanged in toddlers in
households at/above the federal poverty
threshold (7%). In multivariate analyses, Latino
toddlers (OR, 2.2; 95% CI, 1.4-3.4) and
overweight toddlers (OR, 3.0; 95% CI, 1.8-4.8)
had higher odds of ID.
Conclusions: There has been no change in the
prevalence of ID among US toddlers in the last
26 years. Racial/ethnic disparities in ID
prevalence persist between Latino and white
toddlers. The ID prevalence has remained
consistently high in overweight toddlers, higher
than in at-risk for overweight and normal-weight
toddlers.
Implications for Policy, Practice or Delivery:
Efforts to reduce the prevalence of ID in infancy
and early childhood are urgently needed and
should target Latino and overweight toddlers.
Funding Source(s): Medical College of
Wisconsin
™Time to Revive Popeye: Secular Trends in
the Prevalence of Iron Deficiency among U.S.
Toddlers: 1976-2002
Jane M. Brotanek, M.D., M.P.H., Jacqueline
Gosz, M.S., Michael Weitzman, M.D., Glenn
Flores, M.D.
Presented By: Jane M. Brotanek, M.D., M.P.H.,
Assistant Professor, Pediatrics, Medical College
of Wisconsin, 8701 Watertown Plank Road, MS
756, Milwaukee, WI 53226, Phone: (414) 4565778, Fax: (414) 456-6385,
Email: jbrotane@mcw.edu
™Oral Health Care Training among
Graduating Pediatric Residents
Research Objective: Iron deficiency (ID) and
iron-deficiency anemia affect 2.4 million and
490,000 US children, respectively. Striking
racial/ethnic disparities in ID prevalence have
been documented for toddlers, but no studies
have examined national secular trends in ID in
toddlers. The objective of this study was to
examine secular trends in ID among US children
1-3 years old.
Study Design: Time-trend analyses of NHANES
II-IV (1976-2002) were performed for a nationally
representative sample of children 1-3 years old.
Iron status measures included transferrin
saturation, free erythrocyte protoporphyrin, and
serum ferritin. Chi-square tests were performed
to evaluate changes in ID prevalence by
race/ethnicity, weight-for-height status, and
poverty. Multivariate analyses were performed to
adjust for NHANES survey wave, race/ethnicity,
age, gender, birthweight, weight-for-height
status, poverty, and blood lead level.
Principle Findings: Between 1976-2002, there
was no change in the prevalence of ID (9%) in
Gretchen Caspary, Ph.D., Suzanne Boulter, M.D.,
Martha Ann Keels, D.D.S., Ph.D., David Krol,
M.D., M.P.H., Giusy Romano-Clarke, M.D.
Presented By: Gretchen Caspary, Ph.D., Senior
Research Associate, Division of Health Services
Research, American Academy of Pediatrics, 141
Northwest Point Boulevard, Elk Grove Village, IL
60007, Phone: (847) 434-7946, Fax: (847) 4344996, Email: gcaspary@aap.org
Research Objective: There is an oral health care
deficit among American children. Some propose
that pediatricians be trained to identify the signs
of acute dental problems and refer patients to
dentists. This study examines residents’
attitudes toward performing basic oral health
assessments and the amount of training
pediatricians receive during residency.
Study Design: The American Academy of
Pediatrics, AAP, Graduating Pediatric Residents
Survey is fielded annually to a random sample of
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graduating pediatric residents. A section of the
2006 survey focused on oral health. After up to
four mailings to 1,000 residents, 611, 61percent,
responded. A 7-item scale, a=.63, of resident
attitudes about pediatricians’ roles in oral health
assessment tasks was the main dependent
variable examined in a multiple regression
analysis.
Population Studied: The study population
included 611 graduating categorical pediatric
residents.
Principle Findings: Most graduating pediatric
residents believe that pediatricians should
conduct basic oral health assessments,
including: identifying teeth with cavities,
89percent; identifying enamel demineralization,
67percent; and identifying plaque, 64percent.
Most also think pediatricians should inform
patients and their parents on the basics of
maintaining oral health, including: the effects of
sleeping with a bottle, 99percent, the effects of
juice and carbonated beverages, 99percent, and
how to brush correctly, 86percent. Multiple
regression analyses indicated that AfricanAmerican residents, beta equals .991, p equals
.020, and those applying for jobs in the inner
city, beta equals .541, p equals .016, were
especially interested in conducting oral health
assessments. However, 32percent of residents
reported receiving no oral health care training
during residency. Of those who did, 75percent
had less than 3 hours of training, and only
14percent had clinical observation time with a
dentist. Overall, 71percent felt they had received
too little oral health care training. With so little
training, many residents described their
assessment skills as being only fair or poor on
several measures, including: 59percent for
identifying enamel demineralization, 42percent
for identifying plaque, 25percent for identifying
teeth with cavities, and 22percent for informing
patients how to brush correctly. More than half,
52percent, are interested in taking an oral health
CME, rising to 64percent among those entering
general pediatric practice, p less than .001.
Conclusions: This study suggests that
opportunities in oral health education during
pediatric residency are not in line with the
desires of most residents. Recent graduates of
pediatric residency programs report high levels
of interest in conducting oral health assessments
and in informing patients and parents on the
basics of oral health care. However, most report
receiving little or no training.
Implications for Policy, Practice or Delivery:
The problem of poor oral health among
America’s children is widespread, and is due in
part to a shortage of trained dental professionals
available to do basic pediatric oral health
assessments. One proposed method for
addressing this challenge is for pediatricians to
inform patients on how to maintain oral health,
develop the skills to recognize oral health
problems, and refer patients to dentists when
necessary. Successful implementation would
require attention to appropriate reimbursement.
™Performance Incentive Programs &
Pediatrics
Alyna Chien, M.D., M.S., Matthew Colman, B.A.,
Lanie Friedman Ross, M.D., Ph.D.
Presented By: Alyna Chien, M.D., M.S.,
Instructor, Department of Pediatrics, The
University of Chicago, 5841 S. Maryland Avenue MC 6032, Chicago, IL 60637, Phone: (773) 7023874, Email: alyna_chien@yahoo.com
Research Objective: To estimate the number,
scope, and impact of pediatric-relevant
performance incentive programs.
Study Design: To identify the number of
pediatric-relevant performance incentive
programs, we analyzed the 107 programs
described in the Leapfrog Compendium, the
largest publicly available listing of performance
incentive programs, and Centers for Medicare
and Medicaid Services listings. We conducted
semi-structured telephone interviews with the
leaders of these programs to estimate the
number of children potentially affected, the
metrics being targeted, and their potential
effectiveness.
Population Studied: We studied private and
Medicaid-related performance incentive
programs in the United States. These programs
must have incorporated incentive structures
which seek to improve care for the general
pediatric population. In addition, effects of the
incentive programs were considered with regard
to children with special health care needs,
uninsured/underinsured children, children with
emerging chronic conditions, and children with
costly-to-treat inpatient conditions.
Principle Findings: We identified a total of 33
pediatric-relevant performance incentive
programs. These programs target approximately
1.5 million privately-insured and 1 million
Medicaid-insured children. A substantial number
of programs target elements of well-child care
(42%) and asthma care (42%); a minority of
programs target immunization delivery (33%)
and of adolescent health care (24%). Except for
asthma, very few programs incentivize the care
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of children with chronic conditions (e.g. Children
with Special Healthcare Needs, mental health, or
developmental delay). Performance incentive
program leaders are hopeful that their programs
are effective, but few, if any, have rigorous
empiric data to support their perceptions.
Conclusions: A significant proportion of
performance incentive programs are aimed at
children and potentially effect approximately 2.5
million children nationwide. The majority target
very routine aspects of care and do not
incentivize the care of children with more
chronic or complex conditions. Rigorous
evaluative data is needed to determine whether
these programs lead to improved care for all
children.
Implications for Policy, Practice or Delivery:
American healthcare lacks quality. In an effort to
promote greater quality, payors have begun
linking financial and reputation-based rewards
and sanctions to the clinical performance of
physicians, hospitals, and health plans. Over 90
performance incentive programs have been
described and their numbers are growing. It is
unclear how many of these programs are
directed at children, what metrics they are
targeting, and their perceived effectiveness. A
better understanding of their number, scope and
potential impact of these programs will improve
our ability to evaluate whether and how these
programs should be used to improve healthcare
for all children.
Funding Source(s): University of Chicago
and ideal time allocation for each of 7 primary
care activities, (2) their views of the importance
of 8 changes to care, and (3) the obstacles they
face in changing their system of care.
Population Studied: A national random sample
of 1000 primary care pediatricians from the
American Medical Association Masterfile.
Principle Findings: Sixty percent (n=502) of
eligible subjects participated. Pediatricians
estimated they currently spend 30% of their time
on well-child care, 32% providing care for minor
acute illnesses, and 13% providing care for
children with chronic diseases and other special
health care needs. Although the majority of
pediatricians reported that they would ideally
allocate their time as they do now for most tasks,
45% reported that they would ideally spend more
time with children with special health care needs.
All 8 specific changes to care in the survey were
rated by a majority of pediatricians (59-94%) as
being important to improving our system of
primary care. Respondents were most
interested in the provision of a universal
immunization tracking system, increasing
utilization of community resources for
counseling and guidance, and developing
evidence-based guidelines for well-child care.
Inadequate reimbursement, staffing problems,
and parent preferences were rated as the most
important barriers to change.
Conclusions: Nearly half of pediatricians would
allocate more time to children with special health
care needs in their primary care practices. A
large majority support major changes to
pediatric primary care, but identify significant
barriers to change. These findings may be
helpful in efforts to focus improvements in
pediatric primary care in the United States.
Implications for Policy, Practice or Delivery:
Pediatric primary care may undergo drastic
changes over the next few decades as the field of
child health continues its increasing focus on
chronic conditions, developmental and
behavioral issues, and social and environmental
determinants of health. Many pediatricians do
want to change the way that primary care is
provided, and pediatric practices that implement
changes will likely find interest from practicing
pediatricians. There is also a significant
proportion of general pediatricians who want to
focus more time on children with special health
care needs. Designing new reimbursement
systems that would allow this group of
pediatricians to restructure their practices in this
way may help address the complex needs of this
population. Such new reimbursement systems
may also help pediatricians overcome the
™General Pediatricians’ Views on Improving
Pediatric Primary Care
Tumaini Coker, M.D., M.B.A., G. Caleb
Alexander, M.D., M.S., Lawrence P. Casalino,
M.D., Ph.D., John Lantos, M.D.
Presented By: Tumaini Coker, M.D., M.B.A.,
Clinical Instructor, Pediatrics, University of
California, Los Angeles, 1072 Gayley Avenue, Los
Angeles, CA 90024, Phone: (310) 66-6721,
Email: tumaini.coker@gmail.com
Research Objective: To describe pediatricians’
attitudes toward improving primary care,
focusing on how pediatricians report they would
ideally spend their time in primary care, how they
rate the importance of specific changes to care,
and what barriers they face in implementing
changes.
Study Design: A mail survey was sent to a
national random sample of pediatricians in
August 2005. We analyzed data from three
domains of the survey: (1) pediatricians’ current
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obstacles around financing and staffing that
make it difficult to implement many of the
changes that they reported as being important to
the improvement of our primary care system.
Funding Source(s): Robert Wood Johnson
Clinical Scholars Program
Population Studied: Cases of congenital heart
surgery < 18y were identified from the Health
Care Utilization Project KID 2003 database (36
states) using ICD-9-CM codes.
Principle Findings: For 11,272 cases of
congenital heart surgery performed in 167
institutions, the overall mortality rate was 4.2%
and the mean charges were $77,795. Of the 167
institutions, 89 performed = 50 procedures. The
mean charge per institution ranged from
$30,069 to $186,031. Mortality rates per
institution ranged from 0.0% to 12.0%. The
SMR ranged from 0 to 5.30 and SCR from 0.39
to 2.72. The Efficiency Product ranged from 0 to
14.40. Thirteen institutions had an Efficiency
Product <0.50. Thirty two had an Efficiency
Product 0.50 to .99. Twenty two had an
Efficiency Product 1.00 to 1.49. Twenty two had
an Efficiency Product = 1.50. The median SMR
for children’s hospitals versus non children’s
hospital was 0.91 vs 1.16 (p=0.028), SCR 1.07 vs
0.90 (p=0.005), and Efficiency Product 0.93 vs
1.14 (p=0.61).
Conclusions: Institutions varied considerably in
the risk-adjusted measure of quality versus
resource use for congenital heart surgery
procedures. Although risk-adjusted charges are
significantly higher in children’s hospitals vs non
children’s hospitals, mortality is significantly
lower. The Efficiency Product did not differ
significantly between children’s vs non-children’s
institutions.
Implications for Policy, Practice or Delivery:
Examination of quality, resource use and
efficiency for children undergoing congenital
heart surgery are important indicators of
cardiovascular program performance. Findings
of higher resource use in children’s hospitals
may be reflective of higher quality care.
Identification of optimum cost structures to
deliver quality care may be used by health care
providers, institutions, payors, and policy makers
when formulating interventions and policies to
allocate resources for congenital heart surgery.
™Measuring Institutional Relative Quality,
Resource Use & Efficiency for Congenital
Heart Surgery
Jean Connor, D.N.Sc., R.N., C.P.N.P., Kimberlee
Gauvreau, Sc.D., Kathy J. Jenkins, M.D., M.P.H.
Presented By: Jean Connor, D.N.Sc., R.N.,
C.P.N.P., Nurse Scientist Cardiovascular
Program, Cardiology, Childrens Hospital Boston,
300 Longwood Avenue, Farley 135, Boston, MA
02115, Phone: (617) 355-8890, Fax: (617) 7395022, Email: jean.connor@cardio.chboston.org
Research Objective: To examine institutional
variation in quality, resource use, and efficiency
for pediatric congenital heart surgery.
Study Design: Cases of congenital heart surgery
< 18y were identified from the Health Care
Utilization Project KID 2003 database (36 states)
using ICD-9-CM codes. Cases meeting criteria
for the Risk Adjustment for Congenital Heart
Surgery method (RACHS-1) were placed into 1 of
6 risk categories. Mortality was used as a
surrogate for quality and total hospital charges
for resource use. Institutional relative quality
and resource use were examined using the
product of the standardized mortality ratio
(SMR) and the standardized charge ratio (SCR).
This product was termed the Efficiency Product.
For each institution performing = 50 cases of
congenital heart surgery, SMR was defined as
observed mortality/expected mortality; expected
mortality adjusted for baseline case mix
differences using RACHS-1 risk category, age,
prematurity, major non-cardiac structural
anomaly, and multiple surgical procedures.
Similarly, the SCR was defined as observed mean
charges/expected mean charges; expected mean
charges were obtained from a linear regression
model adjusting for the above variables plus
chromosomal abnormality and weekend
admission predicting log transformed total
hospital charges. A state with observed mortality
and charges both equal to expected would have
an Efficiency Product equal to 1. Institutions
were ranked from lowest to highest using the
Efficiency Product. Distributions of SMR, SCR,
and the Efficiency Product were compared for
free-standing children’s hospitals versus other
institutions using the Wilcoxon rank sum test.
™Free Drug Samples: Characteristics of
Pediatric Recipients
Sarah Cutrona, M.D., Steffie Woolhandler, M.D.,
M.P.H., David H. Bor, M.D., David Himmelstein,
M.D., William Shrank, M.D., M.S.H.S., Neal S.
LeLeiko, M.D., Ph.D.
Presented By: Sarah Cutrona, M.D.,
Internist/Clinical and Research Fellow in
Medicine, Medicine, Cambridge Health
Alliance/Harvard Medical School, 1493
Cambridge Street, Cambridge, MA 02067 Phone:
-5-
(617) 665-1032, Fax: (617) 665-1671, Email:
scutrona@hsph.harvard.edu
Research Objective: Free drug samples are
frequently given to children, but little data is
available on distribution patterns in the pediatric
population. We sought to describe
characteristics of free sample recipients and to
determine whether samples are given primarily
to poor and uninsured children.
Study Design: We analyzed data from the 2003
Medical Expenditure Panel Survey (MEPS), a
nationally representative survey which includes
questions on receipt of free drug samples. We
performed bivariate and multivariate analyses to
determine the odds of having received one or
more free drug samples in 2003 and identified
the most frequently reported sample
medications.
Population Studied: We studied 11,699 U.S.
residents under the age of 21.
Principle Findings: Six percent of children under
21 received at least one free drug sample in
2003. In bivariate analysis, the poorest children
(those with family incomes <200% federal
poverty level) were less likely to receive free
samples than those with incomes > 400% of
poverty level (4.9% vs. 7.8%; p<0.0001). There
was no statistically significant difference between
receipt of samples among children with and
without continuous health insurance in 2003. In
multivariate analyses of sample receipt
controlling for demographic factors, neither
insurance status nor income predicted sample
receipt. Children who were uninsured all or part
of the year were no more likely to receive free
samples (Odds ratio [OR] 1.00; 95% Confidence
Interval [CI] 0.76 - 1.32) than those continuously
insured; those with income < 200% of poverty
were no more likely to receive free samples (OR
0.84, CI 0.63-1.13) than those with income >
400%. Variables that captured routine access to
health care were associated with greater receipt
of free sample in multivariate analyses.
