Posters
Poster Session
Saturday, June 25 • 1:15 p.m. - 2:30 p.m.
● Medical Errors, Mortality, and Teaching Hospitals for
Pediatric Injury Hospitalizations
Thomas Bannister, M.D., John M. Tilford, Ph.D.
Presented by: Thomas Bannister, M.D., Fellow PCCM,
Pediatrics, University of Arkansas for Medical Sciences, 800
Marshall Street, Little Rock, AR 72202-3591;
Tel: (501) 364-1008; Fax: (501) 364-1552;
E-mail: bannisterthomasw@uams.edu
Research Objective: Quality of care studies comparing
teaching to non-teaching hospitals have found worse
outcomes in teaching hospitals for pediatric patients.
Estimates are needed for population-based studies with
appropriate measures for severity adjustment. This study
examines the association between medical errors and
mortality in teaching and non-teaching hospitals for
hospitalizations involving pediatric injuries.
Study Design: A retrospecitve analysis of injury
hospitalizations was conducted using a nationaly
representative sample from the Healthcare Cost and
Utilization Project. Hospitalizations involving a medical error
were identified based on ICD-9 CM codes 996-999 and 995.2
following previous studies. Injury severity scores were
calculated using ICDMAP90 software. Rates of medical errors
and mortality were assessed by specific characteristics for
teaching and non-teaching hospitals. Separate logistic
regression analysis was conducted by teaching and nonteaching hospitals to assess the contribution of medical errors
to hospital mortality.
Population Studied: All hospitalizations with a primary or
secondary diagnosis of injury were abstracted from the 2000
Kids’ Inpatient Database (KID). Children between the ages of
0-20 were included.
Principal Findings: The overall rate of medical errors differed
significantly between teaching and non-teaching hospitals with
a higher rate of errors in teaching hospitals (2.7% vs. 1.8%;
p<0.001). Rates of medical errors differed by specific
characteristics with higher rates noted in younger and more
severely ill patients. Injury severity scores were similar
between teaching and non-teaching hospitals. Logistic
regression analysis indicated a significant relationship
between medical errors and mortality for teaching hospitals
(OR=1.40; 95% CI 1.02-1.92) but not for non-teaching
hospitals (OR=1.59; 95% CI 0.79-3.21).
Conclusions: After controlling for injury severity, teaching
hospitals had higher rates of medical errors and mortality
relative to non-teaching hospitals. Administrative databases
such as the KID may be useful for monitoring error rates in
teaching hospitals following changes in rules regarding work
hours.
Implications for Policy, Delivery or Practice: Despite most
studies finding improved outcomes in teaching hospitals for
adult conditions, pediatric studies continue to find worse
outcomes. Additional research is needed to understand the
specific factors contributing to higher rates of medical errors
in teaching hospitals involving pediatric patients.
Primary Funding Source: HRSA, Maternal and Child Health
Bureau
● Medical Injuries and Mortality Following Congenital
Heart Surgery
Oscar Benavidez, M.D., M.P.P., Oscar Benavidez, M.D.,
M.P.P., Kimberlee Gauvreau, Sc.D., Kathy J. Jenkins, M.D.,
M.P.H.
Presented by: Oscar Benavidez, M.D./M.P.P., Cardiology
Fellow, Cardiology, Children's Hospital, Boston, 300
Longwood Avenue, Boston, MA 02115; Tel: (617) 355-8895;
Fax: (617) 739-5022;
E-mail: oscar.benavidez@cardio.chboston.org
Research Objective: Despite complexity of care and high
death risk, there has been no broad assessment of medical
injury rates or its association with mortality following
congenital heart surgery. Our objectives were to examine 1)
the rate of medical injuries and 2) the independent effect of
medical injuries on risk-adjusted mortality following
congenital heart surgery.
Study Design: We selected discharges of congenital heart
surgery from the Healthcare Cost and Utilization Project Kid’s
Inpatient Database 2000 and applied a validated method 60% sensitive, 97% specific - for identifying medical injuries
using ICD-9-CM codes. Cases of medical injury were
identified using this method; injuries were classified into four
categories: 1) drugs; 2)procedures; 3)devices, implants, and
grafts; and 4)radiation related. Adjustment for case-mix was
performed using the Risk Adjustment in Congenital Heart
Surgery method, RACHS-1. We examined the independent
effect of the presence of a medical injury or medical injury
subcategory on unadjusted and risk-adjusted mortality using
generalized estimating equations incorporating RACHS-1
variables, as well as gender, race, insurance type and surgical
volume.
Population Studied: Children ages < 18 years discharged with
ICD-9-CM codes indicating surgical repair of a congenital
heart defect.
Principal Findings: Among the 10,032 congenital heart
surgical discharges, 3159 cases or 32% had at least one
medical injury code; there were a total of 5242 medical injury
codes, 523 injuries per 1000 discharges. Procedure related
injury codes represented 78% of all injury codes, 408 per 1000
discharges; Device, implant, or graft related injuries were 18%,
96 per 1000 discharges; drug related injuries 4%, 19 per 1000
discharges; no radiation injury codes were identified.
In unadjusted analyses, children with a medical injury code
had a substantially greater odds of death compared to
children without injury codes, OR 3.0, p<0.001; medical injury
subcategories: procedure OR 2.9, p<0.001; device, implant, or
graft OR 2.6, p<0.001; drug OR 0.7, p=NS.
Case-mix, gender, race, and surgical volume were significantly
related to mortality. Adjusting simultaneously for case-mix,
gender, race, and surgical volume, cases with medical injury
codes continued to show a substantially greater odds of death
compared to cases without medical injury codes, OR 2.4,
p<0.001. Medical injury subcategories: procedure OR 2.3,
p<0.001; device, implant, or graft OR 2.8, p<0.001 related
injuries; drug related injuries OR 0.7, p=NS.
Conclusions: Codes for medical injuries during admissions
for congenital heart surgery are common. These injuries codes
are associated with more than two-fold increase in riskadjusted mortality following congenital heart surgery. Codes
reporting device, grafts or implant related medical injuries, are
associated with the greatest risk for death.
Implications for Policy, Delivery or Practice: Strategies to
reduce medical injury may result in a substantial reduction in
risk of death in this complex pediatric population.
Primary Funding Source: N/A
● Can Hospital Discharge Data Complement Birth Defects
Surveillance?
James M. Robbins, Ph.D., T.M. Bird, M.S., John M. Tilford,
Ph.D., Mario A. Cleves, Ph.D., Charlotte A. Hobbs, M.D.,
Ph.D.
Presented by: T.M. Bird, M.S., Research Associate, Pediatrics,
University of Arkansas for Medical Sciences, 800 Marshall
Street, Little Rock, AR 72202; Tel: (501) 364-3300;
Fax: (501) 364-1552; E-mail: BirdTommyM@uams.edu
Research Objective: State birth defects surveillance systems
vary in their case ascertainment methodology, case
definitions, and inclusion of pregnancy terminations in counts
of defect occurrences. Because of differences in
methodologies, state systems are not designed to generate
birth defect rates for the country as a whole, and are not
intended to allow comparison of rates across states. Because
states submit hospital discharge information in a
standardized format for inclusion in the Kids' Inpatient
Database (KID), the KID may be used to generate rates of
newborn hospitalizations for select birth defects that are
comparable across states and can be combined to yield
national estimates.
Study Design: The KID is the only publicly available,
nationally representative database of newborn
hospitalizations. The KID includes an 80% sample of newborn
discharge records from hospitals in each of 27 participating
states. Newborns with 37 ICD-9 codable major birth defects
reported by 21 state surveillance systems can be identified in
the KID. State surveillance systems are classified by intensity
of surveillance as active (on-site ascertainment of cases by
abstractors), or passive (reliance on hospital discharge
reports), and by inclusion or exclusion of pregnancy
terminations. Rates generated by the KID were compared to
rates reported by state surveillance systems, stratified by
intensity of surveillance and inclusion of fetal deaths. Rate
ratios (RR) were calculated by dividing the rate derived from
the KID by the rate observed by state surveillance systems.
Rate ratios less than 1.0 indicate that the KID identifies fewer
defects than state surveillance systems.
Population Studied: Hospital births and birth defects from 21
states, 1997 to 2001.
Principal Findings: KID defect rates closely approximate state
rates for most cardiovascular defects (RR = .87 - 1.17) and
orofacial defects (RR = 1.00 - 1.05). The KID consistently
underestimates central nervous system defects (RR = .37 - .80)
and limb reduction defects (RR = .66 - .70) except when those
defects were reported by states that do not include fetal
deaths (RR = .82 - 1.16). Overall, defect rates generated by the
KID were most congruent with rates reported by states
systems that do not include fetal deaths. The KID
overestimates rates of patent ductus arteriosus (RR = 1.48),
gastroschisis/omphalocele (RR = 1.73), and congenital hip
dislocation (RR = 1.33). These defects may be overdiagnosed
at birth (minor umbilical hernia) or resolve soon after birth.
Conclusions: While the KID lacks confirmatory diagnostic
information and does not include information on fetal deaths,
KID-based rates closely approximate rates of defects reported
by passive state surveillance systems and systems that do not
include pregnancy terminations. In contrast to the variability
of state-based systems, the KID employs a single
methodology to derive national rates of birth defects among
livebirths and allows direct state-to-state rate comparisons.
Implications for Policy, Delivery or Practice: Birth defect
rates generated by the KID can be used to monitor conditions
of the newborn, evaluate the impact of societal-wide public
health interventions, and provide rates of birth defects for
participating states with no surveillance system. States that do
not routinely survey fetal deaths may be better served by
devoting surveillance resources to research on the causes and
management of birth defects.
Primary Funding Source: CDC
● Developing Measures of Pediatric Oral Health-Related
Quality of Life to Better Understand Oral Health
Disparities in Children
Joan Bohlke, M.A. - Public Policy, Noelle L. Huntington, Ph.D.,
Dante Spetter, Ph.D., Judith Jones, D.D.S., M.P.H., Avron
Sprio III, Ph.D.
Presented by: Joan Bohlke, M.A. - Public Policy, Research
Assistant, Health Policy & Health Services Research, Boston
University, 560 Harrison Avenue, Boston, MA 02118;
Tel: (617) 414-1144; Fax: (617) 638-6381;
E-mail: jbohlke@bu.edu
Research Objective: To develop a set of measures of
pediatric oral health-related quality of life (POQOL), suitable
for use with children and adolescents, that examines the
impact of oral health on the lives of children and their families.
Study Design: In the first step, impact statements were
created by an expert panel to address three domains of
functioning: social/role, psychological, and physical. Focus
groups then were used to collect qualitative data from children
and their parents on the impact of a child’s oral health status.
Using these data, impact statements were revised creating
three four-page questionnaires: (Child Self Report, Parent
Report on Child, and Parent Self Report). The questionnaires
asked how often an event occurred, how bothered the child
was by this event, and why it happened. In the fourth step, a
sample of children and their parents completed the
questionnaires and engaged in a five-minute debriefing on
clarity, format and content. The final step, currently underway,
is administering the questionnaire to several hundred children
and parents. Item reduction for the final version will result
from the frequency, importance and cause of individual events
as well as parent-child concordance.
Population Studied: Diverse, middle to low income pediatric
patients and their parents at oral health clinics and schools
associated with Boston University’s School of Dental
Medicine.
Principal Findings: Throughout the process, multiple
revisions of the questionnaire were made in form and content.
The focus groups created a number of new items not
anticipated by the expert panel, and made clear the need to
distinguish between the effects of disease v. normative
development (“why it happened”). Barriers to recruitment in
step four included the lack of interest in completing a
somewhat cumbersome and lengthy questionnaire in the
context of a busy waiting room as well as lower literacy skills.
To adjust for this, several shortened versions of all three
questionnaires were created that consisted of different subsets
of ten impact questions asked in two different ways: either
“how often” and “how bothered,” or “how often” and “why.”
In this way, all impact questions included in the original
longer version were distributed throughout the smaller
versions and reviewed through a debriefing. Data collected
from a broad distribution of the survey will create a more
useable final version with fewer items.
Conclusions: To fully develop a pediatric quality of life
instrument that reflects what is important to the population,
children and their parents need to be involved at each step of
questionnaire development and pilot testing needs to occur in
the same context in which the measure will be used. In
addition, flexibility in item construction and testing must be
allowed.
Implications for Policy, Delivery or Practice: The methods
described here will establish POQOL measures that can fully
assess oral health-related QOL in children. The results of a
wide distribution of the final questionnaire will draw attention
to the needs of a population which consistently lacks quality
oral health care
Primary Funding Source: Other, NIH/NIDCR
● Racial/Ethnic and Socio-Economic Disparities in Early
Intervention Participation
Karen Clements, Sc.D., Wanda D. Barfield, M.D., Nancy
Wilber, Ed.D., Milton Kotelchuck, Ph.D.
Presented by: Karen Clements, Sc.D., Research and
Evaluation Specialist, Bureau of Family and Community
Health, Massachusetts Department of Public Health, 250
Washington Street, Boston, MA 02108; Tel: (617) 624-5596;
Fax: (617) 624-6062; E-mail: karen.clements@state.ma.us
Research Objective: Children living in impoverished socioeconomic settings are at risk for developmental delay. Access
to early developmental intervention for this group is critical.
Massachusetts (MA) includes children age 0-3 at social risk in
a federally mandated Early Intervention (EI) program. It is
unknown whether disparities exist in access to and
participation in EI. Our objective was to use population-based
linked data to examine maternal socio-economic
characteristics associated with EI referral, evaluation, and
enrollment in MA.
Study Design: The Pregnancy to Early Life Longitudinal
(PELL) data system contains population-based birth certificate
and hospital discharge data of infants born in MA linked to EI
program records. Maternal characteristics (race/ethnicity, age,
education, US/foreign born, language, poverty rate in town of
residence) and infant risks (eg. birth weight, gestational age)
were obtained from PELL. Outcomes included referral to EI,
evaluation for eligibility among referrals, and program
enrollment among children evaluated and eligible for services.
Multivariate logistic regressions identified independent
predictors of referral, evaluation, and enrollment, adjusting for
maternal and infant characteristics.
Population Studied: 219,037 in-state births to MA resident
women, January, 1998-September, 2000, excluding neonatal
deaths.
Principal Findings: Overall, 37,397 children, 18.8% of births,
were referred to EI. Of referrals, 32,075 (85.8%) were evaluated
for eligibility, and of those eligible, 25,968 (93.0%) enrolled in
EI. Most indicators of low socioeconomic status (SES) were
positively associated with referral, but racial/ethnic disparities
existed. Adjusting for infant and maternal characteristics,
children of foreign-born mothers were less likely to be referred
than children of US-born mothers (OR = 0.70, 95% CI=0.680.73). Referral was negatively associated with non-English
language preference (OR=0.87, 95% CI=0.83-0.91) and Asian
race (OR=0.88, 95% CI=0.82-0.94). Among referrals,
race/ethnicity and some indicators of low SES were associated
with disparities in evaluation. Children born to black
(OR=0.69, 95% CI 0.62-0.76) and Asian mothers
(OR=0.88,95%CI=0.82-0.94) were less likely to be evaluated.