Conclusions: Poor and uninsured children are
not the main recipients of free drug samples.
Implications for Policy, Practice or Delivery: In
the face of mounting data on safety and
prescribing issues, the strongest argument in
favor of free drug sample use has been that
these samples provide pediatricians with the
ability to give free medications to their neediest
patients. Our study demonstrates that this is
not the primary way free drug samples are being
used. Free drug samples go primarily to those
with better access to health care; their
distribution does not substantially decrease
inequalities in medication access.
Funding Source(s): National Research Service
Award
™Communities With & Without Children’s
Hospitals: Where Do the Sickest Children
Receive Care?
Jami DelliFraine, Ph.D.
Presented By: Jami DelliFraine, Ph.D., Assistant
Professor, Department of Health Policy and
Administration, Penn State University, 114
Henderson, University Park, PA 16802, Phone:
(814) 863-2861, Email: jld40@psu.edu
Research Objective: The purpose of this paper
is to examine whether children’s hospitals treat
sicker children within their communities than
general hospitals in the same communities, and
then examine which general acute care hospitals
in communities without children’s hospitals fill
the role of caring for very sick children.
Study Design: Patient level data in the KID was
aggregated to the hospital level to create average
pediatric profile and resource intensity measures
for each hospital. A logit analysis was conducted
using the community sample with freestanding
children’s hospitals. The logit analysis was used
to predict significant differences in pediatric
patient profile and resource intensity measures
between children’s hospitals and general acute
care hospitals in the same communities and
classify hospitals based on their respective
pediatric profile. Hospitals in the community
sample with children’s hospitals were classified
as either a children’s hospital or a general acute
care hospital based on their pediatric profile.
Prediction tables were also examined to
determine the number of freestanding children’s
hospitals that were correctly classified as
children’s hospitals and the number of general
acute care hospitals correctly classified as
general acute care hospitals. The logit regression
equation obtained was used to calculate the
predicted probability that a general acute care
hospital, in the community sample of only
general acute care hospitals, would be classified
as a children’s hospital or a general acute care
hospital.
Population Studied: This study uses the 2000
Health Care Utilization Project (HCUP) KID
database. The HCUP KID database contains
pediatric patient and organizational level data
collected from 27 states. The KID is a sample of
over 2,500 short-term acute care and specialty
hospitals in the participating states and contains
over 2 million pediatric patient discharges. All
-6-
pediatric patients in the KID are under 21 years
of age. The HCUP KID was merged with the
2000 American Hospital Association (AHA)
database. The AHA database contains
organizational level data on over 4,500 hospitals
in the United States.
Principle Findings: The results of the logit
analysis suggest there are significant differences
in pediatric resource intensity between children’s
hospitals and general acute care hospitals in the
same community. The p-value of the model was
0.000 and the pseudo R-squared was 0.4329,
suggesting the variables explained a large
amount of variation in resource intensity
between the two types of hospitals. Overall, case
mix index, percentage of complex patient
discharges, average age, and average number of
diagnoses were significant predictors of a
hospital being classified as a children’s hospital
or a general acute care hospital. Pediatric case
mix index and average number of diagnoses
were positively and significantly related to
children’s hospital status, indicating that
children’s hospitals have significantly higher case
mix indexes and treat more children with
multiple diagnoses than general acute care
hospitals.
Conclusions: Given the lack of pediatric patient
differences between communities with and
without freestanding children’s hospitals, very
sick children in communities without children’s
hospitals are likely receiving care from general
acute care hospitals that serve as de facto
children’s hospitals by providing similar services
as children’s hospitals. After calculating the
predicted probability of being classified as a
children’s hospital based on pediatric resource
intensity measures, some general acute care
hospitals in communities without children’s
hospitals were either likely or somewhat likely to
be classified as children’s hospitals. Nearly all
communities in the sample had at least one
general acute care hospital that fell into one of
these two categories. These results imply that
resource intense children in these communities
without children’s hospitals are likely to have
access to a general acute care hospital that
provides highly specialized services for children.
Implications for Policy, Practice or Delivery:
Health care managers in community hospitals
need to be aware that not all severely ill children
will seek care at a children’s hospital. Although
certain types of specialty care such as transplant
services are often regionalized, most children’s
specialty care is distributed among a handful of
children’s hospitals and large community
hospitals. Hospital managers in communities
without designated children’s hospitals will need
to be prepared to meet the health care needs of
resource intense children in their communities.
Managers will need to actively monitor
community demographics and their pediatric
case mix to determine which pediatric services
are needed by the community. Managers will
need to have appropriate specialized staff and
technology to care for children with special
health care needs. Effective recruitment and
retention of nurses with critical care skills,
neonatologists, pediatric sub-specialists, and
hospitalists will be especially important. Given
the nursing and pediatric subspecialist
shortages, managers will need to carefully
consider which services they can offer. Hospitals
have reported that shortages in pediatric
neurology, pediatric anesthesiology, and
pediatric gastroenterology have hindered their
ability to deliver care (Shelton 2006). These
shortages have also resulted in increased
recruitment costs, delayed and lost clinic visits,
lost referrals, and increased physician salaries
(Shelton 2006). To counter these shortages,
managers can focus on recruitment and
retention efforts such as tailoring compensation
packages to fit individual needs, offering
performance-based compensation, and offering
flexible benefits packages.
™The Relationship Between Caregiver Needs
& Community Stabilization among Children &
Adolescents with a Mental Health Crisis
Richard Epstein, Ph.D., Neil Jordan, Ph.D.,
YongJoo Rhee, Dr.P.H., John Lyons, Ph.D.
Presented By: Richard Epstein, Ph.D.,
Postdoctoral Fellow, Institute for Healthcare
Studies, Northwestern University, 676 N St Clair
Suite 200, Chicago, IL 60611, Phone: (312) 6956986, Fax: (312) 695-4307,
Email: r-epstein@northwestern.edu
Research Objective: Clinical decision making is
of critical importance to systems of care that are
attempting to provide children and adolescents
with appropriate mental health services in the
least restrictive setting. Although considerable
research has been devoted to identifying factors
that predict a decision to hospitalize children
and adolescents with a mental health crisis, less
is known about factors that predict a decision to
stabilize such referrals in the community. The
current paper tests the hypothesis that, after
adjusting for the effects of potential confounding
variables, children and adolescents whose
caregivers have significant needs are more likely
-7-
than those whose caregivers do not have
significant needs to be referred for community
stabilization.
Study Design: The current study is a secondary
analysis of administrative data from the
Screening, Assessment and Support Services
(SASS) program of the Illinois Department of
Human Services (DHS), Department of
Healthcare and Family Services (HFS), and
Department of Children and Family Services
(DCFS). The SASS program serves as a single
point of entry for all children experiencing a
mental health crisis whose psychiatric care will
require public funding from one of these
agencies. Logistic regression models used the
binary SASS decision to stabilize in the
community or refer for inpatient psychiatric
hospitalization as the criterion variable and the
caregiver needs domain of the Childhood
Severity of Psychiatric Illness (CSPI) scale as the
primary predictor variable. Control variables
included standard demographic variables (e.g.,
gender, race, age) and aspects of severity (e.g.,
risk behaviors, emotional and behavioral
symptoms, functioning problems, juvenile
justice risk, a need for child protective services,
whether or not the screening is the child’s first
screening in the time period).
Population Studied: The study sample (n =
14,127) included information on all screenings
conducted by the SASS program between
December 1, 2005, and August 31, 2006, and
was restricted to children and adolescents
between the ages of 3 and 21 years at the time of
screening.
Principle Findings: Results suggest that among
children with a mental health crisis, those with
caregiver needs were more likely to be stabilized
in the community than those without caregiver
needs [OR = 1.386, 95% CI = 1.274, 1.506]. Other
significant predictors of community stabilization
included whether the crisis was the child’s first
crisis during the study time period [OR = 2.684,
95% CI = 2.439, 2.953].
Conclusions: These findings suggest that
among children with a mental health crisis, the
presence of caregiver needs increases a child’s
odds of being stabilized in the community.
Implications for Policy, Practice or Delivery:
Understanding factors related to clinical decision
making for children and adolescents with a
mental health crisis is important to improving
the ability of systems of care to offer appropriate
treatments in the least restrictive setting.
Funding Source(s): Advanced Rehabilitation
Research Training, NIDRR
™How Insurance Instability Impacts Children
Gerry Fairbrother, Ph.D., Paul Newacheck,
Dr.P.H., Amy Cassedy, Ph.D.
Presented By: Gerry Fairbrother, Ph.D.,
Professor, Clinical Effectiveness, Cincinnati
Children's Hospital Medical Center, 3333 Burnet
Avenue MLC 7014, Cincinnati, OH 45229, Phone:
(513) 636-0189, Fax: (513) 636-0171, Email:
gerry.fairbrother@cchmc.org
Research Objective: To examine the influence
insurance continuity and gaps on access to and
use of health care for children.
Study Design: This was a two-year longitudinal
study of children with and without insurance
coverage where gaps in coverage were calculated
using monthly insurance coverage data. We used
bivariate frequencies and multivariate logistic
regression to determine the effect of gaps on
outcomes (usual source of care; routine medical
and dental visits; unmet medical and
prescription needs; and satisfaction with care),
controlling for race, age, language of interview,
income, education and health status. Outcomes
for children who were continuously covered were
compared with those for children with single
gaps, multiple gaps and no coverage during the
two-year period.
Population Studied: We used a pooled sample
from the Medical Expenditure Panel Survey
(Panel 5, 6, and 7) of 12,519 children between the
age of 2 and 17.
Principle Findings: During the two-year period,
68% of the children in the survey were
continuously covered, 22% had a single gap in
coverage, 3% experienced multiple gaps, and 7%
of children had no coverage during the two
years. The average length of gaps for children in
this study was 6.9 months (median 5 months).
In the multivariable analyses, children with
multiple gaps reported most problems with
access to care. For example, children with
multiple gaps had 6.64 higher odds (p<0.0001)
of not having a usual source of care compared to
children continuously insured. The odds ratio
for children with a single gap was 2.65
(p<0.0001), and 4.85 (p<0.0001) for children
continuously uninsured. Patterns for utilization
were similar, with children with gaps, especially
multiple gaps having highest odds of not having
a well care visit (multiple gap: OR=2.61,
p<0.0001; single gap: OR=1.36, p=0.0006;
continuously uninsured: OR=2.55, p<0.0001)
and dental visit (multiple gap: 1.52, p<0.0001;
single gap: NS; continuously uninsured:
-8-
OR=2.48;p<0.0001) in the past 12 months,
compared to continuously insured children.
Conclusions: Having gaps, especially multiple
gaps, in insurance coverage diminishes a child’s
access to and use of the health care system.
Implications for Policy, Practice or Delivery:
Our study demonstrates that insurance gaps are
more prevalent when longer time spans, such as
the 2 year period used in this study, are
considered. Hence, studies using shorter time
frames understate the extent of insurance
instability and the attendant access problems.
Funding Source(s): HRSA
leadership, agency, and practice-related factors
can either hinder or facilitate their sustainability.
Implications for Policy, Practice or Delivery:
Upon further analysis of specific sustainability
barriers and facilitators, future Learning
Collaboratives should play particular attention in
how agencies can overcome these internal
obstacles to increasing engagement and
retention of children and families in care.
™Factors Associated with Hospital Provision
of Child/Adolscent Psychiatric Services
Lea Anne Gardner, Ph.D.
™The Sustainability of a Learning
Collaborative to Improve Mental Health
Service Use among Low-income, Urban Youth
& Families
Presented By: Lea Anne Gardner, Ph.D., Senior
Associate, Clinical Programs and Quality of Care,
American College of Physicians, 190 N.
Independence Mall West, Philadelphia, PA
19106, Phone: (215)-351-2672, Fax: (215)351-2594,
Email: lgardner@acponline.org
Lydia Franco, L.M.S.W., Mary M. McKay, Ph.D.,
Anita Appel, M.S.W., A.C.S.W., William Bannon,
Ph.D., Michael Bigley, M.S.S., A.C.S.W.
Research Objective: To identify environmental
and organizational factors associated with
hospitals in the United States that provides
child/adolescent psychiatric services and the
number of services. There are six
child/adolescent psychiatric services, inpatient
and outpatient psychiatric, ER, partial
hospitalization, and inpatient and outpatient
substance abuse services. The number of
services is divided into high level (5 to 6
services) and low level (1 to 4 services) groups.
Study Design: This study is a cross-sectional
design utilizing the AHA survey.
Population Studied: All non-federal general
acute care hospitals and children's hospitals and
children's hospitals within the United States.
Principle Findings: Preliminary findings
demonstrate hospitals with child psychitric
residency programs, children's hospitals, public
hospitals, and high community orientation
provide child/adolescent psychiatric services.
Market characteristics include a high percentage
of non-profit hospitals, low levels of non white
children and adolescents and a median family
income level of $46,000.
Characteristics of hospitals providing a high
number of services include hospitals in
metropolitan statistical areas, system affiliation,
and children's hospitals.
Conclusions: Psychiatric services, identified as a
stigmatized service, are most likely to be offered
by childrens hospitals. Inclusion of the
percentage of non-profit hospitals in a market
limits the support for secular and Catholic
hospitals. Removal of the percentage of nonprofit hospitals in a market shows very
Presented By: Lydia Franco, L.M.S.W., Senior
Research Coordinator, Psychiatry, Mount Sinai
Medical Center, One Gustave L. Levy Place, Box
1230, New York, NY 10029, Phone: (212) 6598729, Fax: (212) 659-8940, Email:
lydia.franco@mountsinai.org
Research Objective: This study examined the
sustainability of a Learning Collaborative to
improve service use among nine outpatient
mental health agencies in the New York City
area.
Study Design: Questionnaires were sent to
Collaborative participants to determine whether
key practices and interventions were sustained
one year later, and whether aspects of the staff,
leadership, agency, and new practices facilitated
or hindered their sustainability.
Population Studied: Members of the quality
improvement teams of each of the nine child
mental health agencies that participated in the
New York City Learning Collaborative.
Principle Findings: All of the agencies
continued at least one of the new interventions
to varying degrees. Agency openness,
interventions that were aligned with agency
mission, and dedicated leadership were the
most-frequently cited facilitators to sustainability.
In contrast, staff and agency factors, such as not
seeing a need for change, and inadequate
resources, were the most commonly-noted
obstacles to adoption.
Conclusions: Learning Collaboratives appear to
be successful for effecting enduring change in
agency practice, although various staff,
-9-
statistically significant results for both secular
and Catholic hospitals. The second model, level
of services (commitment) didn't show very
significant results in associations with
environmental and organizational
characteristics. Further research into more
hospital specific variables is needed to determine
associations with the actual number of services.
Implications for Policy, Practice or Delivery:
Previously children's hospitals have not been
studied in relation to psychiatric care. This study
demonstrated that children's hospitals not only
provide these services, but a high number of
them. Public, Catholic, and secular non-profit
hospitals also provide these services. Ninety six
percent of all hospitals offering child psychiatric
services have inpatient and/or ER services. ER
services are the highest number provided,
followed by inpatient and outpatient psychiatric
care, partial hospitalization, outpatient and
inpatient substance abuse services. The
geographic distribution of hospitals indicating
child psychiatric services are 76.3% in MSA's and
23.7% in rural areas. Those hospitals with a high
level of services, 85.7% are located in a MSA,
14.3% are in rural areas. The biggest distinction
between the high and low level of provision of
services is in outpatient substance abuse
services. In hospitals with low levels of service
offerings, 24.6% provide outpatient substance
abuse services, versus 97.9% in the high level
group of hospitals. Further research is needed
to identify factors with stronger associations to
the level of service offerings. One possibility is
to focus on hospital specific characteristics such
as number of child psychiatrists or general
psychiatrists in a hospital.
Study Design: As part of recruitment for a
longitudinal prospective study, the Chicago
Initiative to Raise Asthma Health Equity
(CHIRAH), asthma screening was conducted in
105 schools returning 48,917 completed surveys
or 78.9% response rate. The children were then
geocoded and placed into 343 neighborhood
clusters adapted from the Project on Human
Development in Chicago Neighborhoods
(PHDCN). The racial composition of the
neighborhood clusters was incorporated from
census tract data. Race/ethnicity was
categorized as Black, White and Hispanic. The
average asthma prevalence in each
neighborhood cluster, consisting of at least
fifteen children from our sample, was then
determined.
Population Studied: Children attending 105
Chicago Public and Catholic elementary and
middle schools during the 2003-2004 and 20042005 school years.
Principle Findings: 41,255 children were
successfully geocoded into 287 Chicago
neighborhood clusters. Of the children sampled,
30% were White, 29% Black, and 41% Hispanic.
Overall, 5,318 children (12.9%) had been
diagnosed with asthma. By race/ethnicity,
asthma prevalence was 9.4% for White children,
19.4% for Black children and 10.9% for Hispanic
children. Predominantly White neighborhoods
(=80% White, n=43) had a mean asthma rate of
9.4% compared to predominantly Black
neighborhoods (=80%, n=102) with a mean
asthma rate of 18.9% (p<0.0001). White
neighborhoods asthma prevalence ranged from
2% in some neighborhoods to 28% in others
compared to predominantly Black
neighborhoods with asthma prevalence ranging
from 4% in some neighborhoods to 39% in
others.