Evaluation was negatively associated with having a teen
mother (OR = 0.64, 95% CI=0.58-0.73), having no health
insurance (OR=0.77, 95% CI 0.63-0.91), and >15% poverty rate
in town of residence (OR=0.69, 95% CI 0.64-0.75).
Among those eligible, enrollment was negatively associated
with some indicators of low SES, including having a teen
mother (OR = 0.51, 95%CI=0.45-0.58 ) and >15% poverty rate
(OR = 0.71, 95% CI=0.62-0.81).
Conclusions: After controlling for infant and maternal risks,
several disparities existed in referral, evaluation, and
enrollment in EI in MA. The types of social risk associated
with disparity in referral for differed for the most part from
those associated with disparity in evaluation and enrollment.
Implications for Policy, Delivery or Practice: These analyses
identified subsets of the MA population who may face barriers
to EI participation. Some foreign-born women may be
avoiding contact with EI due to documentation concerns.
This information will be utilized by perinatal and EI programs
to improve referral among these women. Additional support
and follow-up with teen mothers, women with no health
insurance, and women living in high poverty areas will be
developed to improve the percentage of referrals who are
evaluated and enrolled.
Primary Funding Source: CDC
● Measuring Relative Quality and Resource use 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., Research
Fellow, Cardiology, Children's Hospital Boston, 300
Longwood Avenue Farley 135, Boston, MA 02115;
Tel: (617) 355-8890; Fax: (617) 739-5022;
E-mail: jean.connor@cardio.chboston.org
Research Objective: To develop a composite measure
reflecting both quality and resource use for pediatric heart
surgery and to examine regional variation for this measure.
Study Design: Cases meeting criteria for the Risk Adjustment
for Congenital Heart Surgery method (RACHS-1) were placed
into risk categories. One state with only 5 identified cases was
eliminated. Relative quality and resource use was examined
using the product of the standardized mortality ratio (SMR)
and standardized charge ratio (SCR). This product was
termed the Efficiency Product. For each state, SMR was
defined as observed mortality/expected mortality; expected
mortality was 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 charges. A state with
mortality and charges both equal to expected would have an
Efficiency Product equal to 1. States were ranked from lowest
to highest using the Efficiency Product. In addition, the
relationship between the mean charge differential for each
state, defined as observed minus expected mean charges, and
the SMR was examined.
Population Studied: Cases of congenital heart surgery < 18y
were identified from the Health Care Utilization Project KID
2000 database (27 states) using ICD-9-CM codes
Principal Findings: Using data from 9,406 cases of
congenital heart surgery, the mortality rate was 4.1% and the
average median charges was $49,722. Across the 26 states,
the mean charge differential per state ranged from -$27,892 to
+$24,020. Mortality rates per state ranged from 0.6% to
6.1%. The SMR ranged from .13 to 1.87 and SCR ranged from
.47 to 1.4. The Efficiency Product ranged from .12 to 1.86. CO,
MA, ME, MD, OR, and WI had a Efficiency Product <0.50. CT,
GA, IA, MO, NC, NY, PA, SC, and UT had an Efficiency
Product 0.50 to .99. CA, FL, HI, TN, VA, WA, and WV had an
Efficiency Product 1.00 to 1.49. AZ, KY, NJ, and TX had an
Efficiency Product = 1.50. There was no correlation between
the SMR and mean charge differential.
Conclusions: States varied considerably in a risk-adjusted
measure of quality and resource use for congenital heart
surgery procedures. This novel approach of assessing
efficiency in this population may be the first step in identifying
optimal charge structures for delivering care.
Implications for Policy, Delivery or Practice: Identification
of optimum charge structures to delivery 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.
Primary Funding Source: Other, T32 HS00063-10
● Measuring the Physician-Parent Relationship in Pediatric
Care
Elizabeth Cox, M.D., M.S., Maureen Smith, M.D., M.P.H.,
Ph.D., Roger Brown, Ph.D., Mary Anne Fitzpatrick, Ph.D.
Presented by: Elizabeth Cox, M.D., M.S., Assistant Scientist,
Population Health Sciences and The Center for Women's
Health & Research, University of Wisconsin-Madison Medical
School, 610 Walnut Street, 634 WARF Building, Madison, WI
53726; Tel: (608)263-9104; Fax: (608)263-2820;
E-mail: ecox@wisc.edu
Research Objective: As provider-patient relationships are key
to shared decision-making (SDM), assessing this relationship
has received considerable attention. However, no standard
measure exists. Prior work has summed Roter Interaction
Analysis System (RIAS) items to create a measure of
‘relationship building’ although no published work has
examined the psychometrics of such a measure. Using RIAS,
we examine this commonly-used measure as well as develop
and test a model of the physician-parent relationship for the
pediatric visit that incorporates two established relationship
domains (“liking” and “understanding”) for physicians and for
parents.
Study Design: Videotapes of the children's visits were coded
with RIAS which categorizes utterances into 34 mutually
exclusive categories. ICCs of >0.70 for all RIAS codes ensured
interrater reliability. We replicated the prior RIAS ‘relationship
building’ summed scale based on personal remarks, laughter,
agreement, approval, compliment, disapprovals, concern,
reassurance, and empathy spoken by physician or parent. Our
new model included additional indicator and latent variables
based on prior literature and theory. All models were
evaluated using confirmatory factor analysis (CFA) in LISREL
8.54 with polychoric correlation matrices, asymptotic
variance/covariance matrices and the weighted least squares
estimation procedure as appropriate to data with variables
whose correlations are not bivariate normal.
Population Studied: 100 parent-child dyads visiting one of 15
pediatricians or family physicians for acute concerns
Principal Findings: Physicians were 60% pediatricians and
26% non-white with a range of practice experience. Parents
were predominantly mothers with high school or college
educations. Unidimensional models of physician or parent
“relationship building” based upon the nine indicators
commonly summed in prior work with RIAS codes
demonstrated poor model fit (?2 of 111.4 with 28 degrees of
freedom; RMSEA of 0.17). An alternative single factor model
of the physician-parent relationship using nine indicators
(including compliments as well as statements of
understanding, approval, agreement, and empathy) had good
model fit (?2 of 38.6 with 27 degrees of freedom; RMSEA of
0.07). A 4-factor model included latent variables for liking
(indicators included approvals, agreements and compliments)
and understanding (indicators included empathy and
understanding) by both physician and parent. Model fit was
good with ?2 of 27 with 21 degrees of freedom and an RMSEA
of 0.05. The ?2 difference between the final two models was
11.5 with 6 degrees of freedom, representing no significant
change in model fit (p<0.10). Equating factor loadings within
either of the final two models resulted in significant model
misfit (ie, ?2 of 95 with 32 degrees of freedom and RMSEA
>0.1).
Conclusions: CFA supported a multidimensional measure of
the physician-parent relationship, suggesting the existence of
multiple domains such as “liking” and “understanding” for
both the parent and the physician. Additionally, item
weighting is indicated when creating a physician-parent
relationship measure. Future work will explore a second order
factor structure and expand the measure to include non-verbal
indicators as well as other relationship domains.
Implications for Policy, Delivery or Practice: Previously used
measures of the physician-patient relationship may not
accurately reflect the physician-parent relationship in pediatric
healthcare.
Primary Funding Source: AHRQ
● A Comparison of Pediatric and Non-Pediatric Nurse
Workload Perceptions
Karen Cox, Ph.D., Cathryn A. Carroll, Ph.D., Susan L. Teasley,
R.N., Kathy Sexton, R.N., Arif Ahmed, Ph.D.
Presented by: Karen Cox, Ph.D., Senior Vice President, Patient
Care Services, Children's Mercy Hospitals and Clinics, 2401
Gillham Road, Kansas City, MO 64108; Tel: (816) 234-3933;
Fax: (816) 346-1333; E-mail: kcox@cmh.edu
Research Objective: To compare and contrast workload
perceptions of pediatric nurses in comparison to their peers
working in non-pediatric institutions.
Study Design: A cross-sectional study of the perceptions of a
convenience samples of over 2300 nursing professionals. The
validated 38-item Individual Workload Perception Scale
(IWPS) was administered to the study population working
within and external to the pediatric practice environment.
Responses were provided on a five-point Likert scale with 1 =
Strongly Disagree to 5 = Strongly Agree. Univariate statistics
were use to characterize mean values for each of the five
domains (managerial support, peer support, unit support,
intent-to-stay, and nurse satisfaction) assessed by this
validated instrument and to evaluate whether statistically
significant differences would be observed in responses obtain
from pediatric nurses.
Population Studied: Over 2300 nursing professionals
working within and external to the pediatric practice setting.
Principal Findings: Pediatric nurse perceptions of their work
environment are generally more positive than nurses working
in non-pediatric environments. Statistically significant
differences were observed with respect to peer support, unit
support, workload, intent-to-stay and overall nurse
satisfaction. Although higher levels of managerial support
were reported by pediatric nurses, these results were not
statistically significantly different than their peers.
Conclusions: Pediatric nurse appear to have higher levels of
professional support and satisfaction than their colleagues
working in non-pediatric environments.
Implications for Policy, Delivery or Practice: Support for
pediatric nursing practice appears adequate to foster positive
perceptions of the work environment. Nurses working in
other professional settings may wish to evaluate and
potentially adopt pediatric best practices fostering a more
positive work environment.
Primary Funding Source: N/A
● How Soon Do Children in Medicaid and S-SCHIP
Receive Dental Visits
Peter Damiano, D.D.S., M.P.H., Elizabeth Momany, Ph.D.,
Steve Flach, M.D., Ph.D., Knute Carter, B.Sc. (Hons), Michael
Jones, Ph.D.
Presented by: Peter Damiano, D.D.S., M.P.H., Professor and
Director, Health Policy Research Program, Public Policy
Center, University of Iowa, 227 South Quadrangle, Iowa City,
IA 52242; Tel: (319) 335-6813; Fax: (319) 335-6801;
E-mail: peter-damiano@uiowa.edu
Research Objective: To determine the amount of time it
takes for children newly enrolled in Medicaid and S-SCHIP to
receive their first dental visit and the factors associated with
the time to the first dental visit. Of particular interest is
whether the plan design (traditional Medicaid fee-for-service,
and three different types of HMOs in the S-SCHIP plan) are
related to the length of time to the first dental visit.
Study Design: Survival analytic techniques were used to study
factors related to the length of time children were in the
Medicaid and S-SCHIP program prior to receiving a dental
visit. Primary dependent variable: time to first dental visit.
Primary covariate: health plan, controlling for age, gender, race
and urban/rural location. Bivariate relationships were
estimated using the life table method, due to the large sample
size. Cox proportional hazard modeling was completed for the
regression analysis of factors related to the time to first dental
visit.
Population Studied: Children newly enrolled in Medicaid and
S-SCHIP between July 1, 2000 through June 30, 2003. Children
were considered “newly” enrolled if they had not been enrolled
in the program in the 12 months preceding the first indication
of enrollment during the study period. 96,704 children met
this criteria with about three-quarters enrolled in Medicaid
(74%); and 7%, 7% and 12% respectively in the three S-SCHIP
plans.
Principal Findings: After 6 months in the program, between
21% and 36%, depending on the plan, had a dental visit. This
increased to 39% to 56% after one year and 73% to 88% after
three years. After controlling for age, race, gender and
urban/rural location, the health plan in which the child was
enrolled was significantly related to whether they received a
dental visit sooner.
Conclusions: The type of dental plan was significantly related
to how soon after enrollment a child received a dental visit.
The closed panel private HMO produced lower utilization
rates than a traditional fee-for-service Medicaid program, a
private open panel HMO or a private traditional indemnity
plan.
Implications for Policy, Delivery or Practice: Although
access to Medicaid dental is low in many areas, alternative
approaches to providing services should be considered
carefully so that access to care is not further hindered as
managed care is implemented for Medicaid and S-SCHIP
programs.
Primary Funding Source: AHRQ
● Cost Utilization Analysis of a Pediatric Emergency
Department Diversion Project: Implications for Policy,
Delivery & Practice
Cheng Wang, M.Sci., M.A., Michelle Doldren, M.P.H.,
C.H.E.S., Deborah Mulligan, M.D., F.A.A.P., F.A.C.E.P., Toran
Hansen, M.S., Mike DeLucca, M.H.M.
Presented by: Michelle Doldren, M.P.H., C.H.E.S., Research
Scientist, Institute for Child Health Policy, Nova Southeastern
University, 3200 S. University Drive, Suite 1213, Fort
Lauderdale, FL 33328; Tel: (954) 262-1932; Fax: (954) 262-3263;
E-mail: mad@ichp.nova.edu
Research Objective: Test the effectiveness of a pilot
emergency department (ED) diversion project developed to
reduce costs associated with the use of hospital emergency
departments for non-urgent care, by offering extended office
hours, multiple access locations, and provision of care
coordination.
Study Design: This study compared claim data of 13,000
children enrolled in an enhanced access program
(intervention group), and data of 19,000 Medicaid eligible
children who received services from other local community
primary care providers (control group). Multiple regression
analyses were performed to analyze the claim data collected
for this project. Three variables were used as dependent
variables to investigate various aspects of the cost utilization:
Per Member Per Month cost, Per Thousand Members Per
Month Encounter frequency, and Per Encounter cost. Thus,
comparisons were made between the intervention and control
group over the project period on ED claim data, as well as for
the overall cost of care data.
Population Studied: Medicaid recipients less than 18 years of
age that utilize a large private primary care pediatric practice
in Broward County, Florida.
Principal Findings: In the initial 12-month period, the average
Per Member Per Month costs for ED utilization in the
intervention group were $1.36 less than that of Control group.
However, there was no significant difference in terms of per
visit cost related to ED utilization. Therefore, the savings came
as a result of a reduction in ED visits, not on reduced cost per
visit. On the average, children in the intervention group
visited the ED 8 fewer times per thousand members per
month than that of the control group. There was no
significant difference in overall cost of care between the
intervention and control groups.
Conclusions: Analysis from the first year of this pilot
program; reveal that by providing extended office hours,
multiple access locations, and provision of care coordination
to children receiving Medicaid significantly lowered the
utilization of the emergency department for non-urgent care
among healthy children, while the overall cost of care
remained the same.
Implications for Policy, Delivery or Practice: These findings
support the need for innovative programs to reduce Medicaid
costs associated with the over utilization of emergency room
services for non-urgent care among the pediatric population.
The results of this study can also be utilized by the managed
care system in the development of strategies to reduce ED
costs among generally healthy children who are not a part of
the Medicaid system.
Primary Funding Source: Other, AHCA
● Preventable, Post-Neonatal Deaths of African American
Infants in Hamilton County, Ohio
Edward F. Donovan, M.D., Steven J. Englender, M.D., M.P.H.,
Kari K. Dunning, Ph.D., Harry Atherton, B.S.E.E., M.S.,
MaryAnn Hamilton, M.A., Barbara Rose, M.P.H
Presented by: Edward F. Donovan, M.D., Director, Cincinnati
Children's Hospital Medical Center, Child Policy Research
Center, 3333 Burnet Avenue, MLC 7014, Cincinnati, OH 452293039; Tel: (513) 636-0180; Fax: (513) 636-0171;
E-mail: edward.donovan@cchmc.org
Research Objective: To determine whether cause specific,
age-of-death specific differences in infant mortality help
identify potential, specific intervention targets.