Conclusions: Significant disparities have been
shown with Black children having a higher overall
asthma prevalence compared to White children.
However, although the rate of asthma by race is
significantly higher for Black children, there is
wide variation by neighborhoods with some
Black neighborhoods having lower asthma rates
compared to some predominantly White
neighborhoods. Race alone can not explain
differences in asthma rates and neighborhood
factors need to be further explored.
Implications for Policy, Practice or Delivery:
Policymakers should look to specific
neighborhod factors that may influence the
increasing disparities seen in childhood asthma
prevalence. Physicians should also consider
™Disparities in Geographic Variability of
Childhood Asthma Prevalence in Chicago
Ruchi Gupta, M.D., M.P.H., Xingyou Zhang,
Ph.D., Lisa Sharp, Ph.D., Jane Holl, M.D.,
M.P.H., Kevin B. Weiss, M.D., M.P.H.
Presented By: Ruchi Gupta, M.D., M.P.H.,
Physican Researcher, Pediatrics, Institue for
Healthcare Studies & Children's Memorisl
Hospital, Northwestern Feinberg School of
Medicine, 2300 Children's Plaza - Box 157,
Chicago, IL 60614, Phone: (312) 573-7747, Fax:
(312) 573-7824,
Email: r-gupta@northwestern.edu
Research Objective: To describe the differences
in childhood asthma prevalence by race/ethnicity
in Chicago neighborhood clusters.
- 10 -
mutable neghborhood factors that may influence
a child's diagnosis of asthma.
Funding Source(s): NICHD
However, this should be correctable with the
implementation of the "present on admission
fields" on the UB-04.
Implications for Policy, Practice or Delivery:
Patient safety and quality metrics are central to
both improvement and accountability efforts.
The AHRQ PDI module is an important step
forward for pediatric patient safety measurement
and improvement. However, before these
indicators are used for improvement initiatives
and hospital comparisons further research is
needed. This systematic, multi-institutional
evaluation of the PDIs is paramount to ensuring
and defining the role of administrative data in a
multi-faceted approach to improving pediatric
patient safety.
™Chart Reviews of Potentially Preventable
Pediatric Events Identified by the AHRQ
Pediatric Quality Indicators (PDI)
James Harris, M.S., Fiona Levy, M.D., James
Harris, M.S.
Presented By: James Harris, M.S., Director,
Research & Statistics, NACHRI, 401 Wythe
Street, Alexandria, VA 22314, Phone: (703) 6841355, Fax: (703) 684-1589,
Email: mharris@nachri.org
Research Objective: The purpose of this study
was to assess the Agency for Healthcare
Research and Quality (AHRQ) Pediatric Quality
Indicators (PDI) and to determine the utility and
potential issues of each indicator in measuring
pediatric inpatient quality. Results are being
used individually and collectively by hospitals to
highlight areas of potential concern as well as
those amenable to quality improvement
initiatives, benchmarking and public reporting
efforts.
Study Design: Working with pediatric experts,
the National Association of Children's Hospitals
and Related Institutions (NACHRI) developed a
set of chart review questions for 11 of the 13
provider-level AHRQ PDIs. The PDI software
was run on children's hospital discharge data to
identify patients with potentially preventable
complications. With a sampling goal of 10 cases
per hospital for each of the 11 PDIs, reviews were
performed using a secure, web-based chart
review tool.
Population Studied: Children's hospital
discharges from 2003, 2004 and 2005 identified
as having a potentially preventable pediatric
complications.
Principle Findings: Over 1700 events were
reviewed by 28 participating institutions.
Unadjusted rates of events ranged from 35.04
per 1000 for Postoperative Respiratory Failure to
0.01 per 1000 for Transfusion Reaction. Event
preventability ranged from a high of 51% for
Decubitus Ulcer to 0% for Transfusion Reaction.
Conclusions: Potentially preventable
complications are occurring in children's
hospitals but with varying frequency. The
percent of events identified as truly preventable
also varied by indicator. Finally, there seem to
be issues with some events already being
present on admission which may incorrectly
show higher rates for some types of institutions.
™Performance on ED Care for Children at
Academic Medical Centers
Samuel Hohmann, Ph.D.
Presented By: Samuel Hohmann, Ph.D., Senior
Research Specialist, Information Architecture,
University HealthSystem Consortium, 2001
Spring Road, Suite 700, Oak Brook, IL 60523,
Phone: (630) 954-1740,
Email: hohmann@uhc.edu
Research Objective: Describe performance of
AMCs on clinical indicators for ED care of
children
Study Design: Retrospective cohort study
Population Studied: ED encounters and
hospitalizations related to ED visits of 250,000
children between July 2005 and June 2006 at 13
academic medical centers geographically
dispersed throughout the US. The focus was on
12 defined cohorts of children's ED and acute
care utilization developed by researchers at the
Institute for Clinical Evaluative Sciences for the
Ontario Hospital Report Research Collaborative.
Principle Findings: Indicators for six of the
conditions included hospital admission following
a visit the ED. While there were far fewer
children hospitalized for the 12 conditions after
ED care than seen in the ED and discharged
from there, a significant number of children were
admitted for acute care. For example, nearly
1,200 children with asthma were admitted for
acute care after being seen in the ED. There
were almost as many children with croup. There
were more than twice as many children with a
fever who were admitted following ED care.
Finally, there were more than 1,600 children with
urinary tract infections (UTIs) who were
admitted for acute care following ED care. Many
of the stays were very brief (1 or 2 days) although
- 11 -
children hospitalized with UTI's stayed 3, 4, and
5 days. Various aspects of ED care were studied
including patient demographics (age, gender,
principal payer), diagnoses and procedures,
resource use (lab, imaging, pharmacy), ED
admission and discharge time of day. Use of
these services related to measures of
performance, and use rates varied considerable
among the 13 AMCs.
Conclusions: There is variability in the care
provided to children in EDs. Measuring
processes and outcomes of care should lead to a
better understanding of random vs. special
variation in the delivery of care.
Implications for Policy, Practice or Delivery:
Health care providers and administrators need
to understand baseline patterns of care to make
informed decisions on the distribution of
resources to meet health care demand.
Identifying variation in pediatric ED care can lead
to a better understanding of resource needs for
EDs and particularly for children seeking care in
the ED.
through Medicaid enrollment and claims data
files. Individual-level data were used to calculate
aggregate EPSDT screening rates for the overall
population, for demographic subgroups, and for
geographic regions to examine patterns in
utilization.
Population Studied: This study used the 2001
Medicaid Analytic eXtract (MAX) files for
Arkansas obtained from Centers for Medicare
and Medicaid Services (CMS), including
enrollment data and claims data for all enrollees
under age 21. Medicaid-eligible children enrolled
in the ARKids A program were observed during
2001. EPSDT procedure billing codes were used
to measure the utilization of well-child visits.
EPSDT ratios were calculated based on the CMS
formula (which adjusts for age and the
recommended periodicity schedule) overall and
by gender, race/ethnicity, and geographic region.
Principle Findings: EPSDT rates varied greatly
across age groups, as expected, being highest for
1-2 year-olds, less than 1 year old, and 3-5 yearolds, with very low rates for teenagers. There
was very little difference in screening rates by
gender, both overall and within age groups. The
total screening rate was virtually the same for all
racial/ethnic groups except for Asian/Pacific
Islanders, who had a higher rate. However, agespecific rates varied somewhat by race/ethnicity.
Hispanic children under age 3 and Native
American children under 1 year old had relatively
lower screening rates. Geographic variation in
EPSDT rates by county and region are presented
graphically in maps.
Conclusions: Arkansas represents a valuable
case study for examining factors related to
EPSDT utilization, since Arkansas has the
greatest need for improvement. In spite of this
need, very little research has been published
about EPSDT utilization patterns or general wellchild care in Arkansas. By tracing patterns in
EPSDT utilization, this study helps to identify
areas where increased outreach efforts to
families and health care providers are needed.
Implications for Policy, Practice or Delivery:
The findings of this project provide useful
information that Arkansas and other states can
use to target strategies for increasing EPSDT
rates. This study also contributes to health
disparities research by identifying gaps in EPSDT
service utilization across racial/ethnic groups,
which can then be targeted in Medicaid EPSDT
outreach efforts to facilitate access to and
utilization of available services.
Funding Source(s): AHRQ
™EPSDT Preventive Services among Children
in Arkansas’ Medicaid Program
Pamela Hull, Ph.D., M.A., Robert Levine, M.D.,
Dustin Brown, M.A., Van Cain, M.A., Marie
Griffin, M.D., Baqar Husaini, Ph.D.
Presented By: Pamela Hull, Ph.D., M.A.,
Associate Director, Center for Health Research,
Tennessee State University, 3500 John A. Merritt
Boulevard, Box 9580, Nashville, TN 37209,
Phone: (615) 320-3005, Fax: (615) 320-3071,
Email: pamhull@tnstate.edu
Research Objective: State-administered
Medicaid programs are federally mandated to
cover free clinical preventive services for
Medicaid-eligible enrollees from birth to age 21,
under the umbrella of the Early and Periodic
Screening, Diagnosis and Treatment (EPSDT)
program. While the national target EPSDT
participation rate (at least one well-child visit per
year) is 80% of eligible children, Arkansas’
official EPSDT participation rate has been the
lowest in the U.S. for several years (around 25%).
The objective of this paper was to use Medicaid
enrollment and claims data to describe patterns
in the utilization of EPSDT services in Arkansas
in 2001 by age, gender, race/ethnicity, and
geographic region.
Study Design: This study employed a
longitudinal observational design. Children
enrolled in Medicaid in Arkansas were observed
across the 12 months of calendar year 2001,
- 12 -
™Reimbursement Program for Curbside
(21%) were also commonly cited. Seventy
percent of consults were of brief duration (less
than 15 minutes) with another 25% lasting 15 - 30
minutes. The remaining 3 calls took greater than
30 minutes to complete. There were no requests
for consultation by email. Specialist-reported
Results of the consults (with more than one
Result allowed) were as follows: specialist
consult avoided (54%), transfer between
hospitals avoided (19%), emergency room visit
avoided (10%) and hospitalization avoided
(10%). In only 15 of the 67 consults for Medicaid
patients (22%) was mention made of referral for
other care. Available self-reported data suggest
greater than $40 saved for each dollar spent for
consults. Updated results will be presented at
the conference.
Conclusions: Available self-reported data
suggest that curbside consults are having the
desired effect of supporting primary care
physicians in the medical home while obviating
the need for many referral visits and avoiding
costly services in the majority of cases. The
program is being expanded to additional clinics
and facilities.
Implications for Policy, Practice or Delivery:
Compensating specialists for curbside consults
may lead to more patient-friendly care and more
optimal use of specialist services.
Funding Source(s): North Carolina Foundation
for Health Care Improvement
Consults for Medicaid Patients in North
Carolina
Charles Humble, Ph.D., Steven E. Wegner, M.D.,
J.D., Alan Stiles, M.D., John Feaganes, Dr.P.H.,
Lori Capmbell, R.N., M.B.A.
Presented By: Charles Humble, Ph.D., Director,
Analytic Services, AccessCare, 3500 Gateway
Centre Boulevard, Ste 130, Morrisville, NC 27560,
Phone: (919) 380-9962, Fax: (919) 468-8573,
Email: chumble@ncaccesscare.org
Research Objective: The supply of pediatric
sub-specialists to support local primary care
providers caring for Medicaid clients across
North Carolina is limited and concentrated in the
major medical centers. The project is designed
to encourage consultation between primary care
providers and these physician specialists with
the goals of supporting care in patients’ medical
homes and optimizing the use of patient time
and provider resources.
Study Design: Pediatric Chairs participated in
the development of the simple data collection
form used to request reimbursement for distant
consults. The Chairs then educated specialists
regarding the program and encouraged them to
accept ‘‘curbside consults’’ by phone or email.
Data collection was kept to a minimum at the
request of participating departments, but
includes the Reason for, Duration of, and Result
of the consult, e.g., whether use of other services
was avoided. Payments to specialists were tied
to length of consult. Savings were estimated
based on average costs of outpatient visits,
emergency department visits and hospital
admissions for Medicaid clients. We here
describe early results from the program.
Population Studied: The program was
implemented in the pediatric Infectious Disease
clinics at each of three medical centers and in
the Gastroenterology clinic at the fourth center.
Therefore, the population directly studied was
comprised of the specialists in the participating
clinics and the primary care physicians referring
patients to them.
Principle Findings: After testing at one center,
requests were collected over a 3 month period.
Sixty-seven requests for reimbursement were
collected for 60 unique Medicaid enrollees.
Ages of patients ranged from 1 to 21 with a
median age of 1 year. The most frequently
mentioned Reason for the consult - with more
than one answer allowed - was advice on a new
problem (69%) although advice on an existing
problem (24%) and interpretation of results
™State Policy Improvements that Support
Children's Development: Expereince from
Eight States
Neva Kaye, Jennifer May, M.P.H., Melinda
Abrams, M.S.
Presented By: Neva Kaye, Senior Program
Director, National Academy for State Health
Policy, 50 Monument Sqare, Suite 502, Portland,
ME 04101, Phone: (207) 874-6524, Fax: (207)
874-6527, Email: nkaye@nashp.org
Research Objective: NASHP has administered
two consortia to help states improve policy and
practice to better support children’s
development. Consortia states (CA, IL, IA, MN,
NC, UT, VT, WA)improved the policies
governing their Medicaid, MCH, early
intervention, and mental health agencies. There
is also evidence that, as called for by the AAP,
more physicians are using developmental
screening tools as part of well-child care. The
objective was to produce an analysis of policy
improvements made by the consortia states and
identify the critical elements to successful policy
- 13 -
improvement with the intent of providing a
starting point for others seeking to improve
policy to: 1. improve the identification of young
children with or at risk for developmental delays
and 2. improve families’ access to follow-up
services.
Study Design: Authors initially identified the
improvements made by the consortia states and
critical elements in the improvement process
based on state progress reports, site visits, and
state presentation material. Authors developed
a matrix displaying policy improvements by
objective, area (coverage, reimbursement, and
performance), and mechanism. Consortia state
staff reviewed initial and revised drafts of the
matrix and critical process elements to ensure
completeness and usefulness. Authors analyzed
the matrix to identify trends and innovations.
Population Studied: Medicaid agencies in
consortia states were the primary study
population. Consortia states often found they
needed to change the policies of other state
agencies to support their efforts------these are also
in the study population. Finally, the states
examined the experiences of physicians as part
of their processes.
Principle Findings: From the final report
(released 12/06) Seven of the eight consortia
states reported improvements to policies
defining program coverage (eligibility and
benefits). All seven reported improvements to
benefits and three reported improvements to
eligibility. The most frequently reported
improvement to benefit coverage was to clarify
the state’s expectations to individual providers to
encourage the use of developmental screening
tools as part of an EPSDT screen. Five states
reported one or more improvements to
reimbursement policies. Three reported
improvements that relate to clarifying that
providers (including primary care clinicians) can
bill for conducting a developmental screen with a
screening instrument using CPT code 96110.
Six states reported one or more policy
improvements designed to enhance program
performance, including performance
measurement. The only policy improvements
designed to improve the delivery of child
development services that were reported by
more than one state were based on two sets of
federal regulations ---- Medicaid managed care
and EPSDT. Factors associated with each state’s
success were: a strategic plan; broad
stakeholder participation; grounding proposed
improvements in experience, and creating
opportunity.
Conclusions: Consortia states changed statutes,
contracts, provider manuals, and other
documents that define state policies to improve
the delivery of child development services. They
also changed eligibility and claims processing
systems to implement the policies described in
the documents, and conducted quality
improvement projects designed to assess
performance and foster change.
Implications for Policy, Practice or Delivery:
Consortia state experience offers guidance and
inspiration others can use to improve children’s
care.
Funding Source(s): CWF
™Predictors of Pediatric Asthma
Hospitalizations
Alana Knudson, Ph.D., Ed.M., B.A., Kyle Muus,
Ph.D.
Presented By: Alana Knudson, Ph.D., Ed.M.,
B.A., Associate Director for Research, Center for
Rural Health, University of North Dakota, 501 N.
Columbia Road, Stop 9037, Grand Forks, ND
58203, Phone: (701)777-4205, Fax: (701)777-6779,
Email: aknudson@medicine.nodak.edu
Research Objective: Examine the incidence,
patterns, and predictors of U.S. hospitalizations
for asthma among children (i.e., aged 2 to 17).
Specifically, we examined the incidence rates for
rural versus urban children and
demographic/geographic factors which increase
the likelihood of being hospitalized for this
condition.
Study Design: Secondary analysis of HCUP
hospital claims data.
Population Studied: Pedicatric hopsitalizations
2003 Healthcare Cost and Utilization Project
(HCUP) Nationwide Inpatient Sample data file.