Study Design: Using Perinatal Periods of Risk methods
(PPOR, http://www.citymatch.org/), post-neonatal, African
American(AA) infant deaths in Hamilton County, Ohio were
identified as potentially preventable. National Center for
Health Statistics, electronic, linked birth-death files were used
to identify cause-specific, U.S. infant mortality. Using the
same linked birth-death file, rates for Hamilton County
resident infants were compared to overall U.S. rates using
rankings and statistical comparisons of proportions.
Population Studied: All AA births and infant deaths of
Hamilton County, Ohio residents from 1/1/1995 through
12/31/1998 were compared to all U.S. AA births and infant
deaths for the same time period.
Principal Findings: PPOR identified that risk of post-neonatal
death (28-364 days of age) was four-fold greater for Hamilton
County AA infants with birth weights greater than 1500 grams.
Comparing Hamilton County and the overall U.S., AA, causespecific, post-neonatal death rates revealed Hamilton County
rates were greater for injuries of any type: 13.9 vs 4.9 per
10,000 births (95% confidence interval for the difference: 2.9,
11.5). For the top ten causes of post-neonatal death (84% of
all deaths), there were 25 excess or possibly preventable AA
deaths during this four year time period. All AA, Hamilton
County infant deaths (0-364 days) that were associated with
LBW were also higher than the U.S. (41 vs 28/10,000 births, p
< 0.05). In addition, for all Hamilton County infant deaths (0364 days), the cause-specific rate for maternal complications
of pregnancy was greater than that for the U.S. (9.6 vs
5.7/10,000 births, p < 0.05).
Conclusions: Comparisons of cause and age-of-death specific
death rates identify opportunities for targeted interventions to
reduce infant mortality.
Implications for Policy, Delivery or Practice: Racial/ethnic
disparities in infant mortality and difficulties in meeting
Healthy People 2010 infant mortality targets may be
addressed by identifying cause and age-specific preventable
infant deaths.
Primary Funding Source: Other, Hamilton County Child and
Family Health Services Consortium
● Possible Errors in Interpreting Population Measures of
Perinatal Health
John Besl, M.A., Edward F. Donovan, M.D., Edward F.
Donovan, M.D., Barbara Rose, M.P.H., Harry Atherton,
B.S.E.E., M.S., Terry Byczkowski, Ph.D.
Presented by: Edward F. Donovan, M.D., Director, Cincinnati
Children's Hospital Medical Center, Child Policy Research
Center, 3333 Burnet Avenue, MLC 7014, Cincinnati, OH 452293039; Tel: (513) 636-0180; Fax: (513) 636-0171;
E-mail: edward.donovan@cchmc.org
Research Objective: To estimate the change over a ten year
period (1990-2000) in county low birth weight rate (LBW) that
is attributable to change in the county's racial composition of
births.
Study Design: Retrospective, population-based, observational
comparison of race-mix-adjusted and unadjusted low birth
weight rates.
Population Studied: Low birth weight rates (LBW, proportion
of all live births with birth weights less than 2500 grams)
between 1990 and 2000 for all 289 U.S. counties with
populations greater than 100,000 and at least 100 annual
African American (AA) births.
Principal Findings: LBW risk for U.S. African Americans in
2000 was 111 per 1000 births compared to 60 per 1000 for
whites (NCHS). There were over 2.9 million and over 2.8
million resident births in the study counties in 1990 and 2000,
respectively. Overall county-level changes in LBW between
1990 and 2000 ranged from a decrease of 38 LBW births per
1000 total births to an increase of 35 LBW births per 1000.
Among these same counties, the proportion of total births
accounted for by AA either increased or decreased between
1990 and 2000 (-13% to +25%). For the 112 counties with an
improved LBW between 1990 and 2000 (39%), some had a
simultaneous decrease in the proportion of AA births and an
improvement in AA LBW both of which would tend to
decrease overall LBW. For the CHSR poster, the magnitude
and direction of differences between race-mix adjusted and
unadjusted changes in county-level LBW will be explored.
Conclusions: With a two fold spread in race-specific LBW risk,
changes in race-mix should be considered in evaluating
possible improvements in overall population health.
Implications for Policy, Delivery or Practice: Changes in
racial composition can lead to both qualitative and
quantitative errors in conclusions related to overall population
health. Public policy makers should consider race-mix
adjusted perinatal statistics when evaluating changes in
population health.
Primary Funding Source: Other Foundation, Cincinnati
Children's Hospital Medical Center
● Making the Case for Improving Children's Healthcare
Quality: No Needless Deaths
Denise Dougherty, Ph.D., Melissa Romaire, M.P.H., Charles
Homer, M.D., Lisa C. White, M.P.H., Lisa A. Simpson, M.B.,
B.Ch., M.P.H., F.A.A.P.
Presented by: Denise Dougherty, Ph.D., Senior Advisory,
Child Health and Quality Improvement, Office of Extramural
Research, Education, and Prioirty Populations, USDHHS
Agency for Healthcare Research and Quality, 540 Gaither
Road, Rockville, MD 20850; Tel: (301) 427-1868; Fax: (301)
427-1562; E-mail: ddougher@ahrq.gov
Research Objective: To develop estimates of the number of
child deaths that could potentially be prevented with improved
quality and patient safety.
Study Design: We applied published estimates of increased
survival from studies on quality improvement interventions to
available national and state level discharge and surveillance
data for selected leading causes of child death ("case
examples"). Sensitivity analyses were performed.
Population Studied: Children who died in 2000 due to
potentially preventable causes in NICU care, from SIDS, from
medical errors during inpatient hospitalizations, from
pediatric trauma, and pediatric cardiac surgery.
Principal Findings: In 2000, between 5- and 10,000
child/adolescent deaths would have been prevented if health
care quality and patient safety had been at achievable levels in
only these five case examples. The greatest numbers of
preventable deaths thru quality improvement were for highrisk infants in NICUs and inpatient medical errors. Referrals
to appropriate levels of trauma care could have prevented 314
pediatric trauma deaths, and regionalization of pediatric
cardiac surgery was hypothesized to prevent 41-83 deaths in
California. Improved Back to Sleep message delivery could
have saved the lives of 256-770 African-American infants,
according to our estimates.
Conclusions: Child lives can be saved with improved
attention to quality and patient safety in a range of health care
settings and thru appropriate referrals.
Implications for Policy, Delivery or Practice: Efforts to
invigorate the quality, patient safety, and healthcare disparities
reduction movements are increasingly framing their messages
in terms of lives saved (IHI; To Err is Human; Woolf et al.).
Although the number of child lives that could be saved is far
less than the larger numbers applied to all Americans
combined (e.g., 100,000), knowing that child lives could be
saved thru these efforts might help "make the case" that
health care for children should be part of larger efforts.
Primary Funding Source: NO FUNDING SOURCE.,
intramural staff support
● Have We Made Any Progress? The Use of Emergency
Services by Medicaid-eligible Children in New York City
Over the Past 10 Years
Bertha Fertil, M.P.H., M.G.A., DelRoy Williams, M.S.W., Tracy
Victor-Grant, M.S.W.
Presented by: Bertha Fertil, M.P.H., M.G.A., Senior Policy
Analyst, Mental Hygiene, NYC Department of Health and
Mental Hygiene, 93 Worth Street, Room 407, New York, NY
10032; Tel: (646) 271-3008; E-mail: BFertil@aol.com
Research Objective: Prior to 1996, the number of children
using New York City emergency room as their access to
primary care was over half a million. Disturbed by these
statistics, over the past ten years both New York State and
New York City has aggressively worked to enroll its children in
public health insurance programs such as Medicaid and
Children Health Plus. By insuring its children, the city
believed that each child and his or her family would develop a
relationship with a primary care provider who would ensure
that the child received the appropriate level of preventative
care. As a result of the City’s efforts, the number of children
who used the emergency room declined by nearly 40 percent
from 1992 to 2002. However, among children who are
insured, there is a segment who continue to use the
emergency room as their primary source of health care. This
research seeks to find out why these families continue to use
the emergency room as their primary health care provider.
Study Design: The design of this study was twofold. The first
part entailed a review of the New York State’s Department of
Health Online PC Database in order to find the rate at which
Medicaid enrolled children were using the emergency room
over the past ten years. Once these numbers were
ascertained, a sample was taken from each year in order to
discover which diagnosis were associated with the children
who obtained care in the emergency room. The New York
State Welfare Management System (WMS) billing database
was then used to analyze the utilization data for each case.
Each sampling was done using a 99% confidence interval and
a +/-2 margin of error. The second part of the study involved
a survey of current Medicaid families who used the emergency
room for their medical care services. For 4000 currently
active public health insurance cases for children between the
ages of 0 to 20 years who are receiving Medicaid, we analyzed
the following variables: 1) Whether children were eligible for
public health insurance; 2) Number of case closings on file, 3)
Parent’s knowledge of whether child(ren) enrolled in health
plan; 4) Number of Address Changes on file); and 5) Coverage
History. This sampling was done using a 99% confidence
interval and a +/-2 margin of error.
Population Studied: Families of New York City children ages
0 to 20 years who use the emergency room and are enrolled in
the Medicaid program.
Principal Findings: •
New York State has made a 40%
reduction in the number of Medicaid children obtaining
primary care in the emergency room.
•
There still remain a significant percentage (20%) of
Medicaid children who continue to use the emergency room
for their primary care needs.
•
Those children (87%) who use the services of the
emergency room are predominantly Black and Hispanic
children.
•
Many of the parents (87%) who took their children to
the emergency room were unaware that the child’s Medicaid
case was active.
•
Many parents (90%) were unaware that their child
was enrolled in a managed care plan.
•
The following services were provided to these
children: asthma, colds, high fevers, mental health issues and
other primary care needs.
•
Long engrained socio-medical behaviors may exist
amongst the families who use the emergency room for their
child’s primary care needs.
•
There is a slow increase in the number of children
using the emergency room to access primary care. In both
2000 and 2001 there was a small increase in the number of
children using the emergency room for preventative care.
Conclusions: Even with the aggressive implementation of
managed care programs in New York City over the past 10
years, 20% of children on Medicaid continue to use
emergency services, the most costly form of care, for their
primary care and mental health needs.
Implications for Policy, Delivery or Practice: There are
numerous policy and practice implications to these findings.
The first and most important is that beyond enrolling lowincome children and families into the Medicaid programs or
health plans, there also need to be education put in place so
these families can truly understand how to use their health
insurance in a more preventative manner. Another
implication is that children are not getting access to the
preventative health care they need during their formative
years. Finally, if these children are enrolled in managed care
organizations (MCO), what then is it obligation of the MCO to
ensure that these children have access to primary care
services?
Primary Funding Source: N/A, None
inpatient, outpatient, pharmacy, and special costs, which
included physical and speech therapy, and emergency room
visits. Non-parametric (Dunn Test) and parametric
(Generalized Linear Model) comparisons of post-diagnosis
costs were completed. Age, gender, insurance plan type, and
costs in the pre-diagnosis period were controlled for within the
multivariate model.
Population Studied: The study population was comprised of
children aged 3 – 17 years newly diagnosed with autism (N =
470), diabetes (N = 522), or asthma (N = 550). All subjects
were continuously enrolled in an HMO, PPO, or Medicaid
plan type throughout the study’s duration.
Principal Findings: The autistic cohort exhibited a higher
proportion of male subjects (80.6%) and a lower mean age
(9.4 years) than the diabetic children (49.8%, 12.6 years) or
asthmatic children (52.9%, 9.9 years). Autistic children
exhibited significantly greater median total healthcare costs
than children with asthma ($2103.58 vs. $850.27, P < 0.05) or
diabetes ($2103.58 vs. $1605.20, P < 0.05) in the 12-month
post-diagnosis period. After controlling for confounders,
autistic children exhibited significantly greater 12-month postdiagnosis total healthcare costs than asthmatic children (P <
0.0001); the difference in total healthcare cost between
autistic and diabetic children was non-significant (P = 0.84).
Conclusions: Results from this study in a privately insured
population suggest that autistic children may incur equivalent
or significantly greater healthcare costs than children
diagnosed with diabetes or asthma in the 12-month postdiagnosis period of their diseases.
Implications for Policy, Delivery or Practice: This study
highlights the costs of care associated with autism as they
compare to other growing public health concerns for children,
such as asthma and diabetes.
Primary Funding Source: Other, Janssen Medical Affairs
● The Burden of Illness in Austim: A Study of the Direct
Cost of Treatment
Scott Flanders, Ph.D., M.S., Julie Whitworth, Pharm.D.,
Mohamed A. Hussein, M.S.C.S., M.S.P.H., Daniel R.
Vanderpoel, Pharm.D., Timothy Sandman, M.B.A., Luella
Engelhart, M.S.
Presented by: Alison Galbraith, M.D., M.P.H., Instructor,
Department of Ambulatory Care and Prevention, Harvard
Pilgrim Health Care and Harvard Medical School, 133
Brookline Avenue, 6th Floor, Boston, MA 02215;
Tel: (617)509-9893; Fax: (617)859-8112;
E-mail: alison_galbraith@hms.harvard.edu
Research Objective: To determine whether socioeconomic
disparities exist in the financial burden of out-of-pocket health
care expenditures for families with children, and whether
health insurance coverage decreases financial burden for lowincome families.
Study Design: Cross-sectional family-level analysis. The main
outcome was financial burden, defined as the proportion of
family income spent on out-of-pocket health care
expenditures. We aggregated annual out-of-pocket
expenditures for all family members. Family insurance
coverage was categorized as: 1) all members publicly insured
all year, 2) all members privately insured all year, 3) all
members uninsured all year, or 4) a mixture of private, public,
and/or no insurance. We used bivariate statistics to examine if
financial burden varied by poverty level. Multivariate linear
Presented by: Scott Flanders, Ph.D., M.S., Associate Director,
Regional Outcomes Research, Outcomes Research, Janssen
Medical Affairs, 740 Waterford Drive, Grayslake, IL 60030
Research Objective: To compare the direct treatment costs
for children newly diagnosed with the pervasive
developmental disorder autism, versus children newly
diagnosed with diabetes or asthma, in a privately insured
population.
Study Design: A retrospective database analysis was
completed using claims derived from the administrative
database of a health benefits organization. Six months of prediagnosis and 12 months of post-diagnosis direct healthcare
cost claims were analyzed for children newly diagnosed with
autism, diabetes, or asthma. Healthcare costs included
● Out-of-pocket Financial Burden for Low-income Families
with Children: Socioeconomic Disparities and Effects of
Insurance
Alison Galbraith, M.D., M.P.H., Sabrina T. Wong, R.N., Ph.D.,
Sue E. Kim, Ph.D., M.P.H., Paul W. Newacheck, Dr.P.H.
regression models were used to assess whether family
insurance coverage was associated with level of financial
burden for low-income families.
Population Studied: Families with a child <19 years old in the
Household Component of the 2001 Medical Expenditure
Panel Survey.
Principal Findings: There was a regressive income gradient in
financial burden such that families with incomes <100% of the
Federal Poverty Level (FPL) had a disproportionately greater
financial burden than families with higher incomes. For lowincome families (< 200% FPL), financial burden was
significantly less for families with full-year public insurance
compared to those without insurance all year and compared
to those with full-year private insurance.
Conclusions: Socioeconomic disparities exist in the financial
burden of out-of-pocket health care expenditures for families
with children. However, financial burden is reduced for lowincome families with full-year public coverage. Full-year public
coverage provides substantially greater protection for lowincome families than full-year private coverage.
Implications for Policy, Delivery or Practice: Public
insurance programs play an important role in protecting lowincome families with children from burdensome out-of-pocket
expenses. Private insurance plans may place low-income
families at greater risk for financial burden from health care
expenditures. Policies to expand health insurance coverage to
the uninsured should consider the effects of cost sharing on
financial burden for families.
Primary Funding Source: AHRQ
● Factors Associated with Behavioral Care Decisions in
Children
James Guevara, M.D., M.P.H., Donald Schwarz, M.D., M.P.H.,
David Shera, Sc.D., Christopher Forrest, M.D., Ph.D., Kelly
Kelleher, M.D., M.P.H., Aileen Rothbard, Sc.D.
Presented by: James Guevara, M.D., M.P.H., Assistant
Professor, Pediatrics, The Children's Hospital of Philadelphia,
3535 Market Street, Room 1531, Philadelphia, PA 19104;
Tel: (215) 590-1130; Fax: (215) 590-0426;
E-mail: guevara@email.chop.edu
Research Objective: Previous research suggests that primary
care providers desire to co-manage behavioral problems in
children with mental health professionals, but provider
characteristics and managed care policies may influence how
treatment decisions are made. Our objective was to determine
factors that are associated with behavioral care treatment
decisions among primary care providers.
Study Design: Secondary analysis of the Child Behavior Study,
a nationwide cross-sectional study of children with behavioral
problems conducted in 2 large practice-based research
networks.
Population Studied: Children aged 4 to 15 years were
identified by clinicians with one or more of 11 behavioral
problems at the time of a non-urgent visit. Provider decisions
at this visit were categorized into mutually exclusive groups:
primary care (PC) treatment only (psychotropic prescription
and/or counseling), mental health (MH) treatment only
(mental health referral or ongoing mental health care), joint
(JT) treatment (primary care and mental health treatment) or
neither (NT). Child-, family-, provider-, and practice-level
factors were examined in multinomial models for association
with provider decisions.
Principal Findings: Over 4000 children (20%) aged 4 to 15
years from 201 practices in 44 states and Puerto Rico were
identified with a behavioral problem. Attentional/hyperactivity
problems (50%), behavioral/conduct problems (40%), other
emotional problems (19%), and developmental delay (17%)
were among the most common problems. Provider decisions
were distributed fairly evenly: PC (36%), MH (21%), JT (25%),
or NT (18%). Children with psychosocial dysfunction were
more likely to receive MH (OR 1.5, 95% CI 1.3-1.9) or JT (OR
1.9, 95% CI 1.6-2.3) but less likely to receive NT (OR 0.7, 95%
CI 0.6-0.9) than PC. Children with family dysfunction were
more likely to receive JT (OR 1.4, 95% CI 1.2-1.8) than PC but
did not differ in their likelihood of receiving MH or NT.
Children whose providers had greater MH orientation were
more likely to receive JT (OR 1.1, 95% CI 1.0-1.3) but less likely
to receive MH (OR 0.8, 95% CI 0.7-1.0) than PC. There were
minor geographic differences in care, but a measure of
managed care penetration was not associated with decisions.
Conclusions: Child and family characteristics had the
strongest effects on behavioral care treatment decisions and
were associated with decisions to co-manage with or refer to
mental health professionals. Provider beliefs regarding
psychosocial aspects of care influenced decisions in favor of
co-management, but a measure of managed care had no
effect.
Implications for Policy, Delivery or Practice: These results
suggest that clinicians consider the needs of children and their
families independent of other factors in treatment decisions
involving behavioral problems. Provider beliefs about
psychosocial aspects of care may also independently influence
decisions, but future study is needed to determine whether
educational interventions that influence beliefs will have an
impact on decision-making.
Primary Funding Source: Other Govt.
● Mothers in Transition from Welfare to Work: Child Care
for their Preschool Age Children
Ruchi Gupta, M.D., M.P.H., Laura B. Amsden, M.S.W.,
M.P.H., Jane L. Holl, M.D., M.P.H.
Presented by: Ruchi Gupta, M.D. M.P.H., Physician,
Pediatrics, Institute for Health Services Research and Policy
Studies and Children's Memorial Hospital, 339 E. Chicago
Avenue, Room 712, Chicago, IL 60611-3071;
Tel: (312) 503 0429; Fax: (312) 503 2936;
E-mail: r-gupta@northwestern.edu
Research Objective: To describe the child care arrangements
of low-income mothers of pre-school age children in transition
from welfare to work, and to determine the role of child care in
a mother’s choice to work and her work stability.
Study Design: We conducted a cross-sectional study of a
cohort of pre-school age, low-income children in Illinois. The
sample is representative of all Illinois households who were
receiving welfare in 1998. The sample was stratified by region
to ensure adequate representation of welfare families in
smaller Illinois counties. Weights were developed to adjust
for non-response and for stratification by region.
Population Studied: The youngest child between 0 and 3
years old at the time of the Year 1 interview (2000) was
selected in each household. An in-person interview with
questions about work, welfare, and child care was conducted
annually with the parent/guardian of each child. This study is
based on interview data from Years 1-3 (2000-2003). The
sample consisted of 554 (Yr.1), 494 (Yr.2), and 445 (Yr.3)
children.
Principal Findings: The most commonly reported child care
arrangement was “staying with a grandparent or other
relative” (60%) with no significant change over the three
years. Only 10% of children were in a child care center and
5% in a non-relative home child care. Children attending nonrelative, home childcare decreased significantly from 10.2% in
Year 1 to 4.8% in Year 3 (p<0.01).
Concerns about the quality of child care decreased
significantly from 22.8% in Year 1 to 5.8% in Year 3 (p<0.01).
Similarly, concerns about child care safety and dependability
decreased from 16.4% and 16.8% to 2.3% and 4.7%
respectively in Year 1 and in Year 3 (p<0.01). Child care costs
were reported as “too much” for 21.1% of mothers in Year 1
compared with 3.7% of mothers in Year 3 (p<0.01). Fortythree percent of families with preschool children did not
receive any child care subsidies in Year 3 despite nearly all
families having a median income of $13,750.
Approximately 47% of all mothers in the study were working in
any given year of the study. In Year 3, 20.4% of mothers
stated problems with child care as a primary reason for not
working; and 17% of mothers stated that being pregnant or
needing to care for a child was their reason for not working.
Among employed mothers who stopped working, 10.3%
indicated that a problem with child care was a main reason for
quitting.
Conclusions: 37.4% of mothers on welfare choose not to
work for reasons related to child care. An additional 10.4% of
employed mothers state child care as the reason for quitting
their job. Remarkably few children receive child care in a
Center (10%) and children receiving child care in a home-care
setting has decreased dramatically. These findings are
substantially different from the 60-75% of children nationally
who are in a formal child care setting. However, mothers do
seem more satisfied with the quality, safety, dependability and
cost of child care over a three year period.
Implications for Policy, Delivery or Practice: In Illinois, few
children of mothers in transition from welfare to work are
benefiting from child care subsidies; few children are cared for
in formal child care settings; and a substantial number of
mothers are not working for reasons related to child care.
Child care issues remain a key barrier to work and work
stability for mothers in transition from welfare to work.
Primary Funding Source: AHRQ, NICHD RO-1 39148
● School Health Services: How Well are They Meeting the
Needs of Children with Asthma?
Marianne Hillemeier, Ph.D., M.P.H., Maryellen Gusic, M.D.,
Yu Bai, M.S.
Presented by: Marianne Hillemeier, Ph.D., M.P.H., Assistant
Professor, Health Policy and Administration, The Pennsylvania
State University, 116 Henderson, University Park, PA 16802;
Tel: (814) 863-0873; Fax: (814) 863-2905;
E-mail: mmh18@psu.edu
Research Objective: Most children spend 7-10 hours a day in
school, and the capacity for appropriate asthma care in school
settings is critical for optimal disease management. The
objective of this study is to assess the availability of
appropriate asthma-related equipment and services in
Pennsylvania public schools.
Study Design: Surveys were mailed to nurses in public
schools that were randomly selected from each of the
Commonwealth’s 500 school districts. Two schools per
district were included in the sample with the exception of 4
districts that each contained only one school. Out of the total
sample of 996 there were 757 completed surveys returned,
resulting in a response rate of 76%. The surveys elicited
information about schools’ asthma management plans,
policies on asthma medication administration, and the
availability of medical equipment and services for children
with asthma and their families.
Population Studied: The study population consisted of
nurses employed in urban and rural schools throughout
Pennsylvania.
Principal Findings: Management plans for children with
asthma were not uniformly available and existing plans lacked
recommended information: 48% had procedures for storing
and administering medications, 32% had peak flow
monitoring procedures, 62% had an emergency protocol, 56%
contained emergency physician contact information, 69% had
emergency contact information for parents, 45% listed specific
environmental triggers, and 40% included a plan for physical
education participation. In one-third of schools children are
not allowed to carry their inhalers, and 3 schools reported
children have no access to inhalers during school even in the
health office. Asthma-related equipment was not uniformly
available, with half of schools having nebulizers and peak flow
meters, and less than one-third having spacers. Only 81% of
schools reported that staff who know what to do for a severe
asthma attack are always available, and just 64% have rapid
communication systems that link to EMS. Case management
for students with frequent asthma-related problems was
available in 31% of schools, and the presence of support
services for children and their families was reported in only
19%.
Conclusions: This study provides evidence that schools do
not consistently maintain recommended standards of care for
children with asthma. In some schools, lack of knowledgeable
staff and equipment represents a threat to child safety in the
event of a severe asthma attack.
Implications for Policy, Delivery or Practice: Improvements
are needed in school settings including more comprehensive
asthma management plans, increased access to medication,
equipment and emergency services, enhanced asthma
education for school personnel, and greater availability of case
management and supportive services for children and their
families.
Primary Funding Source: Other, Center for Rural
Pennsylvania
● Systemic Analysis of Patient Safety Related Clinician
Communication in Pediatric Medical Care
Jane Holl, M.D., M.P.H., Donna M. Woods, Ed.M., Ph.D.,
Edward S. Ogata, M.D., M.M., Gregory Makoul, Ph.D., Kevin
B. Weiss, M.D., M.P.H.
Presented by: Jane Holl, M.D., M.P.H., Assistant Professor of
Pediatrics and Preventive Medicine, Institute for Health
Services Researchand Policy Studies, Feinberg School of
Medicine, Northwestern University, 339 E Chicago Avenue,
Room 717, Chicago, IL 60611; Tel: (312) 503-0392;
Fax: (312) 503-2936; E-mail: j-holl@northwestern.edu
Research Objective: Effective team communication was
identified as important to improved patient safety in the
Institute of Medicine Report, “To Err is Human: Building a
Safer Healthcare System.” At the time, very little was
understood about the manifestations of patient safety
problems related to clinician communication and teamwork in
pediatrics. This study will illuminate the nature and contexts of
risk related to clinician communication in pediatrics and
distinguish pediatric specific systemic contexts for
communication risk.
Study Design: Thirty-five focus groups including over 100
clinicinans were convened by profession and by professional
level (resident physician, attending physician, staff nurse,
advanced practice nurse) for different units and services. The
focus groups were facilitated by trained focus group
facilitators and focus group discussion centered on effective
communication and problematic communication between
clinicians on the same service and across services.
Population Studied: Pediatric clinicians (physicians and
nurses).
Principal Findings: Thirty-five focus groups directed at
problematic and effective clinician communication in pediatric
medical care including over 100 pediatric clinicians were
convened.
Five problematic communication contexts were described in
the focus group discussions. Three of these contexts have
been previously described in the adult patient safety literature,
two have not. Those previously described included: (1)
transitions (patient transfers between services or units,
changes in attending/fellow/resident “coverage”, nursing shift
changes and scheduling of and getting studies and
procedures performed); (2) ICU patients managed by
clinicians not primarily located in the ICU and therefore
requiring intensivist management to improve safety, (3)
patients with complex medical/surgical conditions being cared
for by multiple services leading to breakdowns in
communication.
Two problematic patient safety related communication
contexts were described by pediatric clinicians that have not
been previously described in adult medicine. These included
contexts in which non-pediatric trained clinicians, particularly
surgical clinicians, are responsible for the care of medical
(non-surgical) conditions. Most pediatric surgical residents
have had little pediatric medical training. During a surgical
rotation, however, they must manage co-morbid medical
conditions in their surgical patients (i.e., asthma, diabetes,
etc.). In addition, the training of pediatric surgical attendings
is focused on surgical care and provides little pediatric
medical training.
Another described context of patient safety risk specific to
pediatrics included nurses (including experienced nurses)
being placed in specialty care contexts for which they did not
have specific specialty care experience. This situation largely
arose in response to the nursing crisis.
In person, face to face communication was described as most
effective. Medical work-rounds and clinical conferences were
the most commonly described examples, particularly when
everyone on the team was present. The effectiveness of team
communication was degraded in the context of medical workrounds, if critical members of the team were not present.
Conclusions: Some contexts of patient safety communication
related problems are common to both pediatric and adult
medicine. This study reveals two additional contexts of
pediatric specific medical care risk for further study and
attention for patient safety improvement.
Implications for Policy, Delivery or Practice: To improve
patient safety critical communication in pediatric medical care,
systemic and structural issues in the organization pediatric
medical care and training will require further assessment and
patient safety focus.
Primary Funding Source: AHRQ
● Identification of Actionable Items for Systems
Improvement through Executive Walkrounds in a Pediatric
Hospital
Lisa Horowitz, Ph.D., M.P.H., Melissa McClay, M.P.H., Allan
Frankel, M.D., James Mandell, M.D., Eileen Sporing, M.S.N.,
R.N., Donald Goldmann, M.D.
Presented by: Lisa Horowitz, Ph.D., M.P.H., Quality
Improvement Consultant / Psychologist, Program for Patient
Safety and Quality, Children's Hospital Boston, 300 Longwood
Ave-Wolbach 001, Boston, MA 02115; Tel: (617) 355-7447;
Fax: (617) 730-0632;
E-mail: lisa.horowitz@childrens.harvard.edu
Research Objective: To use comments elicited during Patient
Safety Executive Walkrounds to identify themes and actionable
items in order to resolve potential safety concerns.