Principle Findings: There were an estimated
118,869 hospitalizations for asthma among
children in the U.S. in 2003. Of this number,
103,672 were incurred by urban-based children
and 15,197 involved rural-based children. Per
population, urban children had hospitalization
rates that were substantially higher than for rural
children (193.2 versus 137.4 per 100,000). Using
logistic regression, urban children were 37.7%
more likely than rural children to have a
hospitalization resulting from asthma, after
controlling for age, gender, race, and income
level.
Conclusions: Children residing in urban areas
were much more likely than their rural
counterparts to have been hospitalized for
asthma. Other factors that increased the
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likelihood of being hospitalized for this condition
included being male, aged 2-6, African American
race, and residing in lower income areas.
Implications for Policy, Practice or Delivery:
Implications for policy include ensuring that
Medicaid and SCHIP programs have adequate
reimbursement for follow-up visits for children
and particularly, educating parents on asthma
triggers. In addition, access to timely
pharmacuetical refills are important to the
continuity of their care. Practitioners may need
to pay particular attend to the education they
provide to low-income families to assure that the
information about asthma management is
clearly communicated and understood by the
children's parens.
Funding Source(s): HRSA, ORHP
and related casework, but also through support
groups and educational opportunities.
Population Studied: The population includes
children in the midtown and northside St. Louis
inner-city areas who have been diagnosed with
asthma and whose parents sought assistance
through the community agency.
Principle Findings: Statistically significant
improvements occurred across visits at both
sites in the provision and use of asthma action
plans by children. Emergency department use
and hospitalizations declined for children across
visits at both sites for the total population and
cohorts. The pattern of visits with regard to
controller use and the presence and provision of
bed covers differed between the two sites. Bed
cover usage significantly increased at one site for
the total population and cohorts.
Analysis of the Juniper Surveys is not completed
at this time but will be complete for
presentation. A complete third year of data and
analysis will be available at the presentation.
Conclusions: The Asthma HELP intervention
positively affected the process of care and use of
services. The Asthma HELP intervention
significantly impacted the process of care
through the provision and use of asthma action
plans for both sites, and the provision and use of
bed covers at one site. Controller usage also
increased across sites. The intervention
produced appropriate declines in services usage,
which may indicate reduced asthma morbidity
for these children. Declines in use of both the
emergency department and hospitals occurred at
both sites but did not reach significance. It
should be noted that non-significant effects often
fell between a p-value of .05 and .10.
Implications for Policy, Practice or Delivery:
The Asthma HELP program demonstrates that
an asthma management program can be
integrated into the casework process of a
community agency in which social workers have
received asthma education. Such an integrated
program can also decrease the use of emergency
departments and hospitals, reducing the cost of
care of clients and third party payers.
Funding Source(s): CDC
™Effects of a Community Agency Intervention
on Care Management, Health Services Use &
Quality of Life for Children with Asthma
Richard S. Kurz, Ph.D., Mary E. Homan, M.A.,
Kristin D. Wilson, M.H.A.
Presented By: Richard S. Kurz, Ph.D., Professor
and Chair of the Department of Health
Management and Policy, Department of Health
Management and Policy, Saint Louis University
School of Public Health, 3545 Lafayette Avenue,
Saint Louis, MO 63104, Phone: (314) 977-8111,
Fax: (314) 977-1674, Email: kurzrs@slu.edu
Research Objective: The study assesses the
effects of a community agency intervention,
Asthma HELP, on asthmatic children’s process
of care, health services use, and perceived quality
of life.
Study Design: Annual cohorts of approximately
60 children at two sites of a community agency
receive visits throughout the year. Information is
gathered about their behavior at each visit by an
asthma-educated social worker through a
detailed checklist, and quality of life through an
annual Juniper Survey. Two years of data have
been collected. Dependent variables include:
utilization of emergency departments,
hospitalizations, and controller medications;
provision and presence of an asthma action
plan, provision and presence of a bed cover, and
Juniper Survey scores. The intervention, Asthma
HELP, provides families with support in the
home setting regarding health care and asthma,
environmental triggers, and suggestions for the
prevention of asthma episodes, emergency
department visits, and hospitalizations. Support
is accomplished through home visits, advocacy,
™Does Prenatal Care Improve Utilization of
Well-Baby Care?
Mary Alice Lee, Ph.D., Priscilla Canny, Ph.D.,
Amanda Learned, B.A.
Presented By: Mary Alice Lee, Ph.D., Senior
Policy Fellow, Connecticut Voices for Children, 33
Whitney Avenue, New Haven, CT 06510, Phone:
- 15 -
(203) 498-4240, Fax: (203) 498-4242, Email:
malee@ctkidslink.org
well-baby care in the multivariate model
(OR=1.36; 95% CI=1.21-1.53).
Conclusions: Prenatal care utilization measures
can identify which infants are at risk for receiving
less than recommended well care during the
early months of life.
Implications for Policy, Practice or Delivery:
Prenatal case management can be reconceptualized as just the first step in a
continuum of care coordination for new mothers
and babies. Linking birth certificate data to
Medicaid administrative data is an effective tool
for identifying risk factors for less-thanrecommended care.
Funding Source(s): Connecticut Department of
Social Services
Research Objective: To determine the
relationship between prenatal care and well-baby
care for infants born to mothers in a Medicaid
managed care program.
Study Design: This study used a cross-sectional
retrospective cohort design with bivariate and
multivariate analyses to determine whether an
association exists between early and adequate
prenatal care and receipt of well-baby care.
Potential confounding variables included in the
analysis were maternal age, race/ethnicity,
education, residence, primary language,
managed care plan, and smoking, and birth
plurality and birthweight. Birth data were
matched with Medicaid managed care
enrollment data to identify mothers who were
enrolled in Connecticut’s Medicaid managed
care program when they gave birth in 2003.
Maternal Medicaid managed care enrollment
data were then linked with enrollment data for
infants and their healthcare encounter records.
The analytic file was restricted to infants who
were continuously enrolled for the first 15
months of life. The association between prenatal
care utilization (early prenatal care, adequate
prenatal care) and having had 6 recommended
well-baby visits, adjusted for independent
variables, was determined using logistic
regression. Significant statistically relationships
are reported at the p<0.05 level.
Population Studied: 7,054 infants born in 2003
to mothers in Medicaid managed care and
subsequently enrolled for the first 15 months of
life.
Principle Findings: Just over half (55%) of the
infants received the 6 recommended well-baby
visits in the first 15 months of life. Bivariate
analysis revealed that infants whose mothers
initiated early prenatal care (e.g., first trimester)
were more likely to receive recommended wellbaby care. Similarly, infants with adequate
prenatal care were more likely to receive
recommended well-baby care. Factors also
associated with increased risk for not having
recommended well-baby care included younger
maternal age, non-White non-Hispanic
race/ethnicity, less than a high school education,
urban residence, and switching managed care
plan. After adjusting for these potential
confounders, no statistically significant
relationship between early prenatal care and wellbaby care was found (OR=1.06; 95% CI=0.911.21). However, having had adequate prenatal
care increased the odds of having recommended
™The Effect of Maternal Education on Child
Health & Health Care Use
Dean Lillard, Ph.D., Kosali Simon, Ph.D., Maki
Ueyama, B.A., Ning Zhang, B.A.
Presented By: Kosali Simon, Ph.D., Assistant
Professor, Cornell University, 106 MVR Hall,
Ithaca, NY 14850, Phone: (607) 255-7103,
Email: kis6@cornell.edu
Research Objective: To examine the causal
effect of mother’s high school education and
college education on child health and health care
use.
Study Design: We use an instrumental variables
approach to overcome problems in attributing
difference across education groups to the effect
of education. Our instruments for mothers
education predict educational attainment on two
important margins - the completion of high
school and attendance at and completion of
college. On the first margin our instruments
include state policies governing age of school
entry and exit, high school graduation
requirements. We leverage the school entry and
exit policies by interacting each with a woman's
exact date of birth. On the second margin our
instruments include average distance to a 2- or
4-year college from a woman's place of residence
and the average college tuition she faces for all
colleges within 500 miles of her place of
residence.
Population Studied: Children and mothers from
the National Longitudinal Survey of Youth.
Specifically, the 1979-2002 waves of the NLSY79
and the 1986 -2002 waves of the NLSY79CY.
Principle Findings: We find that mothers who
complete high school are more likely to report
their child was ill enough to need a doctor, that
their child was ill more times, and that their child
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was more likely to have fractured or dislocated a
bone in the past 12 months that required
medical attention or treatment. Across samples
of mothers who dropped out of high school and
who completed high school, we find no
difference in the date of their children’s last
routine health checkup, percentiles for weightfor-age, height-for-age, BMI-for-age, or in the
probability of children at risk of overweight and
of being overweight. When we examined the
possible mechanisms, we found that mother’s
high school education increases mother’s age at
child’s birth, health insurance coverage and child
care use. We also find suggestive evidence of a
much more complex set of behaviors that are
causally related to education (child care use,
health insurance status, fertility decisions) and
that likely affect child health.
Conclusions: This preliminary evidence
suggests that although child health care use
increases with education, much more work
needs to be done before one can strongly
conclude that child health does or does not
systematically vary with differences in maternal
education on the margin we study.
Implications for Policy, Practice or Delivery:
While there have been several studies of the link
between maternal education and child health in
developing countries, there is very little in the
US. Existing research only studies infant birth
outcomes and offers conflicting evidence. Our
paper will provide valuable evidence on the
causal link between maternal education and
child health and health care use. These are
important non-market outcomes of education
that should be considered in policies to publicly
subsidize education.
Transportation and Communications R.O.C., has
mandated the use of safety restraints for children
in 2004, specifying age- and weight-appropriate
rules for children under 12, all in an effort to
improve the safety of child passengers. It
remains unclear how effective this newly enacted
law will be in preventing transport-related
injuries in children since no official studies have
been conducted. The study was undertaken to
determine the rate of child safety-restraint use,
factors for use and nonuse, and a better method
to measure the use.
Study Design: To evaluate the effectiveness of
the newly enacted law and the current practice of
restraint use in Taiwan, this study used a
convenient sampling method to observe and
record the use of safety restraints by the driver
and any child passengers in the parking lots of
several kindergartens in both Kaohsiung City and
Kaohsiung County. To compare the results of
the observational study, questionnaires were
sent to parents of randomly selected
kindergarteners to obtain self-reported data on
driver-restraint use and child-restraint use. A
total of 477 and 512 responses were obtained
from the mailed survey and the observational
study respectively.
Population Studied: Drivers and child
passengers in Kaohsiung City and Kaohsiung
County.
Principle Findings: The study shows that 39.8
percent of subjects self-reported child safetyrestraint use. This contrasts sharply with the
observational study which saw only 9.2 percent
of parents using safety restraints for their
children. Similarly, the self-reported adult
seatbelt use was 80.3 percent ---- far higher than
the 49.0 percent we observed. The use of child
safety-restraint is higher in Kaohsiung City than
in Kaohsiung County. Factors that influence
child safety-restraint use are driver’s gender,
adult seatbelt use, number of children in the
vehicle, and age of the children, but the age of
drivers, gender of the children, the number of
adult passengers in the car, driving distance
from home to the destination are not influential
factors.
Conclusions: The low child safety-restraint use
rates obtained from both methods suggest the
newly enacted law is ineffective in terms of
increasing child safety-restraint use. Both adultand child-restraint use are higher in cities than in
rural areas. In addition, driver seatbelt use and
gender, the number of child passengers in the
car, and the age of child passengers are all
strong predictors of child safety-restraint use.
™Child-Restraint-Use Rate in Taiwan: A
Methodological Comparison
Sue-Jen Lin, Ph.D.
Presented By: Sue-Jen Lin, Ph.D., Assistant
Professor, Mass Communication, I-Shou
University, No.1, Sec. 1, Syuecheng Rd., Dashu
Township, Kaohsiung County, Taiwan, Phone:
011886958035515, Fax: 01188676577277, Email:
suelin@isu.edu.tw
Research Objective: In Taiwan, an average of
3.8 children die each day from injuries sustained
in motor-vehicle accidents -- the leading cause of
death in children. According to U.S. National
Highway Traffic Safety Administration(NHTSA),
61 percent of the occupants killed in motorvehicle accidents used no restraints. Based on
these grim statistics, the Ministry of
- 17 -
Implications for Policy, Practice or Delivery:
The results demonstrate the need for public
education campaigns to inform parents about
child safety-restraint use, especially for parents in
rural areas and those who are less likely to use
car seats. In addition, an observational study is
a better method to estimate the prevalence of car
safety-restraint use than a mailed survey.
Funding Source(s): Bureau of Health
Promotion, Department of Health, R.O.C.
(Taiwan)
5/10 risk factors: developmental delay, family
history of mental disorder, family history of
substance abuse, child maltreatment and
chronic illness. Of these, data was routinely
collected on all patients for chronic illnesses and
developmental delay only. Except for chronic
illnesses and development, most of the data was
not coded. Data elements that were customized
by the practice were most likely to not be coded.
All of the EMR software was capable of provider
alerts during the visit (used by 4/5 practices),
maintaining a task list for provider follow-up
(used by 5/5 practices), or population alerts
(used by 1 practice). The three most common
obstacles described to collecting data on child
mental health risk factors were: 1) Lack of time
by provider and/or parent; 2) Discomfort or lack
of knowledge pertaining to interview questions;
and 3) Lack of standards to code data for EMR
fields.
Conclusions: The results suggest that a variety
of EMR software programs contain data
elements on child mental health risk factors, or
can be modified to contain these elements.
However, most providers do not use systematic,
standardized methods to screen for mental
health risk factors. In addition, there is an
underutilization of EMR systems due to lack of
coded data or limited use of decision support for
mental health promotion.
Implications for Policy, Practice or Delivery:
Effective use of EMR systems to promote child
mental health will require the development of an
interface that includes 1) Valid and reliable
instruments for mental health risk factor
screening; 2) Maximal use of informatics to
simplify data collection and promote
communication; and 3) Incorporation of coded
data elements for mental health risk factors into
EMR software.
™Translational Informatics for Child Mental
Health Promotion
Ariane Marie-Mitchell, M.D., Ph.D.
Presented By: Ariane Marie-Mitchell, M.D.,
Ph.D., Resident in General Preventive
Medicine/Public Health, Community &
Preventive Medicine, University of Rochester,
601 Elmwood Avenue, Box 644, Rochester, NY
14642, Phone: (585) 217-7924, Fax: (585) 4614532, Email:
ariane_mariemitchell@urmc.rochester.edu
Research Objective: Use of informatics could
facilitate screening for mental health risk factors
through primary care practices. The specific
aims of this study were to determine: 1) whether
local pediatric primary care practices use
systematic, standardized methods to collect data
on child mental health risk factors; 2) whether
electronic medical record (EMR) systems are
being used to facilitate data collection and use;
and 3) what obstacles exist to collecting data on
child mental health risk factors through primary
care practices.
Study Design: A cross-sectional survey was
conducted in November, 2006 of primary care
practices for children using different EMR
software in the Rochester, New York area.
Representatives from practices were interviewed
using a semi-structured format to address the
domains of data collection, use and obstacles
related to ten child mental health risk factors. A
physician with specific knowledge of the EMR
system was interviewed from each practice, and
corroborating evidence was obtained when
possible.
Population Studied: A total of five local
practices were identified by referrals from local
experts in pediatrics and information systems.
Principle Findings: Duration of EMR use ranged
from 4 months to 5 years (mean 25 months).
Valid and reliable instruments were not used for
data collection of most factors. All five software
packages included specific data elements for
™An Assessment of Emergency Care for
Children in Nebraska
Michelle Mason, M.A., Michael ShambaughMiller, Ph.D., Liyan Xu, M.S., Kelly ShawSutherland, B.S.
Presented By: Michelle Mason, M.A., Health
Data Analyst, Health Services Research and
Administration, University of Nebraska Medical
Center, 984350 Nebraska Medical Center,
Omaha, NE 68198-4350, Phone: (402) 559-8406,
Fax: (402) 559-7259, Email: mmason@unmc.edu
Research Objective: To assess the extent to
which structures and processes within Nebraska
hospitals and emergency medical services (EMS)
- 18 -
that provide emergency care to children are
consistent with evidence-based guidelines
Study Design: We used the Dillman method to
survey all Nebraska hospital emergency
departments (EDs) that treat children, and all
EMS services in Nebraska. We developed two
surveys (one for EDs and another for EMS
services), using guidelines recommended by the
American Academy of Pediatrics, performance
measures developed by HRSA for the Emergency
Medical Services for Children (EMSC) program,
and recommendations from the National EMSC
Data Analysis Resource Center and the Nebraska
EMSC program.
Population Studied: We received completed
surveys from 78% of 85 EDs contacted [50
Critical Access Hospitals (CAHs) with 25 or
fewer beds, 2 small hospitals with 26 to 49 beds,
and 14 larger hospitals with 94 or more beds]
and 68% of 429 EMS services in Nebraska [13
First Responder services, 214 Basic services, and
49 Advanced services].
Principle Findings: In Nebraska children
account for about one-fourth of all visits to EDs
and about 10% of all EMS runs. Only 16% of
EMS services had all the essential pediatricspecific BLS equipment, and 18% of Advanced
services had all the essential pediatric-specific
ALS equipment. Sixty-six percent of EDs had
written care protocols addressing stabilization of
critically ill or injured children, while 79% of EMS
services utilize the NE State Model Protocol.