Study Design: As part of a multi-center study, the Children’s
Hospital Executive Walkrounds Team (EWT) visited a different
unit in a large pediatric teaching hospital for one hour three
times per month. Three rotating executives conducted semistructured interviews with groups of staff including staff
physicians, physician trainees, nurses and pharmacists, using
standardized questions and explicitly encouraging staff to
share concerns free of retribution. To identify key themes and
actionable items, all staff comments were recorded verbatim
by a scribe during the rounds and entered as text into a
database. Comments were then numbered and coded by two
observers into thematically distinct categories, and
summarized in an Action Plan – a key tool for ensuring follow
up of actionable items. One week later a Debrief Session
including the EWT and clinical leaders from the specific unit
was convened to discuss each item in the Action Plan,
determine actionability, and assign responsibility for resolving
the item. 12 weeks later, staff who participated in Executive
Walkrounds received feedback and progress-to-date in the
form of the updated Action Plan. Each comment was then
labeled “completed,” “in progress,” or “tracked in database,”
depending on the action taken.
Population Studied: Three rotating senior hospital executives
and 550 multidisciplinary staff members, including staff
physicians, physician trainees, nurses, and pharmacists, of a
large urban teaching hospital participated from February
through December 2004.
Principal Findings: Twenty-seven Executive Walkrounds were
conducted in unique clinical areas. Attendance at Executive
Walkrounds ranged from 8-47 (mean 12) staff per round. Of
384 items, 14 thematically distinct categories were identified
by 2 observers, with an agreement rate of 90%. The top five
themes were: Workload/Resources (89% of Executive
Walkrounds), Communication (78%), Facilities (78%),
Information Systems (63%), and Documentation (52%).
Pediatric-specific concerns, such as child safety in medical
exam rooms and sterilizing toys in the waiting area, were
present in 15% of the comments. In a sub-sample of the first
12 Executive Walkrounds, 83% of items incorporated into the
database were considered “actionable” and assigned to
clinical leaders for resolution. At the end of 12 weeks, 32% of
the actionable items were deemed “completed.” Efforts to
resolve the remainder of the items are ongoing.
Conclusions: Concerns regarding workload, resources and
communication were identified frequently by staff as
impacting patient safety. Actionable items were identified and
addressed through the Action Plan. One third of the items
were resolved comprehensively.
Implications for Policy, Delivery or Practice: Conducting
Patient Safety Executive Walkrounds is feasible and effective in
a large tertiary care teaching hospital, and allowed this
institution to recognize and address systems issues with the
potential to compromise high quality healthcare delivery. The
Action Plan is an important tool that helps in assigning
accountability for resolving staff concerns, allows for ease in
feeding back information to staff, and enables the Executive
Walkrounds Team to track what would have been otherwise
unmanageable data.
Primary Funding Source: No Funding
● California’s Children’s Health Initiatives: Towards
Universal Insurance Coverage Among Children
Dana Hughes, Embry Howell, Christopher Trenholm, Ian Hill,
Martha Kovac, Genevieve Kenney
Presented by: Dana Hughes, Assistant Professor, Institute for
Health Policy Studies and Family and Community Medicine,
University of California San Francisco, 3333 California Street,
Suite 265, San Francisco, CA 94143; Tel: (415) 476-0780;
E-mail: dhughes@itsa.ucsf.edu
Research Objective: To describe the development, financing
and implementation of county-initiated efforts to provide
universal insurance coverage for children in California
Study Design: In 2001, Santa Clara County, California,
introduced the Children’s Health Initiative, an ambitious
program designed to assure insurance coverage to all children
in the county. Since then, 9 additional counties, including San
Mateo and Los Angeles counties, have created similar
programs, and several other counties are in the planning
process. This presentation will provide an overview of the
children’s universal coverage movement in California,
including the financing, leadership, implementation
challenges, and the likely future prospects and is designed to
provide context for subsequent presentations which describe
evaluation findings.
Population Studied: Low income, uninsured children.
Principal Findings: In California nearly one million children
were uninsured in 2001. Of these, two-thirds are eligible for
either Medi-Cal or Healthy Families. The remaining children
are ineligible for public programs because they live in families
with incomes too high to qualify or because they are
undocumented. To address these gaps in health insurance
coverage, several counties in California have created new
initiatives to insure children. Referred to as “Children’s Health
Initiatives” (or CHIs), these efforts include a two pronged
approach: creation of a new insurance product for children
ineligible for Medi-Cal or Healthy Families due to income or
documentation status called “Healthy Kids,” and coordinated
outreach and enrollment among county agency outreach
workers, community based organizations and schools across
all three programs. The initiatives are led by generally
informal coalitions comprised of representatives of county
health and social services, local health plans, First 5
Commissions community based organizations and
foundations. Funding comes from a wide range of public
entities (local First 5 Commissions, city and county resources,
healthcare districts) and private foundations. To date, these
programs have cumulatively enrolled more than 50,000
children in Healthy Kids while also finding and covering tens
of thousands more under Medi-Cal and Healthy Families. The
major challenge facing the CHIs is securing long-term
funding.
Conclusions: In a time of severe budget short falls and a week
state and local economies, several counties in California have
managed to extend health insurance to many thousands of
children.
Implications for Policy, Delivery or Practice: The Children’s
Health Initiatives have made great strides towards universal
coverage for children in the counties within which they
operate. Its replication in so many counties holds the
promise of genuine universal coverage state-wide and is a
model for other jurisdictions outside of California.
Primary Funding Source: Multiple sources
● Parents Perceive Pediatric Residents as Providing High
Quality Care
Scott Krugman, M.D., Janet R. Serwint, M.D.
Presented by: Scott Krugman, M.D., Chairman, Department
of Pediatrics, Franklin Square Hospital Center, 9000 Franklin
Square Dr, Baltimore, MD 21093; Tel: (443)777-7128;
Fax: (443)777-7130; E-mail: scott.krugman@medstar.net
Research Objective: To measure the quality of resident
primary care using a version of the Parent's Perception of
Primary Care (P3C) and compare to previously published
community standards.
Study Design: A 23 question version of the P3C was
administered to all parents of children who receive care from
residents at 19 CORNET continuity sites over a two week
period May-June 2004 (n=2107). The average response rate at
each site was 85%. The primary scale was analyzed by
calculating the mean score (scale of 100) and internal
consistency for each question, each primary care domain, and
the total scale.
Population Studied: Parents of children who receive care
from residents.
Principal Findings: Families who completed the survey were
39% Hispanic, 33% African-American, and 16% Caucasian;
81% of the children had medical assistance, 76% were under 5
years old and 19% of the parents had less than a high school
education. The survey demonstrated high internal consistency
with an overall alpha of 0.93. Parents of residents rated the
care they receive highly compared to the community sample
(mean overall score of 76.9 vs 62.07). Resident scores were
higher than the community sample in all primary care
domains except longitudinal continuity (resident mean score
51.87 vs community 53.34). The domains rated most highly by
parents of residents included communication (mean 89.15)
and coordination (mean 79.61). Parents of children under 6
years old rated the care they received significantly higher for all
domains except longitudinal continuity.
Conclusions: Parents perceive that pediatric residents provide
high quality pediatric care as compared to a previously
reported community sample.
Implications for Policy, Delivery or Practice: The P3C can be
used to assess resident care delivery and guide educational
interventions.
Primary Funding Source: Other, Ambulatory Pediatric
Association
● All Improvement is Local: Evaluating the Use of an
Innovative, Multi-Faceted Intervention by a National
Professional Organization to Translate its Guidelines into
Practice
Suzanne Lazorick, M.D., M.P.H., Virginia L.H. Crowe, R.N.,
M.S., Judith Dolins, M.P.H., Carole M. Lannon, M.D., M.P.H.
Presented by: Suzanne Lazorick, M.D., M.P.H., Primary Care
Research Fellow, The Center for Children's Healthcare
Improvement, UNC Chapel Hill, 200 Timberhill Place, Suite
200, CB#7226, Chapel Hill, NC 27599-7226;
Tel: (919)843-8115; Fax: (919)9669203;
E-mail: lazorick@email.unc.edu
Research Objective: Professional organizations have not
engaged in partnership at local levels to translate guidelines
into practice. The objective of this study was to understand
facilitators, barriers, and outcomes of using American
Academy of Pediatrics (AAP) chapters to implement the
evidence-based guidelines for diagnosis and treatment of
Attention Deficit Hyperactivity Disorder (ADHD). With
support from a quality improvement (QI) organization, this
intervention targeted: 1) leadership of AAP state chapters and
2) primary care practices (including participation in online
education modules, attendance at a workshop, completion of
chart reviews, and ongoing coaching in QI).
Study Design: Qualitative analysis of responses from semistructured interviews and chapter monthly progress reports.
Two researchers coded responses for factors related to
program implementation. Outcomes assessed were
development of infrastructure to support participating
practices, or future plans for expansion. Practices audited
charts to identify gaps and track improvements in care based
on the guidelines
Population Studied: Five state chapters were selected from
22 applications. We interviewed project leaders from the four
chapters that completed the intervention phase: the physician
champion, executive director, and project director, where
applicable. One state deferred participation due to competing
state priorities.
Principal Findings: All nine project leaders, representing 60
practice teams, were interviewed and all 22 reports were
reviewed. Facilitators to involving practices, sustaining
interest, and stimulating changes included: personal contact
from local opinion leaders, a face-to-face gathering of teams,
involvement of office staff in addition to a physician, regular
conference calls with teams and chapter staff, involving
experts on calls, frequent contact from project administrators,
and use of measurement to identify gaps in care. Baseline
chart audits demonstrated that no practice was providing care
consistent with the seven components of the guidelines, but
few teams continued ongoing measurement.
Barriers included time commitment, lack of reimbursement
for children’s mental health services, competing clinical
priorities (e.g., winter “flu” season), time required for
clinicians to complete online modules, and lack of availability
of data about progress for tracking changes in care.
Three chapters plan ongoing activities with current practices
in improving ADHD care. Two have secured funding to
expand the program and engage additional practices. Three
have specific plans to use the QI infrastructure developed to
address additional clinical topics.
Conclusions: Chapter leaders believe this intervention helped
them develop the nascent infrastructure needed to support
local practice teams in quality improvement activities. Direct
contact from state opinion leaders and a face-to-face meeting
engaged participants and facilitated collaboration. Use of
baseline measurement identified gaps in care and motivated
participation; however, lack of ongoing measurement inhibited
the use of data to drive further improvements. Support from
the national AAP and a QI organization was important.
Implications for Policy, Delivery or Practice: These findings
will be applied in the next project year involving six additional
chapters. Professional societies at the national and state level
are interested in and can develop local infrastructure for
improvement and translation of guidelines into practice.
Coaching, tools, and support from the national organization
and quality improvement experts are helpful in facilitating
these efforts.
Primary Funding Source: AHRQ
● Differences in Emergency Department (ED) Use
Patterns for Medicaid and Commercially Enrolled Children
in the Same Managed Care Organization.
Patrick Vivier, M.D., Ph.D., William Lewander, M.D., William J.
Lewander, M.D., Stephanie D. Schech, M.P.H., Jeffrey D.
Blume, Ph.D., James G. Linakis, Ph.D., M.D.
Presented by: William Lewander, M.D., Professor of
Emergency Medicine, Emergency Medicine, Brown
University/Hasbro Children's Hospital, Box G-RIH, Brown
University, Providence, RI 02912; Tel: (401) 444-6882;
Fax: (401) 444-6552; E-mail: WLewander@Lifespan.org
Research Objective: The objective of this research is to
examine differences in ED use for Medicaid and commercially
enrolled children in the same managed care organization.
Study Design: We performed a cohort study using
administrative datasets maintained by the managed care
organization. Data was conducted using Stata (version 8.2)
and Excel. All confidence intervals have level 95%.
Multivariate regression analyses were performed using an
over-dispersed Poisson regression model. The primary
diagnoses for visits were grouped into the 17 ICD9 categories,
E code or V code categories.
Population Studied: All children enrolled in the managed
care organization for any length of time from January 1, 2000
through December 31, 2002, who resided in one northeastern
state were included in the study. All enrollment days from all
enrollments during the study period until the day before the
18th birthday were included. An algorithm was used to
identify all ED visits that occurred while study children were
enrolled in the managed care organization during the study
period and before their 18th birthday.
Principal Findings: The 30,720 commercially enrolled
children made 9,270 ED visits in 36,045 years of enrollment
time for an ED use rate of .25 visits per year of enrollment.
The 35,465 Medicaid enrolled children made 28,740 visits in
50,458 years of enrollment for an ED use rate of .57 visits per
year of enrollment. In a multivariate regression analysis
controlling for age and gender the ED use rate of Medicaid
enrolled children was more than twice that of the
commercially insured children (rate ratio 2.15, CI 2.08-2.21).
Sunday had the greatest proportion of ED visits for both the
Medicaid (16.13%) and commercially (17.27%) insured
children, followed by Saturday (15.58% for Medicaid and
15.90% for commercially enrolled) and Monday (14.82% for
Medicaid and 14.06% for commercially enrolled). The ten
most common diagnostic categories were the same, in the
same order, for both the Medicaid and commercially insured
children, accounting for 94% of visits for each group. While
the relative rank of diagnoses was the same, there were
differences in the percentage of visits in each category. Injury
and poisoning was the most common diagnostic category for
both groups, accounting for 42.21% of visits in the
commercial group and 29.46% in the Medicaid group.
Conclusions: The ED use rate for Medicaid enrolled children
was twice that of children enrolled commercially in the same
managed care organization, even when controlling for age and
gender. The pattern of day of the week for visits was similar
for both groups. The top primary diagnostic categories were
also the same, though there were differences in the proportion
in each category.
Implications for Policy, Delivery or Practice: This study
demonstrates that Medicaid enrolled children use the ED
substantially more than commercially enrolled children in the
same managed care organization. Ambulatory care patterns
must be examined to determine whether this greater ED use
by Medicaid enrolled children is related to lower use of nonED ambulatory services. The high proportion of ED visits for
injury and poisoning in both groups emphasizes the
importance of injury prevention programs for all children.
Primary Funding Source: Center For Health Care Strategies
● Ambulatory Use Patterns for Medicaid and
Commercially Enrolled Children in the Same Managed
Care Organization.
Patrick Vivier, M.D., Ph.D., James Linakis, Ph.D., M.D., James
G. Linakis, Ph.D., M.D., William J. Lewander, M.D., Stephanie
D. Schech, M.P.H., Jeffrey D. Blume, Ph.D.
Presented by: James Linakis, Ph.D., M.D., Associate Professor
of Emergency Medicine, Emergency Medicine, Brown
University/Hasbro Children's Hospital, Box G-RIH, Brown
University, Providence, RI 02912; Tel: (401) 444-6680;
Fax: (401) 444-6552; E-mail: James_Linakis_PhD@Brown.edu
Research Objective: The objective of this research is to
examine ambulatory use for Medicaid and commercially
enrolled children in the same managed care organization.
Study Design: We performed a cohort study using
administrative datasets maintained by the managed care
organization. Data was conducted using Stata (version 8.2)
and Excel. All confidence intervals have level 95%.