Only 20% of EMS services utilized on-line
pediatric medical direction at the scene of an
emergency. Less than half of EMS services
required EMTs to have pediatric-specific
training/education. ED providers were not likely
to be required to obtain pediatric-specific CME.
Ninety-eight percent of EDs transferred children
to other facilities for specialized care; over 60%
had a written inter-facility transfer agreement
that specified inter-facility communication (69%)
and transfer of patient materials (65%). About
one-third of EDs annually reviewed the frequency
and outcomes of pediatric patients. Only two
EDs provided a child-life specialist.
Conclusions: Emergency health care providers
in rural areas are most likely to lack the
necessary experience and equipment for treating
pediatric patients due to limited resources and
the low volume of emergencies involving
children. The majority of EMS services lack the
essential equipment needed to treat children in
the prehospital setting. Because CAHs are not
likely to offer specialized pediatric care, they
often transfer children to other facilities,
increasing the need for written inter-facility
agreements. Pediatric-specific education and
increased resources would benefit both
prehospital and in-hospital providers. More
efforts must be made to standardize care
through the use of written protocols and regular
assessment of children’s outcomes in order to
serve this population safely and effectively.
Implications for Policy, Practice or Delivery:
Policymakers in rural states must assess the
infrastructure of emergency pediatric care with a
goal of maximizing access to high-quality
emergency care through coordination at the
state and local level. This assessment must
include the locations of facilities capable of
treating children according to evidence-based
guidelines. Integrated systems of emergency
care for children are necessary in rural states,
where EMS services licensed to provide only BLS
treatment and CAHs serve significant
proportions of the population.
Funding Source(s): Nebraska Health and
Human Services System, EMS Program
™Do Increases in Supply Lead to
Improvements in the Distribution of Pediatric
Subspecialty Care
Michelle Mayer, Ph.D., M.P.H.
Presented By: Michelle Mayer, Ph.D., M.P.H.,
Research Assistant Professor, Health Policy and
Administration, University of North Carolina at
Chapel Hill, CB #7590, Chapel Hill, NC 275997590, Phone: (919) 966-7666, Fax: (919) 9661634, Email: michelle_mayer@unc.edu
Research Objective: One remedy to physician
shortages is to increase supply; however, supply
increases only ameliorate physician shortages if
they lead to dispersion of physicians into
underserved areas. The study objective is to
examine whether recently certified pediatric
subspecialists enter markets that previously
lacked providers and determine if increases in
supply are associated with increased geographic
availability of care.
Study Design: For each pediatric subspecialty,
we identified new entrants using 2005 data from
the American Board of Pediatrics (ABP). ‘‘New
entrants’’ were defined as those providers who
first obtained board certification in 2004 or
2005. First we examined whether new entrants
were more likely than their counterparts to
practice in locations that were lacking providers
in 2003 using Fisher’s exact tests. Second, we
examined whether the percent of Hospital
Referral Regions (HRR) with at least one
provider increased from 2003 to 2005. Finally
- 19 -
we examined whether the number of providers in
an HRR increased from 2003 to 2005 among
those HRR that had any providers. All analyses
were done separately for each subspecialty.
Bivariate comparisons used Fisher’s exact test to
compare ‘‘new entrants’’ versus their
counterparts and student’s t-test to compare
supply at the HRR level between 2003 and 2005.
Population Studied: 2003 and 2005 physician
data from the American Board of Pediatrics and
Hospital Referral Regions from the Dartmouth
Health Care Atlas.
Principle Findings: During the time period
studied, the number of board certified pediatric
subspecialists increased 5% overall. New
entrants comprised 10% of pediatric
subspecialists. New entrants were significantly
more likely than previously certified providers to
locate in an HRR that lacked a provider in 2003
for the following specialties: developmental
behavioral pediatrics, neurodevelopmental
disabilities, cardiology, infectious diseases,
emergency medicine, nephrology, rheumatology
and sports medicine. Despite the statistical
significance, the actual number of providers in
previously unserved markets was small;
consequently, the percent of HRR with a provider
did not increase significantly with the exception
of developmental behavioral pediatrics. Among
HRR with a provider in 2003, the number of
providers increased significantly between 2003
and 2005 for pediatric critical care medicine,
neonatology, developmental and behavioral
pediatrics, neurodevelopmental disabilities,
pediatric cardiology, pediatric emergency
medicine, and pediatric endocrinology.
Conclusions: Our findings suggest that
increases in the number of pediatric
subspecialists do not generally lead to
improvements in the distribution of these
providers. With the exception of developmental
behavioral pediatrics, the percentage of HRR
with providers was virtually unchanged between
2003 and 2005. The significant increases in the
number of providers in HRR that already had
providers suggest that increases in supply may
actually reinforce the existing distribution for
certain pediatric subspecialties.
Implications for Policy, Practice or Delivery:
Efforts to increase geographic access to pediatric
subspeciality care should extended beyond
increases in general supply. Programs that
encourage placement in underserved areas,
capitalize of off health information
technologises, or use other physician providers
to substitute for or comanage care with pediatric
subspecialities might be considered.
Funding Source(s): AHRQ
™National Clinical Practice Guideline &
Regional Practice: Lessons Learned from
Early-Onset Group B Strep Prevention.
Christopher Morabito, M.D., Krista Casey, B.A.,
Debra Carter, M.D., Scott Rice, M.D., Michael
Schwartz, M.D.
Presented By: Christopher Morabito, M.D.,
Chief of Neonatology, Pediatrics, Lehigh Valley
Health Network, 1200 S. Cedar Crest Boulevard,
Allentown, PA 18105, Phone: (610) 402-7632, Fax:
(610) 402-7600,
Email: christopher.morabito@lvh.com
Research Objective: Like many health care
organizations, we have sought to implement
clinical practice guidelines (CPG) in accordance
with national standards. In August 2002, the
CDC published new guidelines aimed at
minimizing the incidence of early-onset Group B
Strep (GBS) disease in newborn infants, with a
goal of <0.5 per 1000 by 2010. These guidelines
were implemented locally in October 2002. We
sought to determine whether implementation of
a national CPG (in this case the CDCs GBS
prevention guidelines, 2002) at a large
community hospital improves quality and health
outcomes.
Study Design: The setting is an academic
community hospital with a Level III NICU and a
regional perinatal center (3,300 deliveries per
year). The study period spanned March 2001
through March 2004 and included time before
and after the implementation of the CPG in
October 2002. All live births were included for
analysis. Outcome measurements include the
incidence of disease (blood culture), laboratory
test utilizations, and mean variable costs. A
novel model to prevent GBS is proposed.
Population Studied: All inborn neonates in the
normal newborn and intensive care nurseries at
Lehigh Valley Hospital in Allentown, PA.
Principle Findings: 12,893 live births were
studied. Implementation of the CPG increased
the number of blood cultures (p<0.001), number
of complete blood counts (p<0.001), total
number of laboratory evaluations (p<0.001), and
the number of newborns treated (p<0.001), but
decreased the total number of newborns
evaluated (p<0.001). There was a trend towards
increased incidence of maternal GBS-positive
status (NS). There were a total of 3 cases of GBS
during the period, all after the implementation of
the CPG. 21 patients were treated per case
- 20 -
prevented and the mean variable costs were
$3185 per case prevented.
Conclusions: While the local incidence of
disease is low (0.23 per 1000), the overall quality
of care was not improved. Generally, adherence
to the CPG was good, but the CPG based on
national guidelines did not improve clinical
outcomes and resulted in increased expense.
Implications for Policy, Practice or Delivery:
We believe that while community hospitals
should follow the lead of academic, professional
and governmental health care organizations,
national standards of care may not be
appropriate for local organizations. Using the
expanding evidence base, we have developed a
novel evidenced-based practice model that will
treat 7 patients per case prevented and decrease
mean variable costs to $931 per case prevented
and improve quality.
services following the index asthma ED visit was
associated with the risk of a subsequent ED
asthma visit. The model controlled for age,
gender, race (African-American vs. White),
geographic location (urban vs. rural), and
asthma severity as characterized by high shortacting beta-agonist use (6 or more dispensings a
year).
Population Studied: A total of 3,839 children
with persistent asthma were included in the
cohort, with 1,772 (46.2%) female, 2,562 (66.7%)
African-American, and 3,410 (88.8%) living in
urban areas; mean age (2002) was 10 years.
Principle Findings: Of these children, 116
(4.3%) had controller medications or controller
medication and an office visit within 30 days of
their asthma ED visit. Similarly, 119 (3.1%) had
an office visit only; the remaining children
(92.6%) had neither an office visit or controller
medication within 30 days of their ED asthma
visit. Controlling for demographics and severity,
those who did not have an office visit or
controller medications were 1.8 times as likely to
have a subsequent ED asthma visit (p<.0001)
compared to those who had controller
medication or controller medication and an
office visit (hazard ratio = 1.8, 95% CI= 1.3 ---- 2.5).
Those who only had an office visit were 2.0 times
as likely to have a subsequent ED asthma visit
(p=.002) compared to those who had controller
medication or controller medication and an
office visit (hazard ratio = 2.0, 95% CI= 1.3 ---- 3.1).
Conclusions: The vast majority of children with
persistent asthma do not have health services
use following an asthma ED visit that is
consistent with NHLBI recommendations.
Receipt of an office visit alone is not associated
with decreased risk of subsequent asthma ED
visits. However, use of asthma controller
medications - alone, or in combination with an
office visit - is associated with decreased risk of
subsequent asthma ED visits.
Implications for Policy, Practice or Delivery:
Improving post-ED review of the use of
appropriate long-term controller medications
may be an effective mechanism to reduce repeat
ED visits for asthma among Medicaid enrollees.
Funding Source(s): Child Health Evaluation and
Research Unit, Division of General Pediatrics,
University of Michigan.
™The Effect of Follow-Up Care on Repeat
Pediatric Asthma Emergency Department
Visits
Kamilah Neighbors, M.H.S.A., Acham
Gebremarium, M.S., Kevin Dombkowski,
Dr.P.H., M.S.
Presented By: Kamilah Neighbors, M.H.S.A.,
Ph.D. Student, Child Health Research and
Evaluation Unit, University of Michigan, 300 N.
Ingalls Room 6E08, Ann Arbor, MI 48106-0456,
Phone: (734) 649-1571, Fax: (734) 615-0616,
Email: kamilahn@umich.edu
Research Objective: To 1) describe the degree
to which children receive care consistent with
National Heart, Lung and Blood Institute
(NHBLI) guidelines and 2) associate this care
with subsequent ED usage for asthma.
Study Design: We conducted a retrospective
cohort analysis of claims for children 5-18 years
old with persistent asthma (using HEDIS
criteria) continuously enrolled in Michigan
Medicaid (2001-04). Eligible cases were
identified as those with an initial (index) asthma
ED visit in 2002-2003; asthma utilization history
was also recorded for the year prior (2001) and
subsequent (2004) to the eligibility period.
Asthma health services use was assessed for a
period of 30 days following the index asthma ED
visit and included: office visit (using CPT and
ICD-9 Codes) and controller medication
dispensing (using National Drug Codes). The
outcome of interest was time (days) until
subsequent asthma ED visit. We used Cox
proportional hazard regression analysis to
determine if the receipt of asthma health
™Repeat Pediatric Asthma Emergency
Department Visits among Frequent Users of
Short-Acting Beta-Agonists
Kamilah Neighbors, M.H.S.A., Acham
Gebremariam, M.S., Kevin Dombkowski,
Dr.P.H., M.S.
- 21 -
Presented By: Kamilah Neighbors, M.H.S.A.,
Ph.D. Student, Child Health Evaluation and
Research Unit, University of Michigan, 300 N.
Ingalls Room 6E08, Ann Arbor, MI 48106-0456,
Phone: 734-649-1571, Fax: 734-764-2599, Email:
kamilahn@umich.edu
ED asthma visits. Although it is feasible to
identify this population with either NHLBI or
literature-based criteria, the risk of subsequent
ED visits was nearly identical among those
identified with the less conservative (literaturebased) criterion.
Implications for Policy, Practice or Delivery: A
substantially larger group of children with
asthma may be at risk for repeat ED use than
those identified by NHLBI criteria for SABA
overuse. Using criteria less restrictive than
NHLBI definitions of high SABA use may be an
effective mechanism for healthcare providers
and public health officials to identify poorly
controlled asthma cases for intervention targeted
at achieving long term control of asthma
symptoms.
Funding Source(s): Child Health Evaluation and
Research Unit, Division of General Pediatrics,
University of Michigan.
Research Objective: The objectives of this study
were to 1) examine alternative definitions of
short-acting beta-agonist (SABA) overuse among
children with asthma and 2) assess the
association between SABA overuse and
subsequent asthma ED visits.
Study Design: We conducted a retrospective
cohort analysis of claims for children 5-18 years
old with persistent asthma (using HEDIS
criteria) continuously enrolled in Michigan
Medicaid (2001-04). Eligible cases were
identified as those with an initial asthma ED visit
in 2002-2003; asthma utilization history was also
recorded for the year prior (2001) and
subsequent (2004) to the eligibility period.
SABA dispensings were identified from
pharmacy claims (using National Drug Codes)
and overuse was defined using two alternative
criteria: >5 annual dispensings (literature-based
criteria) and >12 annual dispensings (National
Heart, Blood, and Lung Institute criteria). The
specific outcome of interest was time (days)
until subsequent asthma ED visit. We used Cox
proportional hazard regression analysis to
determine if SABA overuse was associated with
the risk of a subsequent ED asthma visit. The
model controlled for age, gender, race (AfricanAmerican vs. White), geographic location (urban
vs. rural), and controller medication use (1 or
more dispensings a year).
Population Studied: A total of 3,839 children
with persistent asthma were included in the
cohort, with 1,772 (46.2%) female, 2,562 (66.7%)
African-American, and 3,410 (88.8%) living in
urban areas; mean age (2002) was 10 years.
Principle Findings: Of these children 370
(9.6%) had >5 SABA dispensings and 78 (2.0%)
had >12 SABA dispensings in 2001. Controlling
for demographics and asthma controller
medication use, those who had >5 SABA
dispensings were 1.5 times as likely to have a
subsequent ED asthma visit (p<.0001)
compared to those who had <= 5 dispensings
(hazard ratio = 1.5, 95% CI= 1.2 ---- 1.8). Similarly,
those who had >12 SABA dispensings were 1.4
times as likely to have a subsequent ED asthma
visit (p=.032) compared to those who had <= 12
dispensings (hazard ratio = 1.4, 95% CI= 1.0-1.9).
Conclusions: Overuse of SABA medication is
associated with an increased risk of subsequent
™Assessing Adolescent Caregiver's Decision-
Making Ability to Recognize Child Illness
Severity & Utilize Health Care Resources
Using the CROSS scale
Christine Nelson, D.N.S., R.N.C., P.N.P.
Presented By: Christine Nelson, D.N.S., R.N.C.,
P.N.P., Research Assistant Professor, School of
Nursing, University at Buffalo, 11127 Alaura
Drive, Alden, NY 14004, Phone: (716) 651-9957,
Fax: (716) 829-2021,
Email: cnelson2@buffalo.edu
Research Objective: Adolescents who are
parents or caregivers to small children must
learn to recognize symptoms of illness severity
and make decisions regarding appropriate health
care management that is safe and cost-effective.
This study identifies factors that influence this
decision-making process, which can alert health
care providers to a need for education in this
high-risk population.
Study Design: Prior psychometric analysis of the
Caregiver Recognition of Symptom Severity Scale
(CROSS) established adequate validity and
reliability (Nelson, 2005). Secondary analysis of
demographic data used in a study to test the
psychometrics was performed using ANOVA to
evaluate group differences in scores on the
CROSS scale related to age, school grade,
ethnicity, type of residence, and child care
experience. Participants determine how ill they
think the child is (mild, moderate or severely ill)
and the health care management needed (home
care, office, emergency department).
- 22 -
Population Studied: An ethnically and socioeconomically diverse sample of 702 parenting
and non-parenting male and female adolescents,
13 to 19 years of age participated.
Principle Findings: No differences were found
among mean scores on factors of age, school
grade and residence (who they reside with) in
illness recognition or management. Significant
gender differences were present in ability to
accurately identify severe illnesses but not in
management. Childcare experience was a
significant factor in moderate illness recognition
and management of severe illnesses. Mean
scores for teens with childcare experience were
more predictive for appropriate management of
all illness severities. Ethnicity was not a
significant factor in illness recognition. There
were significant differences in choices of
appropriate management among white, black
and Hispanics.
Conclusions: Groups at high risk for errors in
illness identification and management can be
targeted for additional childcare education and
assistance by their health care providers. The
need for assistance with these tasks is especially
important for teen parents.
Implications for Policy, Practice or Delivery:
The CROSS scale can be easily used by health
care clinicians in health education classes to
evaluate the ability of adolescent parents and
caregivers to recognize illness severity in small
children and chose appropriate and cost-effective
health care options before the need arises in
their caregiving roles.