Multivariate regression analyses were performed using an
over-dispersed Poisson regression model.
Population Studied: All children enrolled in the managed
care organization for any length of time from January 1, 2000
through December 31, 2002, who resided in one northeastern
state were included in the study. All enrollment days from all
enrollments during the study period until the day before the
18th birthday were included. All ambulatory visits that
occurred during the study period, prior to the child’s 18th
birthday were included.
Principal Findings: The 30,720 commercially enrolled
children made 139,791 ambulatory visits in 36,045 years of
enrollment time for an ambulatory use rate of 3.88 visits per
year of enrollment. The 35,465 Medicaid enrolled children
made 184,683 ambulatory visits in 50,458 years of enrollment
for an ambulatory use rate of 3.66 visits per year of
enrollment. In the multivariate regression analysis controlling
for age and gender the rate of ambulatory visits for Medicaid
enrolled children was somewhat less than that of the
commercially enrolled children (rate ratio .85, CI .84-.87). A
majority of ambulatory visits for both groups were to office
based practices (94.83% for commercially enrolled and
74.10% for Medicaid enrolled children). However a
substantially greater proportion of visits of Medicaid children
were to hospital based clinics (20.53% versus 3.67%).
Pediatrician was the most common physician specialty at
ambulatory visits for both groups (71.91% for Medicaid
enrolled and 67.79% for commercially enrolled children).
Ambulatory care was uncommon on the weekends for both
groups (3.92% of ambulatory visits for Medicaid enrolled and
5.82% of ambulatory visits for commercially enrolled).
Conclusions: The ambulatory use rate for Medicaid enrolled
children was somewhat less than that of children
commercially enrolled in the same managed care
organization, when controlling for age and gender. While a
majority of ambulatory visits for both commercial and
Medicaid children were to office based practices, substantially
more visits for Medicaid enrolled children were to hospital
based clinics compared to commercially enrolled children.
Implications for Policy, Delivery or Practice: The somewhat
lower rate of ambulatory use and the greater proportion visits
to hospital-based clinics for Medicaid enrolled children may
have implications for other care indicators such as emergency
department use.
Primary Funding Source: Center for Health Care Strategies
● Factors Associated with Family-Centered Care for
Children with Special Health Care Needs (CSHCN)
Jacalyn Yingling, M.S., Gregory Liptak, M.D., M.P.H., Monica
Serdinow, Au.D., Mark Orlando, Ph.D., Karen Nolan, P.T.,
M.S., Amy Luvera, M.S., O.T., Emily Kuschner, M.A.
Presented by: Gregory Liptak, M.D., M.P.H., Professor of
Pediatrics, Pediatrics, University of Rochester Medical Center,
601 Elmwood Avenue, Rochester, NY 14642;
Tel: (585) 275-5962; Fax: (585) 275-3366;
E-mail: Gregory_Liptak@urmc.rochester.edu
Research Objective: Family-centeredness is a critical element
of health care for all children, and provides the context in
which health and health-related services are delivered to the
child and family. Care that is family-centered can promote the
psychosocial well-being of children and their parents, and
increase satisfaction with services. The purpose of the study
was to evaluate the family-centeredness of care delivered to
CSHCN.
Study Design: Secondary analysis of data obtained from the
State and Local Area Integrated Telephone Survey (SLAITS),
developed by the Centers for Disease Control and Prevention.
Data were analyzed using SUDAAN statistical software.
Family-centered care (FCC) was evaluated by creating a
composite variable, the sum of responses on five questions
that focused on attributes of FCC. Each attribute was scored
using a Likert-scale that ranged from 1 (never) to 4 (always).
Interactions between the FCC score and demographic,
financial characteristics, access, and coordination of health
care services were assessed.
Population Studied: Families of 36,453 CSHCN (weighted
sample size of 8,742,837), younger than 18 years, responding
to the SLAITS
Principal Findings: The possible range of scores on the FCC
was 5-20. The mean was 17.16, (SE mean 0.03), with a median
of 18; 33% lacked =1 component of FCC. The factor rated the
lowest was getting sufficient information about the child’s
condition (5% said they ‘never’ received specific information).
Using multiple linear regression, family-centeredness was
significantly associated (all p<0.01) with the providers’ ability
to communicate with other providers, measures of access to
care (including delay in care, continuity of care, and health
insurance), severity of the condition, and care coordination.
The overall R2 for the model was 0.32.
Conclusions: Although families of CSHCN generally perceive
that their care is family-centered, gaps exist. Families often do
not receive sufficient information about their child’s care or
condition. FCC is associated with (1) providers'
communication skills, (2) access to care, including continuity
of care, (3) severity of the condition (including impact on the
family), and (4) care coordination.
Implications for Policy, Delivery or Practice: Models of care
delivery, such as the Medical Home, may be able to address
these issues and improve FCC. Continuing education for
providers that includes communication skills and knowledge
of CSHCN may be able to improve FCC as well.
Primary Funding Source: Other Govt, DHHS: Maternal and
Child Health Bureau; Leadership Education for Neurological
and Related Disabilities
● Factors Associated with Early Intervention Utilization
among Infants with Hearing Loss in Massachusetts
Chia-ling Liu, R.N., M.P.H., Sc.D., Chia-ling Liu, R.N., M.P.H.,
Sc.D., Janet Farrell, B.A., Sarah Stone, B.B.A., Wanda Barfield,
M.D., M.P.H., Nancy Wilber, Ed.D.
Presented by: Chia-ling Liu, R.N., M.P.H., Sc.D., Research and
Evaluation Specialist, Bureau of Family and Community
Health, MA Dept. of Public Health, 250 Washington Street,
Boston, MA 02108; Tel: (617) 624-5262; Fax: (617) 624-6062;
E-mail: penny.liu@state.ma.us
Research Objective: Every year, about 200 newborns in
Massachusetts (MA) are affected by a hearing loss. Without
appropriate intervention, children with hearing loss can
experience delays in cognitive, verbal, behavioral, and
emotional development, which later affect academic
achievement and employment success. Our objective is to
examine factors associated with the receipt of Early
Intervention (EI) services among infants with hearing loss in
MA.
Study Design: We analyzed data from birth certificates,
audiologic evaluation reports, and EI reports for infants with
hearing loss. Multivariate logistic regression was estimated
on EI enrollment, adjusting for infant factors (birth weight,
laterality, type, and severity of hearing loss) and maternal
factors (age, race/ethnicity, preferred language, country of
birth, education, health insurance, and poverty status in town
of residence). For children who were not enrolled in EI, we
conducted qualitative analysis based on information from
family reports collected through outreach activities and
audiologic evaluation reports from infants’ Audiologic
Evaluation Centers (AECs).
Population Studied: This study consists of 403 MA residents
born in 2002-2003 that were diagnosed with hearing loss
through the 26 state-approved AECs by December 2004.
Principal Findings: A total of 285 (71%) study children
received EI services. Having more severe forms of hearing
loss, other health risks, or living in more affluent towns was
associated with EI utilization for infants with hearing loss in
MA. Families were more likely to enroll children in EI services
if the hearing loss was bilateral (adjusted odds ratio (aOR)=
4.4, 95%CI= [2.6, 7.2]) or severe/profound (aOR= 2.7, 95%CI=
[1.4, 5.2]). Furthermore, being low-birth-weight (aOR= 5.3,
95%CI= [2.4, 11.7]) or residing in towns with <10% families
living below the poverty line (aOR= 2.1, 95%CI= [1.2, 3.9])
strongly predicted the receipt of EI services for infants with
hearing loss in Massachusetts. Qualitative analysis revealed
that both parents and providers were responsible for failing to
enroll infants with hearing loss in EI programs. Of those who
did not receive EI services (n=118), 74 (63%) reported hearing
testing was still ongoing. About one-third of parents of the
non-enrolled children believed that 1) their child’s hearing was
fine, 2) their child did not need EI services, or 3) they wanted
to “wait and see” how things went. Five percent of families
reported that their pediatrician did not encourage EI services.
In addition, 70% of audiologic evaluation reports for these
non-enrolled children indicated that no EI information was
discussed with families during the visits.
Conclusions: Children’s health status and residence
significantly predict EI utilization among infants with hearing
loss in MA. Pending diagnosis as well as parental and
providers’ attitude toward EI services prevent infants with
hearing loss from EI participation.
Implications for Policy, Delivery or Practice: Timely
diagnosis, provider and parental education on the need to use
EI services for infants with milder hearing loss, as well as
outreach efforts to communities with higher poverty
concentration are key factors to improve EI utilization among
infant with hearing loss in MA.
Primary Funding Source: CDC, MCHB
● Are We There Yet? The Distances Children Travel to
Obtain Pediatric Subspecialty Care
Michelle Mayer, Ph.D., M.P.H., R.N.
Presented by: Michelle Mayer, Ph.D., M.P.H., R.N., Research
Assistant Professor, Cecil G. Sheps Center for Health Services
Research, University of North Carolina, 725 Airport Road, CB
7590, Chapel Hill, NC 27599; Tel: (919) 966-5967;
Fax: (919) 966-5764; E-mail: michelle_mayer@unc.edu
Research Objective: There is currently concern that the
supply of pediatric subspecialists is not sufficient to meet the
needs of children; however, the adequacy of pediatric
subspecialists supply relative to patient demand or need has
not been assessed. Geographic accessibility is one important
measure of workforce adequacy. To date, no one has
estimated the distances that children must travel to obtain
pediatric subspecialty services in the United States. Our
objective was to estimate the distance between pediatric
populations in the United States and identify county
characteristics that are associated with greater distances to
pediatric subspeciality care.
Study Design: Using physician data from the American Board
of Pediatrics and county level data from the Bureau of Health
Professions Area Resource File (ARF) and the Bureau of the
Census, we calculated the straight line distance between each
county in the United States and the nearest pediatric
subspecialty provider. We merged 2003 estimates of the
under-18 population from the United States Bureau of the
Census. Using distance and population data, we calculated
the percentage of the pediatric population living within 10, 1150, 51-100, 101-200, and 200 or more miles of a provider for
each specialty. Using county level observations for all
pediatric subspecialties simultaneously, we performed
random effects logit to identify county characteristics
associated with living more than 50 miles from a pediatric
subspecialty provider.
Population Studied: Nationally representative study of US
pediatrician specialists and children.
Principal Findings: Across all counties in the United States,
the population-weighted average distance to a board-certified
pediatric subspecialist ranged from 12.6 miles for neonatology
to 76.7 miles for pediatric sports medicine. For most pediatric
subspecialties, more than 75% of the pediatric population lives
within 50 miles of a certified physician. Adolescent medicine,
developmental and behavioral pediatrics, pediatric
rheumatology, and pediatric sports medicine are exceptions.
Non-metropolitan counties and those in the Pacific and
Mountain regions of the United States were significantly more
likely to be located more than 50 miles from a pediatric
subspecialist.
Conclusions: For most pediatric subspecialties, more than
75% of the under-18 population lives within 50 miles of a
provider. Pediatric subspecialists in adolescent medicine,
developmental pediatrics, rheumatology, and sports medicine
are less widely available.
Implications for Policy, Delivery or Practice: These results
suggest that the practice locations of pediatric subspecialists
parallel the geographic distribution of children in the United
States. Nonetheless, children from non-metropolitan counties
and those in selected regions of the United States face
significant geographic barriers to receipt of pediatric
subspecialty care. Future studies should identify ways to
improve access for those children living in areas without a
nearby provider and should evaluate the extent to which
pediatric subspecialist supply is adequate to meet patient
demand in the areas that currently have providers. Efforts to
expand access through innovative physician networks and care
delivery systems are warranted to expand access to children
who reside in areas that lack sufficient population density to
support pediatric subspecialists.
Primary Funding Source: AHRQ
● Measurement Dependent Variations in Prevalence of
ADHD and ADHD-Related Conditions in Children
Elizabeth Momany, Ph.D., Peter C. Damiano, D.D.S., M.P.H.
Presented by: Elizabeth Momany, Ph.D., Assistant Research
Scientist, Public Policy Center, The University of Iowa, 227
South Quad, Iowa City, IA 52242; Tel: (319) 335-6812;
Fax: (319) 335-6801; E-mail: elizabeth-momany@uiowa.edu
Research Objective: To determine the prevalence of Attention
Deficit/Hyperactivity Disorder in an S-SCHIP program utilizing
3 different methods of defining the group with ADHD and to
describe the population with ADHD in a publicly funded
program.
Study Design: Encounter and enrollment data were used to
determine the proportion of children within the S-SCHIP
program who had ADHD during 2001. Three methods of
determining prevalence rates were utilized. Method 1 included
all children regardless of length of enrollment and counted a
child as having ADHD if they had one encounter during 2001
with a diagnosis code of 314.00, 314.01, or 314.9. Method 2
included all children regardless of enrollment period, utilized
the same diagnosis codes and added children with at least
one filled prescription for Adderall, Cylert, Dexedrine,
Methylphenidate Hydrochloride, Pemoline, Ritalin, or
Strattera. Method 3 followed Method 2, but limited the
prevalence to children with 11-12 months of enrollment.
Population Studied: Children ages 3-18 years enrolled in the
Iowa S-SCHIP program for at least 1 month during calendar
year 2001.
Principal Findings: The prevalence of ADHD for all children
using diagnosis codes, Method 1, was 1.0%-children 3-6,
4.5%-children 7-9, 5.3%-children 10-12, 4.1%-adolescents 13-15,
and 1.9%-teens 16-18. Prevalence increased when determined
through diagnosis and prescriptions, Method 2, to 1.5%children 3-6, 6.8%-children 7-9, 8.5%-children 10-12, 6.8%adolescents 13-15, and 3.0%-teens 16-18. When the prevalence
rate was limited to children who were eligible for 11-12 months
who had a diagnosis of ADHD or a filled prescription, Method
3, there were even greater increases. The prevalence for this
method was 2.2%-children 3-6, 9.3%-children 7-9, 12.2%children 10-12, 9.8%-adolescents 13-15, and 4.1%-teens 16-18.
8% of children who didn't have a diagnosis code of ADHD
and/or a filled prescription for an ADHD medication were
reported to have attention problems by their paretns. In
addition, 28% of children who did have a diagnosis of ADHD
and/or a filled prescription for an ADHD medication were not
reported as having attention problems by their parents. In
keeping with previous research, we found that the prevalence
of ADHD was higher for boys than girls across age categories.
We also found that the prevalence of ADHD was highest for
caucasians.
Conclusions: A variety of characteristics need to be taken into
account in prevalence calculations. Time of enrollment, type of
data, and method of identifying the disease are all important
aspects of the methodology. For ADHD the most valid
prevalence rate was determined using a popluation that has
been in the program for 11-12 months and had a diagnosis of
ADHD on a medical encounter or a filled prescription for an
ADHD medication. In addition, parental survey reports and
secondary data sources cross-validate whether a child has
ADHD.
Implications for Policy, Delivery or Practice: When
managing health care for a large population of children and
adolescents, ADHD becomes a major source of cost. Accurate
determinations of prevalence are required to anticipate the
resources needed to meet the needs of this population.