Funding Source(s): Sigma Theta Tau Gamma
Kappa Chapter and Nursing Economics
Foundation
described. Our objectives were: 1. To identify
clinical quality measures that may be used to
assess the quality of care provided to children
hospitalized with asthma exacerbations. 2. To
evaluate provider compliance with these
measures
Study Design: We identified key asthma quality
measures using the RAND appropriateness
method combining a literature review of asthma
practice guidelines and evidence-based
recommendations with an expert panel
consensus. Clinical measures were selected
based on published evidence demonstrating a
link between specific asthma care processes and
defined patient outcomes. Provider compliance
with these clinical measures was evaluated
through a retrospective manual chart review of
250 children > 2 years of age admitted in 2005
for asthma exacerbations to Primary Children’s
Medical Center, a tertiary care children’s
hospital.
Population Studied: Children > 2 years of age
admitted in 2005 for asthma exacerbations to
Primary Children’s Medical Center, a tertiary care
children’s hospital.
Principle Findings: A total of 22 clinical quality
measures were identified and 8 met the
inclusion criteria of published evidence of an
existing link between process and outcome: Four
were specific to inpatient care and four were
related to re-exacerbation/re-admission
prevention. Inpatient care specific clinical
measures included acute asthma severity
assessment at the time of admission, use of
Ipratropium Bromide (IB) restricted to less than
24 hours after admission, use of oral (not IV)
systemic corticosteroids, use of albuterol
delivered by MDI (not nebulized) as age
appropriate. Re-exacerbation/readmission
prevention measures included a documented
chronic asthma severity assessment, parental
participation in an asthma education class,
written asthma action plan and scheduled followup appointment with the primary care provider
(PCP) at discharge. Provider compliance with
these measures demonstrated: 38% of children
were assessed for acute asthma severity. 76% of
children received IB for less than 24 hours after
admission. 82% of children received oral
steroids. 23% of children received albuterol
delivered by MDI during hospitalization. 19% of
children were assessed for chronic asthma
severity. 39% of parents attended asthma
education class and 22% had scheduled
appointment with the PCP at discharge. Few
patients had a written asthma action plan.
™Quality of Care for Children Hospitalized
with Asthma Exacerbations
Flory Nkoy, M.D., M.S., M.P.H., Bernhard Fassl,
M.D., Tamara Simon, M.D., M.S.P.H.,
Christopher Maloney, M.D., Ph.D., Brent James,
M.D., M.Stat., Rajendu Srivastava, M.D., M.P.H.
Presented By: Flory Nkoy, M.D., M.S., M.P.H.,
Research Assistant Professor/Research Director,
Pediatric Inpatient Medicine, University of Utah
(Primary Children's Medical Center), 100 North
Medical Drive, 3rd floor, Salt Lake City, UT 84113,
Phone: (801) 662-3660, Fax: (801) 662-3664,
Email: flory.nkoy@hsc.utah.edu
Research Objective: Pediatric asthma is
associated with significant morbidity. However,
the quality of inpatient care provided to children
with asthma exacerbations has not been well
- 23 -
Conclusions: The overall quality of care
provided to hospitalized children, based on
these clinical measures, is suboptimal.
Implications for Policy, Practice or Delivery:
This study uncovers several clinical care process
issues that require provider targeted
interventions to improve the quality of asthma
care in hospitalized children.
public health department. Less than half,
40percent, of pediatricians view vaccine
reimbursement from both public and private
insurers as adequate; 30percent view the
reimbursement for vaccine administration costs
as adequate. In comparison, 55percent say VFC
reimbursement for vaccines is adequate and
40percent say the VFC administration fee is
adequate. Multivariate analysis shows
pediatricians in solo or 2-physician practices are
less likely than those in other settings to say
public or private insurers adequately reimburse
for vaccine purchase and administration costs.
Four out of ten pediatricians, 41percent, say they
would be very or somewhat likely to provide a
vaccine if the purchase price is greater than the
reimbursement. Two-thirds, 65percent, are very
or somewhat likely to give a VFC vaccine to an
eligible un- or under-insured child even if not
paid an administration fee rather than refer to a
public health clinic. Those in hospital or clinic
practice are more likely to give a vaccine if price
exceeds reimbursement, 58percent v 36percent
group v 22percent solo, p equals .05, and give a
VFC vaccine with no administration fee,
77percent v 67percent v 41percent, p equals .01.
Conclusions: Less than half of pediatricians
think vaccine reimbursement from private and
public health insurance is adequate and fewer
think reimbursement for administration costs
are adequate. Opinions regarding VFC
reimbursements are more positive. Most
pediatricians are reluctant to provide a vaccine
when the purchase price exceeds the
reimbursement but will forego an administration
fee to give a VFC vaccine to an uninsured child
rather than refer to the public health department.
Implications for Policy, Practice or Delivery:
The number and costs of vaccines are increasing
which is affecting pediatricians’ ability to provide
comprehensive care. Continued efforts are
needed to assure adequate payment by insurers
and by the government to cover vaccine
purchase, storage and administration costs.
Funding Source(s): CDC, American Academy of
Pediatrics
™Are Reimbursement Levels for Vaccines &
Administration Costs Adequate? A National
Survey of Pediatricians
Karen O'Connor, David L. Wood, M.D., M.P.H.,
Kempe Allison, M.D., M.P.H., Denia Varrasso,
M.D., Maureen Kolasa, R.N., M.P.H., Abigail
Shefer, M.D.
Presented By: Karen O'Connor, Survey
Manager, Department of Research, American
Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, IL 60007, Phone:
(847) 434-7630, Fax: (847) 434-4996, Email:
koconnor@aap.org
Research Objective: To examine pediatricians’
perception of adequacy of reimbursement for
vaccine purchase and administration costs and
their willingness to provide immunizations given
different levels of reimbursement.
Study Design: A national random sample,
mailed Periodic Survey of Fellows conducted by
the American Academy of Pediatrics, AAP, in
2006, N equals 1620; response equals 53
percent. Questions assessed whether
pediatricians provide or refer for immunizations
under various reimbursement conditions, as well
as perception of adequacy of reimbursement for
vaccines and administrative costs. Bivariate and
multivariate analysis examined associations
between pediatricians’ demographic and practice
characteristics and their reported practices.
Population Studied: 629 nonretired, United
States members of the AAP who offer
immunizations in their practice.
Principle Findings: On average pediatricians
reported patients’ coverage for vaccines as:
20percent are fully covered by private insurance,
23percent are partially covered by private
insurance, 20percent are covered by public
insurance, 31percent by the Vaccines for Children
Program, VFC, and 6percent have no coverage
for vaccines. Sixty percent of pediatricians say
they always and 15percent sometimes provide
VFC or publicly purchased immunizations for
patients with no insurance coverage or a high
vaccine co-pay; about 30percent each say they
always or sometimes refer these patients to the
™Delivery of Asthma Education & Pediatric
Asthmatics: Is It Effective?
Jeannette Oshitoye, Ph.D., M.S.A.S., M.P.A.
Presented By: Jeannette Oshitoye, Ph.D.,
M.S.A.S., M.P.A., 2909 Buckner Boulevard,
Dallas, TX 75044, Phone: (214) 676-3560,
Email: oshitoye@msn.com
- 24 -
Research Objective: To determine whether
asthmatic patients are receiving required
educational information to self-manage their
asthma as outlined in the National Asthma
Guidelines (NAGs). Cote et al. (2001) indicate
that the single prescription of a self-action plan
does not diminish asthma morbidity. When
patients with asthma are not given sufficient
information and reinforcement, they do not
seem to have enough self-confidence to increase
the dosage of inhaled corticosteroids according
to asthma symptom severity or PEF. The NAGs
offer specific techniques that allow physicians to
provide both information and reinforcement.
These strategies include the provision of
understanding causes and triggers, proper
metered dose inhaler and peak flow meter use,
following written guidelines, keeping written
diaries, and evaluating results of treatment. The
guidelines specify that there should be a strong
emphasis on education in patients at the time of
diagnosis and as part of continuing care. The
NAGs list detailed strategies, including
understanding causes and triggers, following
written guidelines, keeping written diaries, and
evaluating results of treatment, teaching of
asthma self-management, basic facts about
asthma, roles of medications, skills such as how
to use their inhaler, spacer, holding chamber,
and how to self-monitor. Most studies that have
been completed to date have tried to determine
the concordance between physician practice and
the NAGs on the basis of pharmacological
management. Fewer numbers have looked at
whether physicians’ provision of asthma
education is in concordance with the NAGs.
Finkelstein et al. (2000) found that only half of
those pediatric and family physicians they
surveyed reported providing written care plans.
Legorreta et al. (1998) found that only 26% of
asthmatics reported having a peak flow meter.
Krishnan et al. (2001) found that fewer African
Americans than whites reported care consistent
with recommendations for self-management
education.
Study Design: This study is a retrospective study
which analyzes data from the National Asthma
Survey. It uses a logit regression to predict the
probability of a pediatric asthma patient
receiving appropriate educational information as
outlined in the NAGs.
Population Studied: U.S. asthmatics between
the ages of 5-17 years old.
Principle Findings: The literature clearly
documents that in the U.S., minority groups are
least likely to receive treatment in accordance
with established guidelines. Similar findings
have been documented in relation to the
provision of educational information that allows
patient self-management. However, this study
found that African Americans received similar
information as their Caucasian counterparts.
Only those individuals who self-identified as
Latino were least likely to receive the required
medications as outlined by the NAGs.
Conclusions: Those individuals who self-identify
as Latino are least likely to receive the required
medications as outlined by the NAGs. Thus,
steps need to be taken to address this group,
either through re-release of the NAGs or some
other mechanism.
Implications for Policy, Practice or Delivery:
Given the increasing number of Latinos in the
U.S., if the delivery of information which it
technically free does not meet the required levels
in this population, the U.S health care system
could experience increased cost outlays in the
area of asthma as seen in the 80s and 90s.
™Making the Connection Between School-
Based Health Programs & Academic
Achievement: Practical Experiences from the
Dallas Independent School District Youth &
Family Centers
Jeannette Oshitoye, Ph.D., M.S.A.S., M.P.A.
Presented By: Jeannette Oshitoye, Ph.D.,
M.S.A.S., M.P.A., Evaluator, Research and
Evaluation, Dallas Independent School District,
2909 S. Buckner Boulevard, Dallas, TX 75044,
Phone: (214) 676-3560,
Email: oshitoye@msn.com
Research Objective: School-based health
centers (SBHCs) began emerging in the late
1960s in recognition of the increasing number of
children who lacked access to health care.
Efforts to document the connection between
school health programs and academic
improvement have become more urgent due to
the increasing accountability pressures placed on
schools by the No Child Left Behind. Districts
must now document improvements in school
achievement for all their campuses, and because
SBHCs are part of the school system they are not
exempt. The objective of this presentation is to
illustrate how the Dallas Independent School
District (DISD) established SBHCs to deliver
services to their most disadvantaged clientele.
And how the services provided by the centers
have been successfully linked to academic
achievement measures.
Study Design: Using data from the 30,747
students and their families served in 2004-2005
- 25 -
™Why WIC Appears to Improve Birth
Outcomes: Evidence of Gestational Age Bias
and 2005-2006 who received 75,207 services.
Promotion rates, Texas Assessment and
Knowledge and Skills (TAKS) the state mandated
test which evaluates student learning based on
the state-required curriculum and attendance
rates. Clients seeking services were divided into
four groups ---- low-frequency and high-frequency
physical health clients, low-frequency and highfrequency behavioral health clients. Data were
analyzed first by year, for each of the outcome
variables using paired t-tests and chi-square
analysis. Secondary analysis was conducted
using longitudinal data of those clients who had
received services for more than one year.
Population Studied: The study populations
consisted of DISD students (ages 4-21years old)
and their parents who used the nine Youth and
Family Centers to receive physical health and
behavioral health services in 2004-2005 and
2005-2006 school years.
Principle Findings: Initial analysis showed that
students using the Youth and Family Centers for
either physical or behavioral health services had
lower rates in terms of promotion, attendance,
and TAKS passing rates than students in the
control group who did not use the Youth and
Family Centers. However, when comparisons
were made between physical health and
behavioral health cohorts and matched control
groups results were favorable for the Youth and
Family Centers. In both years there was no
difference in outcome measures for the
treatment group and the control group. In fact,
in 2005-2006 passing rates were higher for those
students receiving behavioral health services
from the Youth and Family Centers despite the
increase morbidity burden.
Conclusions: The findings of this study show
that the DISD’s Youth and Family Centers are
having a positive effect on improving student
achievement outcomes and have the ability to
document these results. The method used to
analyze the data is as important as providing
services in a school-based health program.
Implications for Policy, Practice or Delivery:
Many SBHCs have closed due to funding
shortages because of their inability to link
academic achievement with the services
provided. These centers are responsible for
reducing the number of children who lack access
to health care. Thus, as the numbers of children
who are eligible for SCHIP are being reduced
because of state funding constraints, it is
important that the number of SBHCs, who can
serve as a safety-net, continue to increase. This
can only be accomplished if funding is constant.
Andrew D. Racine, M.D., Ph.D., Theodore J.
Joyce, Ph.D., Christina Yunzal-Butler, M.A.
Presented By: Andrew D. Racine, M.D., Ph.D.,
Director, Division of General Pediatrics,
Pediatrics, Albert Einstein College of Medicine /
Children's Hospital at Montefiore, 1621
Eastchester Road, Bronx, NY 10461, Phone: (718)
405-8092, Fax: (718) 405-8091, Email:
aracine@montefiore.org
Research Objective: To estimate the effect of
participation in the WIC program on birth
outcomes, we compared, among singleton
births, the mean birth weight (BW), percent of
small for gestational age deliveries (SGA), rates
of premature birth (PREM), and rates of low
birth weight (LBW) of prenatal WIC enrollees by
trimester of enrollment to that of post-natal WIC
enrollees.
Study Design: A cross-sectional analysis of data
from the Pregnancy Nutrition Surveillance
System was conducted on all singleton live
births for which complete information was
available. Multivariate OLS and marginal Probit
regressions were used to estimate the effect of
WIC, by trimester of enrollment, on mean BW,
percent SGA, percent PREM, and LBW rate
adjusted for maternal demographics and other
program participation characteristics.
Population Studied: All singleton deliveries
among WIC participants in North Carolina for
the years 1996-2003 (N=356,495). The sample
was 45% white, 36% black, and 13% Hispanic;
9% of mothers were under 18 years of age, 53%
were between 18 and 24; 26% of mothers had
less than high school education.
Principle Findings: Compared to post-partum
WIC enrollees, prenatal participants had 87.2 gm
higher mean BW (p<0.01), 0.9% lower percent
of SGA deliveries (p<0.01), 3.9% lower rate of
PREM (p<0.01), and 3.2% lower LBW rates
(p<0.01). Compared to post-partum enrollees,
adjusted WIC effects for first, second, and third
trimester of enrollment respectively were BW
increases of 69.6 gms, 75.0 gms, and 130.1 gms
(p<0.01 for all); SGA decreases of 1.3%, 0.7% ad
0.5% (p<0.01 for all); PREM decreases of 2.0%,
2.8%, and 5.5% (p<0.01 for all); and LBW rate
decreases of 2.0%, 2.2%, and 4.2% (p<0.01 for
all). Thus earlier WIC enrollment produced
greater improvements in SGA but later WIC
enrollment produced greater improvements in
PREM, BW, and LBW.
- 26 -
Conclusions: These findings suggest that
inclusion of third trimester WIC enrollees in
cross sectional analyses of WIC effects on birth
outcomes introduces a gestational age bias that
accounts for much of the program's observed
effects on mean birth weight and on the
probability of a premature or LBW delivery.
Implications for Policy, Practice or Delivery:
The overall impact of the WIC program on birth
outcomes may have been overestimated in
previous research. Further careful analysis that
takes into account the timing of enrollment may
help to elucidate the true impact of this
important public health initiative on birth weight
and prematurity.
Funding Source(s): U.S.D.A.
Population Studied: 5,513 subjects aged 0 to 21
years of age who recorded 26,700 follow-up
visits during the 300 day study period were
tracked. Of the total sample, 34% were African
American, 56% Hispanic, 52% male, and 44%
had publicly financed health insurance. The age
distribution indicated that 15% were infants, 18%
toddlers, 31% adolescents and the remainder
school aged. The 50% randomized to the
intervention group did not differ from the control
subjects in the above parameters.
Principle Findings: Compared to control
subjects, intervention subjects had lower rates of
follow-up Pediatric ED visits (OR 0.88; p<0.001),
higher rates of pediatric sub-specialty visits (OR
1.11; p<0.001) and no difference in
hospitalizations during the follow-up period.
During weekday office hours, intervention
patients had fewer mean number of Pediatric ED
visits (1.70 vs 1.88; p<0.001); higher mean
number of pediatric sub-specialty visits (4.8 vs
3.5; p<0.001) and slightly more hospitalizatoins
(0.56 vs 0.51; p<0.03). Mean number of followup primary care visits did not differ between the
two groups.
Conclusions: The use of follow-up phone calls
from the primary care office to counsel families
regarding ED use and primary care availability is
a useful tool that can successfully modify
subsequent care seeking behavior in pediatric
populations.
Implications for Policy, Practice or Delivery:
Follow-up phone calls after an initial emergency
department visit represent low cost interventions
requiring little modification of existing practice
operations that have the potential to generate
significant cost savings by modifying subsequent
care seeking behavior during episodic illness in
pediatric populations.
Funding Source(s): CWF
™Decreased Use of the Pediatric Emergency
Department: Just a Phone Call Away
Andrew D. Racine, M.D., Ph.D., Elizabeth M.
Alderman, M.D., Jeffrey R. Avner, M.D.
Presented By: Andrew D. Racine, M.D., Ph.D.,
Director, Division of General Pediatrics,
Pediatrics, Albert Einstein College of Medicine/
Children's Hospital at Montefiore, 1621
Eastchester Road, Bronx, NY 10461, Phone: (718)
405-8092, Fax: (718) 405-8091, Email:
aracine@montefiore.org
Research Objective: To test whether a follow-up
phone call to counsel families about Pediatric
emergency department (ED) use and primary
care availability, made by the primary care
practice within 72 hours of a Pediatric ED visit,
would modify subsequent decisions to seek care
in the Pediatric ED.
Study Design: A longitudinal prospective
intervention wherein subjects who visited a
Pediatric ED from April-December 2005 and who
received their primary care at any of four
pediatric practices associated with an urban
academic medical center, were randomized to
receive either routine recommendations to
follow-up with their primary care practice or to
receive an intervention consisting of a follow-up
phone call from the primary care practice within
72 hours of the initial Pediatric ED visit. All
subsequent visits to the primary care practice, to
the Pediatric ED, to pediatric sub-specialists, or
for inpatient hospitalization were recorded for
each subject during a 300 day follow-up period.
Logistic and OLS regressions were used to
estimate unadjusted and adjusted odds ratios
and mean number of follow-up visits of various
types.
™Pathways into Mental Health Services &
Risk of Polypharmacy among Adolescents in
Foster Care
Ramesh Raghavan, M.D., Ph.D., J. Curtis
McMillen, Ph.D.
Presented By: Ramesh Raghavan, M.D., Ph.D.,
Assistant Professor of Social Work and
Psychiatry, George Warren Brown School of
Social Work, Washington University in St. Louis,
Campus Box 1196, One Brookings Drive, St.
Louis, MO 63130, Phone: (314) 935-4469, Fax:
(314) 935-8511, Email: raghavan@wustl.edu
Research Objective: To examine associations
between pathways into mental health services
- 27 -
and risk of polypharmacy (concurrent use of
greater than 3 psychotropic medications) among
older youth in foster care.
Study Design: Consecutive sample of 403 youth
in foster care in a Midwestern state. Youth
about to age out of foster care were identified by
the state child welfare system, and trained
interviewers conducted in-person interviews
within participants’ homes following informed
consent/assent. Outcome variable was selfreport of number of psychotropic medications
currently consumed by participants, validated by
medication container audits where available.
Predictors included sociodemographic
characteristics, history and type of maltreatment,
current placement status, history of stability of
placement, and current (past 12 months) DSMIV psychiatric diagnosis as obtained from the
Diagnostic Interview Schedule. Information on
pathways into mental health care utilized in the
past 12 months was elicited. These included:
direct specialty and non-specialty mental health,
emergency room, self-help group, special
education, and school-based services. We
developed 2-stage logistic regression models
estimating odds of any medication use, and then
odds of polypharmacy conditional upon any
medication use controlling for individual-level
characteristics, and type of pathway into care.
Population Studied: 403 adolescents aged 17
years about to age out of foster care in a
Midwestern state. Data were obtained from inperson interviews conducted with these
participants between December 2001 and June
2003.
Principle Findings: Overall counts of concurrent
psychotropic medications ranged from 0 to 6.
Most youth (63%) reported taking no
psychotropic medications at all, while 6.4%
reported being on greater than 3 psychotropic
medications simultaneously. On the model
predicting any use of psychotropic medications
(first stage), youth of color had 0.3 times the
odds of taking any psychotropic medications.
Youth placed in family foster care or in
congregate care settings (OR=2.3), and with
diagnoses of bipolar disorder (OR=6.5) or major
depressive episode (OR=3.1) had higher odds of
receiving any psychotropic medication.
On models estimating associations between of
service pathways and polypharmacy conditional
upon any use (second stage), youth with past 12
month use of non-specialty mental health
services had significantly lower odds of
polypharmacy (OR=0.1). Youth who had used
school-based services were at significantly higher
risk of polypharmacy (OR=3.1) controlling for
psychiatric diagnosis, sociodemographic
characteristics, and maltreatment history.
Conclusions: Youth in the child welfare system
seem to be at differential risk of polypharmacy
depending on the service pathways they utilize in
order to seek care. While we do not expect
service pathways to be associated with
polypharmacy controlling for psychiatric
diagnosis, youth receiving non-specialty services
are at lower risk, and those receiving schoolbased services are at higher risk, for
polypharmacy.
Implications for Policy, Practice or Delivery:
Child welfare agencies should consider carefully
examining the quality of school-based mental
health services received by youth in foster care,
with specific reference to behavioral problems
warranting medication use, assessment
instruments, referral mechanisms, and the
provider doing the prescribing.
Funding Source(s): NIMH
™After-Hours Telephone Triage- An Analysis
of the Content and Acuity of After-Hours Calls
to a Joint Academic & Community Service
Kathleen Ryan, M.D., Katerina Backus, Sanjeev
Tuli, M.D., Lindsay Thompson, M.D., M.S.
Presented By: Kathleen Ryan, M.D., Pediatrician,
Pediatrics, University of Florida, 1701 SW 16th
Avenue, Building A, Gainesville, FL 32608,
Phone: (352) 334-1357, Fax: (352) 334-1348, Email:
ryanka@peds.ufl.edu
Research Objective: Providing after-hours
access to health advice is critical for patient care,
but it is costly, as phone calls are not
reimbursable, time consuming, and burdensome
to providers. Little is known about the content or
relative urgency of after-hours calls. Pediatric
After-Hours (PAH) is a joint community and
academic service for children who attend one of
fourteen practices in Gainesville, FL that
provides telephone triage, advice, and outpatient
visits during weeknights and weekends. We
hypothesize that while the majority of calls are
relevant and necessary, a subset are non-urgent.
Study Design: We evaluated the content and
relative urgency of 100 consecutive calls to PAH
in May and October 2005. Routinely generated
call summaries provided a record of patient age,
primary practice, and chief complaint; they do
not record race, ethnicity or insurance status.
The chief complaint was classified into 13
common pediatric diagnoses or an ‘other’
category and separately into 5 levels of urgency:
1. Unnecessary, administrative or chronic non-
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™Reliability & Validity of an Objective Tool to
Assess Inappropriate Antibiotic Prescribing
from Visit Videotapes
urgent problems; 2. Questions better served by
the primary provider during day hours; 3. Advice
that could not wait until day hours; 4. Immediate
PAH visit or, if overnight, visit to the primary
provider once opened; 5. Immediate Emergency
Department referral. Calls in levels 1 or 2 were
defined as non-urgent.
Population Studied: Pediatric patients (0 - 21
years) who utilized the PAH telephone service
from fourteen contributing practices; four are
University-affiliated and ten are solo or group
practices.
Principle Findings: Of all calls, 5.0% were
classified as level 1; 26.0% level 2; 32.0% level 3;
28.0% level 4 and 9.0% level 5. Calls were most
commonly for toddlers (1-4 years) and infants (612 months, 59.0% total).The most frequent
diagnoses across all levels of urgency were
‘other’ (27.0%), fever (22.0%), URI (18.0%) and
major illness/ trauma (12.0%). Urgent and nonurgent calls both had ‘other,’ fever, and URI as
the most frequent diagnoses. However, the
proportion of ‘other’ significantly varied (21.7%
urgent vs 55.1% non-urgent, p<.001), while the
frequencies of fever (21.7% vs 24.1%) and URI
(18.8% vs 17.2%) remained constant (p=ns).
Qualitative review of non-urgent ‘other’ calls
revealed a broad range of minor complaints such
as ‘flushed cheeks’ and over the counter
medication doses. Patients of academic and
community practices were equally likely to call
for all levels of acuity.
Conclusions: While the majority of after-hours
calls were necessary, a third were non-urgent.
Calls in the ‘other’ category, while frequent, did
not follow an identifiable pattern; fever and URI
were the most common medical diagnoses
regardless of level of urgency. Patients belonging
to academic and community practices had
similar utilization.
Implications for Policy, Practice or Delivery:
These data suggest that while providing afterhours advice is integral to patient care, reducing
non-urgent calls could improve the clinic
workload. Because caregivers seem unable to
discern the relative urgency of complaints,
especially for fever and URI, enhanced
anticipatory guidance about the varied
presentations of fever and URI and the types of
symptoms that indicate increased severity may
reduce the burden of non-urgent calls. Calls
classified as ‘other,’ with their broad range of
complaints, may be harder to modify.
Saurabh Saluja, B.A., Elizabeth Dianne Cox,
M.D., Ph.D.
Presented By: Saurabh Saluja, B.A., Senior
Research Assistant, Department of Population
Health Sciences, University of Wisconsin Madison, 540 WARF Office Building; 610 Walnut
Street, Madison, WI 53726, Phone: (608) 2629959, Fax: (608) 263-2820, Email:
ssaluja2@wisc.edu
Research Objective: Studies of inappropriate
antibiotic prescribing often rely on physician
report of diagnosis and prescribing, although the
Hawthorne effect significantly biases these
reports (i.e., increased reporting of a bacterial
diagnosis for what are likely viral illnesses). We
develop a reliable, objective method to assess
inappropriate antibiotic prescribing from upper
respiratory infection (URI) visit videotapes by
assessing key clinical criteria for sinusitis, otitis
media and streptococcal pharyngitis. These
criteria, derived from guidelines for judicious
antibiotic prescribing, support determination of
objective diagnoses which can then be used to
assess appropriateness of prescribing.
Study Design: Two trained coders assessed key
clinical criteria and physician-stated diagnosis
and prescribing during videotaped pediatric
visits. The three bacterial URIs of interest were
streptococcal pharyngitis (clinical criteria are
rapid antigen detection test or throat culture),
sinusitis (nasal symptoms, cough, and fever
>39.2° or length of URI >10 days) and otitis
media (ear pain and use of pneumatic
otoscopy/acoustic reflectometry with red, yellow,
or perforated tympanic membrane). All criteria
were coded as ‘‘Present,’’ ‘‘Absent,’’ or ‘‘Not
Discussed,’’ excepting diagnostic procedures
which were coded as Present/Absent. Objective
diagnosis (otitis media, sinusitis, streptococcal
pharyngitis or non-bacterial URI) was
determined based on these clinical criteria.
Physician-stated diagnosis and prescribing were
selected from a list of common URI diagnoses
and medications. Inter-rater reliabilities were
determined for 30% (n=22) of the sample using
Cohen’s kappa or phi. Validity was determined
by comparing physician-stated diagnosis to the
objective diagnosis supported by the coded
clinical criteria, for those visits diagnosed as
non-bacterial URI (where the Hawthorne effect is
expected to be minimal).
- 29 -
Population Studied: Children’s (n=73) acute
upper respiratory infection (URI) visits to 1 of 15
physicians.
Principle Findings: For most of the key clinical
criteria (n=8; 75%), a code of ‘‘Present’’ or
‘‘Absent’’ was obtained from at least half of the
visits. Of all key criteria, ear pain was most often
coded as ‘‘Not Discussed’’ (63% of visits). All
clinical criteria assessments demonstrated
substantial or greater reliability (phi >0.67 or
kappa >0.60), excepting length of illness which
demonstrated fair reliability (kappa=0.55).
Determination of objective diagnosis from key
clinical criteria was substantially reliable
(kappa=0.74). Reliabilities for physician-stated
diagnosis were highly positive (phi>0.75 for both
bacterial URI and non-bacterial URI). Physicianstated diagnosis of non-bacterial URI matched
the objectively determined diagnosis for 78.8%
of visits; while the match was only 58.8% when
the physician stated a diagnosis of bacterial URI
(p<0.05). Reliability for determining whether an
antibiotic was prescribed was nearly perfect
(kappa=0.91).
Conclusions: Key clinical criteria used in URI
diagnoses as well as the diagnosis and
prescribing stated by the physician can be
ascertained reliably and objectively from visit
videotapes. These key clinical criteria can be
used to reliably and objectively ascertain
diagnosis for three common bacterial URIs.
Implications for Policy, Practice or Delivery:
Future work that assesses inappropriate
antibiotic prescribing could utilize this reliable,
objective technique for determining diagnosis
and reduce the impact of the Hawthorne effect
on study results.
Funding Source(s): AHRQ
multivariate analyses to determine whether an
association exists between early and adequate
prenatal care and receipt of well-baby care.
Potential confounding variables included in the
analysis were maternal age, race/ethnicity,
education, residence, primary language,
managed care plan, and smoking, and birth
plurality and birthweight. Birth data were
matched with Medicaid managed care
enrollment data to identify mothers who were
enrolled in Connecticut’s Medicaid managed
care program when they gave birth in 2003.
Maternal Medicaid managed care enrollment
data were then linked with enrollment data for
infants and their healthcare encounter records.
The analytic file was restricted to infants who
were continuously enrolled for the first 15
months of life. The association between prenatal
care utilization (early prenatal care, adequate
prenatal care) and having had 6 recommended
well-baby visits, adjusted for independent
variables, was determined using logistic
regression. Significant statistically relationships
are reported at the p<0.05 level.
Population Studied: 7,054 infants born in 2003
to mothers in Medicaid managed care and
subsequently enrolled for the first 15 months of
life.
Principle Findings: Just over half (55%) of the
infants received the 6 recommended well-baby
visits in the first 15 months of life. Bivariate
analysis revealed that infants whose mothers
initiated early prenatal care (e.g., first trimester)
were more likely to receive recommended wellbaby care. Similarly, infants with adequate
prenatal care were more likely to receive
recommended well-baby care. Factors also
associated with increased risk for not having
recommended well-baby care included younger
maternal age, non-White non-Hispanic
race/ethnicity, less than a high school education,
urban residence, and switching managed care
plan. After adjusting for these potential
confounders, no statistically significant
relationship between early prenatal care and wellbaby care was found (OR=1.06; 95% CI=0.911.21). However, having had adequate prenatal
care increased the odds of having recommended
well-baby care in the multivariate model
(OR=1.36; 95% CI=1.21-1.53).
Conclusions: Prenatal care utilization measures
can identify which infants are at risk for receiving
less than recommended well care during the
early months of life.
Implications for Policy, Practice or Delivery:
Prenatal case management can be reconceptualized as just the first step in a
™Does Prenatal Care Improve Utilization of
Well-Baby Care?
Karen Sautter, M.P.H., Priscilla Canny, Ph.D.,
Amanda Learned, B.A., Mary Alice Lee, Ph.D.
Presented By: Karen Sautter, M.P.H., Project
Manager, Health Policy and Management,
Boston University School of Public Health, 715
Albany Street, T5-West, Boston, MA 01864,
Phone: (781) 424-1477, Fax: (617) 638-5374,
Email: ksautter@gmail.com
Research Objective: To determine the
relationship between prenatal care and well-baby
care for infants born to mothers in a Medicaid
managed care program.
Study Design: This study used a cross-sectional
retrospective cohort design with bivariate and
- 30 -
continuum of care coordination for new mothers
and babies. Linking birth certificate data to
Medicaid administrative data is an effective tool
for identifying risk factors for less-thanrecommended care.
Funding Source(s): Connecticut Department of
Social Services
Population Studied: A nationally representative
sample of youth between the ages of 11 and 21
were included in this study.
Principle Findings: From the latent class
analysis, four classes of symptomatology
emerged: internalizing symptoms, externalizing
symptoms, a combination of both (i.e., most
severe), and a normative class. These classes
varied by race and ethnicity, gender, and age.
Youth in all three symptomatology classes were
more likely to access and continue mental health
care. Results from the multivariate logistic
regressions examining one time care, continued
care, and service setting showed that several
individual and environmental level factors (i.e.,
parent characteristics, race/ethnicity, gender,
and provider availability) were associated with
mental health utilization. Furthermore, youth
who accessed care were more likely to do so at
school and a doctor’s office. African-American,
Hispanic, and poor youths were more likely to
obtain care at school.
Conclusions: An apparent racial and ethnic
disparity exists for youth most in need of mental
health care, particularly in continuing care.
Additionally, minority youth were less likely to
obtain care in specialty care settings such as a
physician’s office.
Implications for Policy, Practice or Delivery:
There are several programmatic and policy
implications. Minority youth in need of mental
health care clearly need to be reached and this
could be done through schools. Schools played
a central role in obtaining mental health care for
younger youth and this was particularly true for
racial and ethnic minorities. However, since the
question of whether schools are appropriate
locations for mental health care is still debated,
there is a need for policy changes that would
ensure quality care and a standardization of
services in school mental health clinics.
™Factors Associated with Adolescents'
Mental Health Access & Patterns of
Utilization
Nancy Scotto Rosato, Ph.D., Judith Baer, Ph.D.