Awareness of different prevalence rates based on
methodologic approach is important to understand.
Primary Funding Source: Other Govt, State of Iowa
Department of Human Services
● An Exploratory Study of Dental Health Status and Risk
Factors for Dental Disease: Findings from a Network of
Child Care Centers in the Mississippi Delta
Linda Southward, Ph.D., Angela Robertson, Ph.D., Elisabeth
Wells-Parker, Ph.D.
Presented by: David Parrish, M.S., Research Associate III,
Social Science Research Center, Mississippi State University, 1
Research Boulevard, Suite 103, Mailstop 9628, Mississippi
State, MS 39762; Tel: (662) 325-7127;
Email: david.parrish@ssrc.msstate.edu
Research Objective: This paper describes caries prevalence
among preschool children in the Mississippi Delta, associated
parent and child oral health practices, and oral health
environments of the15 child care centers in which they are
enrolled.
Study Design: Exploratory study to determine the prevalence
of caries in a preschool, population. Parental self-report
surveys were conducted regarding their own oral health status,
their child. Child care directors also completed surveys on the
oral health practices within the child care setting. A pediatric
dentist completed on-site oral health assessments.
Population Studied: Convenience sample of 346 children,
ages 3-5 attending 15 child care centers in a twelve-county
Mississippi Delta region.
Principal Findings: Children (3-5 yrs) with public insurance
were twice as likely to have caries history, caries present, early
childhood caries and urgent treatment compared to children
with private insurance. Among parental factors, soft drink
consumptions of parent and parent abscess history were
strong predictors of presence of caries and urgent treatment
needs, respectively in their children. While not statistically
significant, children 3 years and older attending centers
without center based oral care programs were twice as likely to
have urgent dental needs compared to children attending
centers with no center based oral health programs.
Conclusions: The importance understanding a broad array of
risk factors within young children’s environment is critical. The
combined use of the two variables: parental soft drink
consumption, and parental abscess history, appears
promising for prediction of early caries experience. Oral health
prevention and treatment programs that may be implemented
in child care venues merit further exploration, particularly
among young children at greatest risk for developing caries.
Implications for Policy, Delivery or Practice: Potential
outcomes of defining a caries risk assessment instrument
include: reduced disease rates, delay of onset of disease,
decreased need for treatment and subsequent reduction of
dental costs for treatment.
Primary Funding Source: AHRQ
● Children's Racial Heritage and the Child Health
Behaviors/Beliefs of Their Child Care Directors
Ruchi Gupta, M.D., M.P.H., John Pascoe, M.D., M.P.H., Linda
Southward, Ph.D., Paula Duncan, M.D., Peter Gorski, M.D.,
M.P.A., Robert Greenberg, M.D.
Presented by: John Pascoe, M.D., M.P.H., Physician,
Pediatrics, Children’s Medical Center, One Children’s Plaza,
Dayton, OH 45404; Tel: (937) 641-3277; Fax: (937) 641-3278;
E-mail: john.pascoe@wright.edu
Research Objective: To examine the child health related
beliefs and behaviors of child care administrators in child care
settings that serve primarily Hispanic-American, AfricanAmerican or Euro-American young children.
Study Design: : Telephone survey of a random sample of over
2000 licensed child care center directors from a total of four
states including Northeastern, Southeastern and Western
states.
Population Studied: Child care directors in four states
including Mississippi, Vermont, Florida, and New Mexico
were randomly selected for the study.
Principal Findings: 2201 directors (response rate=89%)
completed the survey. 1713 (78%) reported that at least 50% of
the children attending their centers were Hispanic-American
(HAC) (N=182), African-American (AAC) (N=557) or EuroAmerican (EAC)(N=974). Lack of funds was a significant
barrier to health education in AAC (34%) compared to HAC
(19%) and EAC (20%), p<0.0001. HAC directors were more
likely to cite difficulty with English as a barrier to health
education (28%) compared to directors of AAC (8%) or EAC
(8%), p<0.0001. HAC were more likely to screen for health
problems (78%)compared to AAC (65%) or EAC (64%),
p=0.003. HAC directors were also more likely to be concerned
about children s dental health (40% vs 12%-AAC, 11%-EAC,
p<0.0001), children s weight (19% vs 8%-AAC, 11% -EAC,
p<0.001) and physical inactivity (49% vs 17%-AAC, 28% -EAC,
p<0.0001). In addition, HAC were more likely to have
nutritionist consultants (36%) compared to AAC (23%) or
EAC (16%), p<0.0001. AAC directors were less concerned that
parental smoking was having an impact on children s health
(47%) compared to HAC (58%) or EAC (61%) directors ,
p<0.0001.
Conclusions: HAC directors had more health concerns
related to childhood obesity and dental health for the children
in their centers compared to AAC or EAC directors. HAC
directors were more likely to cite difficulty with English as a
barrier to health education efforts at their centers, while AAC
directors were more likely to cite lack of funds. AAC directors
were less concerned about the impact of parental smoking on
children s health compared to HAC and EAC directors.
Implications for Policy, Delivery or Practice: Targeted health
promotion interventions must be developed for preschool
children in child care. Understanding important health issues
based on race/ethnicity will help us focus our interventions to
better serve individual populations.
Primary Funding Source: none, MSU SSRC
● Emergent and Non-Emergent Visits to a Children's
Hospital's Emergency Department Between 1987 and 2003
John Pascoe, M.D., M.P.H., Adrienne Stolfi, M.S.P.H., Arthur
Pickoff, M.D., Carla Clasen, M.P.H., Katherine Cauley, Ph.D.
Presented by: John Pascoe, M.D., M.P.H., Professor,
Pediatrics, Wright State University School of Medicine, One
Children's Plaza, Dayton, OH 45404; Tel: (937)641-3277;
Fax: (937)641-3278; E-mail: susan.howard@wright.edu
Research Objective: To examine the annual proportions of
emergent/non-emergent visits to a children's hospital
Emergency Department over 17 years (1987-2003).
Study Design: The Emergency Department Profiling
Algorithm created by John Billings, M.D. and his colleagues at
the New York University Center for Health and Public Service
Research was applied to the administrative records of all
children seen at The Children's Medical Center of Dayton's
Emergency Department (ED) from 1987-2003. The four
algorithm categories included: Non-Emergent,
Emergent/Primary Care Treatable, Emergent/ED Care Needed
but Preventable, and Emergent/ED Care Needed, Not
Preventable. The algorithm was developed by a panel of
emergency department physicians and is based on
information abstracted from a total of 5700 emergency
department records of children and adults from six Bronx,
New York hospitals in 1994 and 1995. For each diagnosis a
specific proportion of patients was assigned to each of the
four categories noted above, thus the sum of the proportions
for each diagnosis equals 100%.
Population Studied: There were 717,355 visits to the
Emergency Department at The Children's Medical Center of
Dayton for children less than 19 years old between 1987 and
2003 and 461,796 visits "mapped" to the algorithm.
Principal Findings: The most common Emergency
Department diagnoses that "mapped" to the algorithm were
otitis media (64,199), asthma (42,306), acute URI(40,692),
fever(39,878) and gastroenteritis(33,043). The overall mean+/standard deviation(SD) of proportions for each of the
algorithm's four categories over 17 years: Non-Emergent
.35+/-.27, Emergent/Primary Care Treatable .36+/-.25,
Emergent/ED Care Needed, but Preventable .17+/-.31,
Emergent ED Care Need, Not Preventable .12+/.21. The
proportion of Non-Emergent visits ranged from .29 to .37
between 1987 and 1996. The State Child Health Insurance
Plan was enacted by Congress in 1997 and the proportion of
Non-Emergent visits dropped to .25 in 1997, .26 in 1998 and
.30 in 1999. Between 2000 and 2003 Non-Emergent visits
ranged from .37 to .45. During the same interval (1997-2003)
Emergent visits, Not Preventable ranged from .10 to .17. Total
ED visits at The Children's Medical Center of Dayton that
"map" to the algorithm have almost doubled between
1987(n=17269) and 2003(n=32504) while total ED visits have
increased from 29913 (1987) to 46834 (2003).
Conclusions: Children with common primary care diagnoses
(e.g., otitis media, acute URI) are often seen at The Children's
Medical Center of Dayton's Emergency Department. Mean
Non-Emergent visits (.35) for children less than 19 years are
less common in Dayton compared to Non-Emergent visits to
New York emergency departments (.42) as reported by Dr.
Billings in 1998. Emergent Visits/Not Preventable were
similar for Dayton (.12) and New York (.15). There was a
temporal association between enactment of the State Child
Health Insurance Program and a decrease in Non-Emergent
visits for two to three years. However, Non-Emergent visits
have risen during the last several years to more typical levels.
Implications for Policy, Delivery or Practice: Emergency
department physicians at The Children's Medical Center of
Dayton have provided health care to thousands of children
over many years for non-emergent conditions. The State Child
Health Insurance Plan has not resulted in permanent change
to fewer Non-Emergent visits. While improving access to the
primary care delivery system for children and adolescents is a
complex task, it is a vitally important component of any
comprehensive strategy that aims to provide high quality, cost
effective medical care for children and adolescents in the 21st
century.
Primary Funding Source: N/A
● Potentially Medically Unnecessary Transports (PMUTs)
of Public Emergency Medical Services (EMS) Systems
Among Children 17 Years and Younger
Daniel Patterson, Ph.D., M.P.H., Janice C Probst, Ph.D.
Presented by: Daniel Patterson, Ph.D., M.P.H., AHRQ-NRSA
Post Doctoral Research Fellow, Cecil G. Sheps Center for
Health Services Research, University of North Carolina at
Chapel Hill, 725 Airport Road CB #7590, Chapel Hill, NC
27599; Tel: (919) 966-0047; Fax: (919) 966-5764;
E-mail: dpatterson@schsr.unc.edu
Research Objective: Estimate the prevalence of Potentially
Medically Unnecessary Transports (PMUTs) by public
Emergency Medical Services (EMS) among children in three
counties of a Southeastern state.
Study Design: To estimate the prevalence of PMUTs we
merged administrative billing data collected from one EMS
billing entity representing three public EMS systems with ED
data from a state-level ED data repository. These data include
EMS transports for all children ages 0 to 17 years to any
hospital within one Southeastern state. A PMUT was defined
using emerging criteria developed at the Neely conference
held in Panama City, Florida January 2003. Independent
variables include rural-urban status, age, gender, race,
insurance status, and dispatcher impression.
Population Studied: All patients aged 17 years and younger
transported by one of three public EMS systems within one
Southeastern state over the course of 27 months.
Principal Findings: A total of 5,693 children were transported
between January 1, 2001 and March 31, 2003. One in every six
EMS transports was potentially medically unnecessary. The
most common primary diagnosis among PMUTs was ICD9
code 382, Acute Suppurative Otitis Media. The prevalence of
PMUTs was higher among transports originating from a rural
location versus urban (18.6% versus 15.8%; p=0.02). As age
increases, the prevalence of PMUTs decreases ranging from
24.4% for 0-4 year olds to 13.3% for 13-17 year olds (test for
trend p<0.0001). This study found no significant differences
between males and females. The proportions of PMUTs
across race, insurance status, and dispatch impression were
highest among children of races other than white, African
American, and Hispanic (20.8%, p<0.0001), Medicaid insured
(21.7%, p<0.0001), and children assumed to be suffering from
a behavioral emergency by EMS dispatch (46.5%, p<0.0001);
e.g. hysteria, fainting, overdose, psychiatric/behavioral,
impairment similar to alcohol, or altered mental status. In
looking further at children transported for behavioral
emergencies, the most common diagnosis for children for age
10 and less was ICD9 code 79.9 and 312.8; unspecified viral
infection, and other specified disturbances of conduct, not
elsewhere defined. For children 11 and older, the most
common diagnosis was ICD9 code 305, 311, and 312.8 nondependent abuse of drugs, depressive disorder, and other
specified conduct, not elsewhere defined.
Conclusions: This study provides evidence that one in every
six child related transport is potentially medically unnecessary.
A greater understanding of PMUTs among children, and
whether or not disparities in access to care contribute, is
needed.
Implications for Policy, Delivery or Practice: Most public
EMS systems respond, provide care, and transport patients
for a variety of illnesses and conditions regardless of need.
Due to rising costs and decreases in reimbursement, many
systems have adopted no-transport policies for patients
determined to not need EMS services. Widespread adoption
of no-transport policies could have a significant impact on the
type of prehospital care many very young patients receive.
Primary Funding Source: AHRQ
● Blood lead testing in Medicaid Children: Comparison of
Parental Responses with Medicaid Claims and with
Surveillance Data
Barbara Polivka, Ph.D.
Presented by: Barbara Polivka, Ph.D., Associate Professor,
College of Nursing, The Ohio State University, 1585 Neil
Avenue, Columbus, OH 43201; Tel: (614) 292-4902;
Fax: (614) 292-4948; E-mail: polivka.1@osu.edu
Research Objective: Screening for lead poisoning in children
receiving Medicaid is federally mandated at ages 12 and 24
months, yet only about one-third of Ohio’s eligible children at
this age are screened. Using the Access to Care model as a
guiding framework, this study compared parental/caregiver
self-report of blood lead testing with blood lead testing
evidence in Medicaid claims data or in blood lead surveillance
data.
Study Design: Data from parents/caregivers were collected
via a mailed survey of a random sample of 1,372 parents;
blood lead testing data were validated with Ohio Medicaid
claims and lead surveillance databases.
Population Studied: Survey respondents (n=542) were
primarily white (76%), female (97%), with at least a high
school education (79%).
Principal Findings: Fifty-six percent (n=296) reported their
child had a blood lead level (BLL) drawn; 16% did not know. A
blood lead testing could be not confirmed with
claims/surveillance data for 44% (n=140) of these children.
For 23% (n=54) of those reporting their child had not been
tested, claims/surveillance data indicated blood lead testing
had been completed. Logistic regression revealed the odds of
a blood lead test per claims/surveillance data was 3.1
(CI=1.9,4.9) times greater if the child had a well-child visit in
the previous three years; 1.8 (CI=1.2,2.7) times greater if they
were an urban dweller, 1.8 (CI=1.2,2.7) times greater if the
parent reported receiving a reminder to have their child tested,
1.6 (CI=1.1,2.4) times greater if the child was over 2 years old;
and 1.6 (CI=1.1, 2.5) times greater if the parent reported
receiving lead poisoning prevention information.
Conclusions: Results suggest parents may not be aware if
their child had actually been tested for blood lead. Multivariate
analyses to determine factors related to a recorded blood lead
test and to parental report of blood lead testing indicated a
greater likelihood if a reminder, card, letter or call was made
and if the respondent recalled receiving information on lead
poisoning.
Implications for Policy, Delivery or Practice: Healthcare
providers need to supply parents with documentation
regarding blood lead testing, assure reminders are sent to
parents, and provide lead poisoning prevention education to
all parents of young children.