Presented By: Nancy Scotto Rosato, Ph.D.,
Senior Research Analyst, Center for State Health
Policy, Rutgers University, 55 Commercial
Avenue, New Brunswick, NJ 08901, Phone: (732)
932-4648, Fax: (732) 932-0069, Email:
nscottorosato@ifh.rutgers.edu
Research Objective: Epidemiological studies
have found a large gap between mental health
need and actually obtaining services by children
and adolescents. According to the 2001 Surgeon
General’s Report on children’s mental health,
20% of children needed mental health care but
only a small percentage of these children were
receiving appropriate care. These statistics are
particularly disconcerting when expansions of
federal programs such as systems of care were
initiated to improve access and services to
children. The question then remains about
barriers to children and adolescents accessing
services, especially continued services.
Basing the conceptual framework on the Helpseeking Decision-Making model and extending it
to include outcomes in help seeking (i.e.,
continued or stopped), the present study
addresses the following: o What individual and
environmental factors influence youth’s mental
health utilization? oGiven their entry into care,
what service settings were utilized?
Study Design: The present study used an ex
post facto design. Previously collected data from
the National Longitudinal Study of Adolescent
Health (Add Health) was used to test the
hypotheses. A latent class analysis was
conducted to derive categories of
symptomatology and several multivariate logistic
regressions were performed to measure the
factors that predicted one time care, continued
care, and two service settings: schools and
physician’s office. Although the Add Health
includes information by several sources, the
present study relied primarily on information
from the youth’s in-home questionnaires from
Wave I and Wave II.
™Vermont Child Health Improvement
Program
Judith Shaw, R.N., M.P.H., Richard Wasserman,
M.D., M.P.H., Sara Berry, M.P.H., Thomas
Delaney, Ph.D., Paula Duncan, M.D., Patricia
Berry, M.P.H.
Presented By: Judith Shaw, R.N., M.P.H.,
Executive Director, Pediatrics, Vermont Child
Health Improvement Program, One South
Prospect Street, Burlington, VT 05401, Phone:
(802) 847-9642, Fax: (802) 847-8170, Email:
judith.shaw@uvm.edu
- 31 -
Research Objective: To test the effectiveness of
a statewide pediatric QI outreach program in
improving preventive services for children less
than 5 years of age.
Study Design: A preventive services quality
improvement (QI) intervention to improve
health care at the practice level. Practices were
1)trained in rapid cycle change quality
improvement in three face-to-face group
meetings, 2)instructed to identify an office
improvement team and to set measurable goals
for improvement in one or more PS areas,
coached by staff experienced in quality
improvement through conference calls, phone
contacts, and email consultations. Pre and post
measurement of practice's preventive services
rates were conducted.
Population Studied: All pediatric practices in
Vermont were invited to participate and 91%
agreed. Participating practices serve over 80%
of all Vermont children less than 5 years of age.
Principle Findings: All practices demonstrated
improvement in one or more preventive services
areas. The mean number of areas chosen was 5
(range 1-9). Practices that selected a specific
preventive service area as a QI goal were more
likely to demonstrate improvement in that area
than practices not choosing to focus on that
preventive services area.
Conclusions: The Vermont Preventive Services
Initiative was the first project of the Vermont
Child Health Improvement Program (VCHIP), a
program of the University of Vermont
Department of Pediatrics, in collaboration with
the Vermont Department of Health (VDH) and
the American Academy of Pediatrics-Vermont
Chapter (AAP-VT). The work in this project has
provided the evidence for an effective statewide
pediatric quality improvement outreach program
to improve preventive services for children less
than 5 years of age. Practices' decision to focus
on a specific preventive service area as a QI goal
appears necessary to improving in that area.
This approach may be effective in other states or
regions.
Implications for Policy, Practice or Delivery:
An improvement partnership, such as VCHIP, is
well positioned to promote outstanding
pediatric child health care by creating an
organizational hub for QI and maintaining a
focus on local efforts. These durable, regional
collaborations engage an array of public and
private organizations, support the commitment
and creativity of health care professionals and
serve as a motivational force for the many
individuals and organizations committed to
improving children's health care.
Funding Source(s): Federal Medicaid matching
™Health Care for Children & Youth in the
United States: Focus on Injury-Related
Emergency Department Utilization, Quality &
Expenditures
Lisa Simpson, M.B., M.P.H., Marc W. Zodet,
M.S., Terceira Berdahl, Ph.D., Lisa Simpson,
M.B., M.P.H., Denise Dougherty, Ph.D., Marie
McCormick, M.D., Sc.D.
Presented By: Lisa Simpson, M.B., M.P.H.,
CCHMC Child Policy Research Center, Cincinnati
Children's Hospital Medical Center, Cincinnati,
OH 45229, Phone: (513) 636-2781, Email:
lisa.simpson@cchmc.org
Research Objective: To characterize children’s
access to, utilization of, and expenditures for
injury-related emergency department (ED) care
across 14 states and nationally.
Study Design: A retrospective analysis was
performed using the 2003 State Emergency
Department Databases (SEDD) and State
Inpatient Databases (SID) from the Healthcare
Cost and Utilization Project (HCUP) and the
Medical Expenditure Panel Survey. ED visits
with injury International Classification of
Diseases Clinical Modification, Ninth Version
(ICD-9-CM) codes consistent with the State and
Territorial Injury Prevention Directors
Association’s definition were selected. The
Barell Injury Diagnosis Matrix, ICDMAP-90
software, and the Trauma Information Exchange
Program (TIEP) data were used to classify
injuries, produce injury severity scores and
examine utilization in trauma centers.
Population Studied: All ED visits for children
and adolescents less than 18 years of age.
Principle Findings: Over 1.5 million or nearly
one-third of ED visits were for pediatric injuries
in the 14 states studied. In addition, nationally
representative data suggest that 40.1 percent of
children had an injury-related ED visit and
approximately $2.3 billion were spent on injuryrelated ED visits in 2003. Falls were the most
common cause of injury (29.1% of ED visits),
followed by being struck by or against an object
(21.6%), cutting/piercing (8.1%), motor vehicle
traffic (7.1%) and overexertion (6.9%). Although
the majority of injuries were considered mild
(72.2%), over 15% of injuries were classified as
moderate and 1.0% were classified as serious to
critical. Nearly 2.6% of ED visits resulted in
hospital admission. Admission rates varied by
type of injury, severity of injury, and expected
payer. Injury-related ED visits for children were
- 32 -
more likely to result in hospital admission if the
injuries were related to motor vehicle accidents,
other types of transport accidents, or fires.
Injury-related ED visits billed as uninsured were
less likely to result in hospital admission
compared with visits billed to private insurance
or Medicaid, regardless of the nature or severity
of injury. Moreover, injury-related ED utilization,
the nature of injury, and admission rates varied
by state.
Conclusions: This study provides support that
not only do pediatric injuries place a significant
burden on EDs, but they also cause significant
morbidity among children and place a
substantial burden on the health care system.
Implications for Policy, Practice or Delivery:
State and payer variation suggests that there is
potential to influence ED utilization rates for
pediatric injuries. Policies directed at the
prevention of injuries and state emergency care
systems may prove useful to reduce pediatric
injuries and the burden of ED care. In addition,
this study demonstrates that a relatively new set
of databases, the HCUP SEDD, can be used to
study policy-relevant ED issues among children.
Funding Source(s): AHRQ
have 21 Emergency Departments (ED) in 9
states and the District of Columbia. A Central
Data Management Coordinating Center
(CDMCC) is also funded through a separate
cooperative agreement to provide data
management support and clinical monitoring.
With more than 800,000 annual pediatric visits
among its 21 participating emergency
departments, the network has been able to study
important conditions with infrequent or rare
outcomes in diverse populations.
Population Studied: Children under 18 years of
age.
Principle Findings: Three important studies
have been completed since the inception of
PECARN. The first study titled the PECARN Core
Data Project (PCDP), collected and analyzed
data from existing electronic sources and
medical records at all sites in the network. This
project demonstrated the PECARN’s capacity to
collect and synthesize large quantities of basic
epidemiologic information, provided data on the
frequency of diagnoses seen at each ED within
the PECARN, and provided information for the
purposes of hypothesis generation and study
design development. Two manuscripts from this
study have been published in peer reviewed
journals. The ‘‘Childhood Head Trauma: A
Neuroimaging Decision Rule’’ study represents
the first prospective observational study for
PECARN. The purpose of the study is to derive
and validate a clinical decision rule that
accurately and reliably identifies children at high
risk and near-zero risk for significant traumatic
brain injuries needing acute intervention after
blunt head trauma. PECARN sites enrolled over
40,000 patients across 25 hospital ED’s in this
study. Data analysis is currently underway.
The third study was the first prospective
interventional study for PECARN. The purpose of
this study was to assess the effectiveness of a
promising treatment, oral dexamethasone, for
acute moderate-to-severe bronchiolitis. One
prior study suggested benefit but was limited by
its small sample size and single-institution
setting. The PECARN study enrolled over 600
patients from approximately 20 sites nationwide.
The results of this study have been submitted for
publication.
Conclusions: PECARN has demonstrated high
success in collaborating with a mix of academic
centers and community hospitals to conduct
high quality research.
Implications for Policy, Practice or Delivery:
The success of PECARN demonstrates the ability
of institutions to collaborate and conduct
scientifically rigorous research to create an
™Using Research Networks to Promote
Pediatric Emergency Research
Tasmeen Singh, M.P.H., N.R.E.M.T.P, Peter
Dayan, M.D., James Chamberlain, M.D., Rachel
Stanley, M.D., J. Michael Dean, M.D., Nathan
Kupperman, M.D.
Presented By: Tasmeen Singh, M.P.H.,
N.R.E.M.T.P., Executive Director, Emergency
Medical Services for Children, EMSC National
Resource Center, 8737 Colesville Road, Silver
Spring, MD 20910, Phone: (202) 884-6866, Fax:
(202) 884-6845, Email: tsingh@emscnrc.com
Research Objective: To demonstrate the ability
to conduct multi-center pediatric research using
a federally funded infrastructure.
Study Design: The Pediatric Emergency Care
Applied Research Network (PECARN),
established in 2001, is the first federally funded
national network of emergency departments
focusing on research in emergency medical
services for children (EMSC). PECARN was
established to address historical barriers with
conducting EMSC research such as low numbers
of pediatric patients, ethical challenges in EMSC
research, and the lack of rigorous research in
EMSC. The network is funded through 4
cooperative agreements, each of which
comprises a PECARN node. The nodes together
- 33 -
evidence base for clinical care and to ultimately
improve health outcomes of acutely ill and
injured children.
Funding Source(s): HRSA/MCHB/EMSC
Principle Findings: Overweight children,
compared to healthy-weight children, have
significantly (p<0.05) increased risk for high total
cholesterol (15.7% vs. 7.2%), high (11.4% vs.
7.7%) or borderline LDL cholesterol (20.2% vs.
12.5%), low HDL cholesterol (15.5% vs. 3.0%),
high triglycerides (6.7% vs. 2.1%), high fasting
glucose (2.9% vs. 0.0%), high glycohemoglobin
(3.7% vs. 0.5%), and high systolic blood pressure
(9.0% vs. 1.6%). Overweight children, compared
to healthy-weight children, demonstrate
significantly (p<0.01) lower prevalence of
excellent health (NHANES, 36.5% vs. 53.3%;
MEPS, 42.8% vs. 55.6%). Compared to healthy
weight children, overweight children are less
likely to have any health care expenditure
(OR=0.7, p<0.01); this difference does not
remain after adjusting for socioeconomic status
(aOR=0.9, p=ns).
Conclusions: Our data suggest that overweight
children have more chronic conditions, poorer
health, and greater health care expenditures than
healthy weight children. Strategies must be
developed to increase access to care and
physician recognition of overweight and related
chronic conditions.
Implications for Policy, Practice or Delivery:
To address the gap between the care needed to
address chronic conditions and poor health, and
the care overweight children actually receive, it
may be beneficial to consider designating
overweight children as CSHCN. Including
overweight children under the umbrella of
CSHCN is one potential strategy for highlighting
the chronic nature of overweight for clinicians,
improving access to care, and enhancing health
care resources available to overweight children.
Such strategies to address overweight during
childhood are critical to prevent chronic
conditions, improve health status, and reduce
health care expenditures, both during childhood
and into adulthood.
Funding Source(s): AHRQ
™Health Status & Health Care Expenditures
in a Nationally Representative Sample: How
Do Overweight & Healthy-Weight Children
Compare?
Asheley Cockrell Skinner, B.S., Michelle L. Mayer,
Ph.D., M.P.H., Kori Flower, M.D., M.S., M.P.H.,
Morris Weinberger, Ph.D.
Presented By: Asheley Cockrell Skinner, B.S.,
Health Policy and Administration, The University
of North Carolina at Chapel Hill, CB 7411, Chapel
Hill, NC 27599, Phone: 336-392-5021,
Email: asheley@unc.edu
Research Objective: Childhood overweight is an
epidemic in the US. Overweight children are at
increased risk for chronic disease, poorer health
status as a child, and are more likely to be
overweight or obese as an adult. To our
knowledge, the prevalence of these conditions
has not previously been established in a
nationally representative sample. A more
complete understanding of the effect of
overweight on children’s health requires a
nationally representative, population-based
sample. Specifically, we examine whether,
compared to healthy-weight children, overweight
children have: 1) a higher prevalence of selected
chronic conditions (hypertension, dysglycemia,
and hyperlipidemia); 2) poorer health; and 3)
greater health care expenditures.
Study Design: Cross-sectional study. Chronic
conditions were measured as the prevalence of
dyslipidemina, hyperglycemia, and hypertension;
health was assessed as self-reported health
status, school days missed due to illness or
injury, and functional status; and health care
expenditures. Using body mass index, we
classified children as overweight (> 95th
percentile), at risk for overweight (=85th - <95th
percentiles), and healthy weight (=5th - <85th
percentile); because children with a body mass
index <5% may have underlying malnutrition
and/or medical conditions, they were excluded
from all analyses.
Population Studied: Children aged 6-17
participating in one of two nationally
representative surveys of civilian, noninstitutionalized Americans: the 2001-2002
National Health and Nutrition Examination
Survey (NHANES) and the 2002 Medical
Expenditure Panel Survey (MEPS).
™Strategies for Improving Access to
Comprehensive Obesity Prevention &
Treatment Services for Medicaid-Enrolled
Children
Sara Wilensky, J.D., M.P.P., Ramona Whittington,
Sara Rosenbaum, J.D.
Presented By: Sara Wilensky, J.D., M.P.P.,
Assistant Research Professor, Health Policy,
George Washington University, 2021 K Street,
NW - Suite 800, Washington DC, 20006, Phone:
(202) 530-2359, Email: wilensky@gwu.edu
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Research Objective: This policy brief is a followup to our initial Robert Wood Johnson report
that evaluated the role of public and private
insurance in financing preventive care and
treatment for at-risk and obese children. One of
the key findings from that report was that
Medicaid’s existing Early and Periodic Screening
Diagnostic and Treatment (EPSDT) coverage
standards provide for comprehensive, obesityrelated pediatric health care interventions. This
report examines the extent to which state
Medicaid programs currently use EPSDT benefits
to address and finance obesity-related services
that advance best-practice standards in obesity
prevention, treatment and management in
children.
Study Design: We reviewed the current standard
of care for childhood obesity prevention and
treatment, payment policies and information
provided by states Medicaid programs to
providers about childhood obesity prevention
and treatment (in both managed care and feefor-service settings), and medical procedure
coding through CPT-4 and HCPCS coding
systems.
Population Studied: Medicaid
programs/Medicaid-enrolled children.
Principle Findings: 1. Existing state EPSDT
coverage and payment policies suggest that state
EPSDT operational standards generally do not
focus on obesity as a specific focus of pediatric
intervention activities to be encouraged and
supported. 2. A review of available Medicaid
managed care contracts suggests that
contractual requirements generally do not
highlight obesity prevention and treatment
strategies in reference to EPSDT standards or
performance measurement requirements. 3.
Several states have taken important steps to use
EPSDT coverage standards to incentivize best
practices among pediatric health professionals
and providers. 4. A review of state EPSDT
billing, coding, and payment practices
underscores that existing billing codes permit
coverage of all procedures and interventions
essential to high quality obesity-prevention
pediatric practice.
Conclusions: Medicaid is currently wellequipped to tackle the childhood obesity
problem if states take advantage of the
opportunities available to them. Our specific
recommendations to state Medicaid programs
include: 1. Clarify the application of obesity
prevention and treatment guidelines as part of
the EPSDT benefit for children and adolescents;
2. Clarify proper coding and payment procedures
for obesity prevention and treatment services;
3. Bundle obesity prevention and treatment
services into a single package following a disease
management model.
Implications for Policy, Practice or Delivery:
The significant and rising level of childhood
obesity in this country gives rise to numerous
negative consequences in terms of the health
status of individuals and financial costs to
individuals, government, providers and society
as a whole. Medicaid providers frequently report
barriers to receiving payment when treating
children for obesity-related conditions. This
report provides specific steps state Medicaid
programs may take to alleviate this critical
obstacle to preventing and treating childhood
obesity.
Funding Source(s): RWJF
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