Primary Funding Source: Other, Ohio Department of Job and
Family Services and Ohio Board of Regents
● Impact of Patient-Centered Decision-Support on Quality
of Asthma Care in the Emergency Department
Stephen Porter, M.D., Peter Forbes, M.S., Henry Feldman,
Ph.D., Donald Goldmann, M.D.
Presented by: Stephen Porter, MD, MPH, MSc, Assistant
Professor, Division of Emergency Medicine, Children's
Hospital Boston, 300 Longwood Avenue, Boston, MA 02115;
Tel: 617 355 2136; Fax: 617 730 0335;
E-mail: stephen.porter@childrens.harvard.edu
Research Objective: We evaluate the impact of the asthma
kiosk on measures of quality during ED care, specifically,
parent-reported satisfaction with communication and provider
compliance with guideline-endorsed processes of care.
Study Design: An intervention trial was conducted at a single
tertiary care pediatric ED. Eligible subjects were English or
Spanish-speaking parents of children age 1 to 12 years with a
respiratory complaint and history of asthma. Parents used the
kiosk to report children's symptoms, current medications and
unmet needs. During baseline, no output from the kiosk was
shared and usual care proceeded. During intervention, the
output was shared with ED clinicians. Subjects completed a
telephone follow-up interview one week after discharge.
Primary outcomes were: 1) prescription of controller
medication to patients not on controllers whose disease
severity met persistent criteria, and, 2) mean problem ratings
for domains of information-sharing and partnership.
Population Studied: Eligible subjects were English or
Spanish-speaking parents of children age 1 to 12 years with a
respiratory complaint and history of asthma
Principal Findings: Over 5 months, 1090 parent-child dyads
were screened and 430 were eligible. 286/430 (66.5 percent)
parents enrolled in the trial. The kiosk generated severity
classifications for 264/286 (92.3 percent) of children. 131
subjects enrolled during baseline, 13 during a run-in phase,
and 142 during intervention. Baseline subjects were older
(mean age 5.3 yr) compared to intervention (4.4 yr) but did
not differ on chronic severity, current use of controllers, or
race. During the intervention phase, providers gave a
significantly higher proportion of inhaled corticosteroid to
eligible patients compared to baseline (9/50 versus 2/43, p
less than 0.05). Between baseline and intervention, the
reported number of partnership problems rose from a mean
of 1.4 (SD 1.7) to a mean of 1.8 (SD 1.4, p less than 0.05); the
number of information problems was unchanged. When ED
providers acted on kiosk data, reports of information
problems were fewer with a mean of 0.6 problems (SD 0.8),
than when no action was taken, mean 1.2 (SD 1.1, p equals
0.06.)
Conclusions: The asthma kiosk successfully produced
actionable output during ED care. The technology intervention
demonstrated modest and variable impact on quality.
● Improving Child Health Measures with Item Response
Theory
Anastasia Raczek, M. Ed., John E. Ware, Jr., Ph.D., Michael A.
DeRosa, M.A.
Presented by: Anastasia Raczek, M. Ed., Scientist,
QualityMetric Incorporated, 235 Wyman Street, Waltham, MA
02451; Tel: (781) 890-8882 X323; Fax: (781) 890-0910;
E-mail: sraczek@qualitymetric.com
Research Objective: Item response theory (IRT) and
computerized adaptive testing (CAT) hold much promise in
improving assessments of child health. Currently, fixed-item
surveys present trade-offs when used for identifying disability,
measuring functional status, or evaluating progress as
children age or receive treatment. Short-forms may not be
sufficiently precise for individual monitoring, or suffer from
floor or ceiling problems. On the other hand, comprehensive
long-form surveys may prove burdensome to complete. CAT
uses a computer interface to administer an assessment
specifically tailored to the unique functional level of a
particular child. This poster will present the application of
CAT and IRT in child health through two projects:
1) A pilot test in a clinical setting of a computerized, adaptive
application for measuring mobility in children based on one
scale of the Pediatric Evaluation of Disability Inventory (PEDI)
(Haley Coster, Ludlow, Haltiwanger, & Andrellos, 1992); and
2) An improved measure of child functioning developed using
IRT to analyze items from two widely-used surveys, and
generating a combined measure with an expanded range.
Study Design: 1) CAT Pilot Test: Items were calibrated using
the Rasch model, differential item functioning was assessed,
and a CAT was developed. The CAT and a corresponding
paper-and-pencil survey were administered to 80 children/
clinicians. Scoring comparability and respondent burden were
compared. Participants also completed a post-assessment
evaluation.
2) Improved Functional Measure: The Rasch model was used
to calibrate items from functional scales on the PEDI and
Child Health Questionnaire (CHQ), two widely-used surveys
of child disability and functioning.
Population Studied: 1) CAT Pilot Test: IRT analyses were
completed using an existing database of 881 children age 6
months to 17 years; 469 children were receiving rehabilitation
services. The CAT was completed by clinicians or caregivers
for 80 children in an urban children's hospital and
rehabilitation center: 39 children with disabilities (6 months to
18 years), and 41 children without disabilities (6 months to 7.5
years).
2) Improved Functional Measure: In addition to the PEDI
sample, data from a representative sample (N=391) of the
non-institutionalized general U.S. population, ages 5-18,
collected in 1994 as part of the National Survey of Functional
Health Status were used; 55% reported having one or more of
a list of physical and psychosocial conditions.
Principal Findings: 1) CAT Pilot Test: Field test results
confirmed the correspondence between scores from the two
forms (full-length fixed and brief adaptive, r=0.98, p<.0001).
The pediatric CAT was much less burdensome to complete,
requiring about 15% the number of items and 21% the
administration time. Participants generally preferred the
computerized assessment.
2) Improved Functional Measure: items from the PEDI
instrument tended to measure the “low” end of the functional
continuum well, although the range of measurement was
somewhat narrow. Items from the CHQ tended to measure a
wider range. IRT can be used to co-calibrate items measuring
the same construct, producing improved measures.
Conclusions:
Implications for Policy, Delivery or Practice: As pediatric
rehabilitation and other health services are increasingly called
on to demonstrate effectiveness, more precise, yet easy-toadminister, tools for documenting progress will be needed.
Advantages of CAT applications include more precise
measurement over a wider range of score levels and
substantial reductions in respondent burden.
Primary Funding Source: Other Govt, National Institute of
Child Health and Human Development (NICHD)
● Provider-Level Differences in Psychotropic Medication
Use Among Children in the Child Welfare System
Ramesh Raghavan, M.D., Ph.D., Bonnie T. Zima, M.D.,
M.P.H., John Landsverk, Ph.D.
Presented by: Ramesh Raghavan, M.D., Ph.D., Policy
Director, The National Center for Child Traumatic Stress,
University of California, Los Angeles, 11150 W Olympic
Boulevard, Suite 650, Los Angeles, CA 90064;
Tel: (310) 235-2633, x233; Fax: (310) 235-2612;
E-mail: rraghavan@mednet.ucla.edu
Research Objective: To estimate the prevalence rate of and
variations in psychotropic medication use by type of provider
visit (specialty only, primary care only, or both) among a
nationally representative sample of children in the child
welfare system.
Study Design: We merged child-level data from the National
Survey of Child and Adolescent Well-Being, and county-level
provider supply data from the Area Resource File. We
performed logistic regressions to estimate the odds of
psychotropic medication use among children with a past year
contact with specialty, primary care, and both types of
providers for a mental health problem, adjusting for child-level
characteristics and county-level provider supply variables.
Population Studied: 3041 children aged between 2 and 16
years investigated by child welfare agencies for suspected
child maltreatment between November 1999 and April 2002.
Principal Findings: Overall, 14% of children were taking
psychotropic medications. Male gender, history of sexual
abuse, and a borderline score on the internalizing subscale of
the Child Behavior Checklist (CBCL) predicted medication use
among children with specialty provider visits. Older age,
African-American race/ethnicity, and a borderline score on the
externalizing subscale of the CBCL predicted medication use
among children with primary care provider visits. For children
who saw both specialty and non-specialty providers, male
gender, history of sexual abuse, and a borderline score on the
externalizing subscale of the CBCL were predictive of
medication use. Controlling for sociodemographic variables
and CBCL scores, the probability of psychotropic medication
use was 0.3 for children with a specialty provider visit, and 0.5
for children with a non-specialty provider visit.
Conclusions: There exist differences in the use of
psychotropic medications by children in child welfare settings
that are not explained by sociodemographic characteristics,
abuse history, or family/placement status. These differences
are likely related to the type of provider doing the prescribing.
Implications for Policy, Delivery or Practice: Provider-level
differences in psychotropic prescribing need to be understood
if children in child welfare settings are to receive high-quality
mental health care.
Primary Funding Source: AHRQ
● Reductions in Newborns Diagnosed with Fetal Alcohol
Syndrome in the United States, 1993 to 2002
James M. Robbins, Ph.D., James M. Robbins, Ph.D., T.M. Bird,
M.S., John M. Tilford, Ph.D.,
J. Alex Reading, M.S., Mario A. Cleves, Ph.D., Mary E. Aitken,
M.D., M.P.H.
Presented by: James M. Robbins, Ph.D., Professor, Pediatrics,
University of Arkansas for Medical Sciences, 800 Marshall
Street, Little Rock, AR 72202; Tel: (501) 364-3300;
Fax: (501) 364-1552; E-mail: robbinsjamesm@uams.edu
Research Objective: Consumption of alcohol during
pregnancy has declined over the past 10 years. Variation in
birth defect surveillance system methodologies across states
limits our understanding of whether rates of fetal alcohol
syndrome have declined along with rates of drinking during
pregnancy. This study uses national hospital discharge data to
determine whether rates of newborn hospitalizations for fetal
alcohol syndrome have declined over the past 10 years.
Study Design: Data from the Healthcare Cost and Utilization
Project Nationwide Inpatient Sample were used to estimate
rates of newborn hospitalizations with the ICD-9-CM
discharge code of fetal alcohol syndrome for years 1993
through 2002. Rates of newborn hospitalizations for fetal
alcohol syndrome per 1,000 live births in the United States
were determined. Additional analyses using the Kids' Inpatient
Database compared changes in rates for whites, blacks, and
Hispanics, and changes in rates for newborns from low,
middle, and high-income families from 1997 to 2000.
Drinking rates during pregnancy were obtained from the
Behavioral Risk Factor Surveillance System for 1993 through
2002.
Population Studied: All hospital births in the United States
from 1993 through 2002.
Principal Findings: Newborn hospitalizations with the
discharge diagnosis of fetal alcohol syndrome declined from
.73 per 1,000 live births in 1993 to .17 per 1,000 live births in
2002. Among blacks the rate declined from 2.03 in 1993 to .56
in 2002. From 1997 to 2000, rates declined significantly for
lower income blacks and for middle and higher income
whites. Rates declined concurrently with rates of alcohol
consumption during pregnancy.
Conclusions: Rates of fetal alcohol syndrome among
newborns have declined 75% over the past 10 years. Results
may be due to decreases in drinking during pregnancy,
changes in hospital coding tendencies, or increased exposure
to maternal protective nutrients such as folic acid. This study
is limited by an ecological research design, ascertainment of
cases in the newborn period only, and lack of independent
validation of the fetal alcohol syndrome diagnosis.
Implications for Policy, Delivery or Practice: Drastically
declining rates of newborns with fetal alcohol syndrome may
reflect greater concern with toxic fetal exposures as
emphasized in the media and as legislated via warning labels
on alcoholic beverages. National hospital discharge databases
provide an important public health surveillance mechanism
for conditions of the newborn.
Primary Funding Source: CDC
● Development of the SF-10 for Children™ Version 2: A
Tool to Monitor Pediatric Health Outcomes
Renee Saris-Baglama, Ph.D., Michael DeRosa, M.A., Diane
Turner-Bowker, Ph.D., Jakob Bjorner, M.D., Ph.D.
Presented by: Renee Saris-Baglama, Ph.D., Scientist,
QualityMetric Incorporated, 640 George Washington
Highway, Lincoln, RI 02865; Tel: (401) 334-8800;
E-mail: rsbaglama@qualitymetric.com
Research Objective: The objective of this research is to
develop a caregiver-completed, alternative short-form of the
Child Health Questionnaire™ (CHQ) that is comprehensive,
reliable, and valid. The primary goal of this study is to select a
small set of items from a larger pool of CHQ items that
reproduces the CHQ-50 physical (PHS) and psychosocial
(PSS) summary component scales.
Study Design: The SF-10 for Children™ Version 2 (v2) was
derived from cross-sectional CHQ data obtained through the
National Survey of Functional Health Status (NSFHS). Items
from the pool (k=68) were categorized by the CHQ content
domain and submitted to a series of forward stepwise
regressions. Results were evaluated by how consistently items
(independent variables) entered the model as strong
predictors of the criterion dependent variables (summary
scale scores). The psychometric properties of the resulting
items and scales were examined.
Population Studied: Participants were parents/guardians
(N=411) who responded to questions about their child’s
health-related quality of life (HRQOL) through the NSFHS,
conducted by the National Opinion Research Center in 1994.
More than half of the children were male (54%) and the mean
age of the children was 11 years.
Principal Findings: Ten items emerged as strong predictors
of the PHS and PSS summary scales. Five items score the
PHS-10 summary scale and five items score the PSS-10
summary scale. Summary component scores are norm-based
scored (standardized to a mean of 50 and SD of 10 in the
general US population) allowing scores to be directly
comparable to one another and interpreted in relation to
population-based norms. Scale-level discriminant and relative
validity tests show that the SF-10 for Children (v2) retains the
validity of the CHQ with substantially less respondent burden.
Internal consistency reliability met the minimum of 0.70 for
group comparisons.
Conclusions: Development of the SF-10 for Children (v2) was
a data-driven process resulting in an empirically sound and
useful tool for measuring HRQOL in a pediatric population.
Traditional HRQOL measures such as the CHQ typically are
comprehensive, reliable, and valid, but include numerous
items and can be impractical for use in some settings.
Although not as precise as longer alternative forms, a brief
instrument like the SF-10 for Children (v2) offers many
advantages for practical application and yields results that are
comparable to those that would be obtained with the longer
form CHQ in population studies.
Implications for Policy, Delivery or Practice: Standardized
generic HRQOL measures may be used to identify those at
risk for psychological or physical problems; quantify the
effectiveness of treatment; monitor progress over time; and
describe variations in treatment response and long-term
prognosis in chronically ill children. With just 10 items on a
one-page form, the SF-10 for Children (v2) can be easily
integrated into many settings including routine clinical
practice, disease management, and quality improvement
initiatives. Enhancing the practicality of children’s HRQOL
tools will make the management of children’s health more
effective in meeting patient care needs.
Primary Funding Source: N/A
● Child Characteristics and Enrollment Patterns for
Medicaid and Commercially Enrolled Children in the Same
Managed Care Organization
Patrick Vivier, M.D., Ph.D., Stephanie Schech, M.P.H.,
Stephanie D. Schech, M.P.H., Jeffrey D. Blume, Ph.D., James
G. Linakis, Ph.D., M.D., William J. Lewander, M.D.
Presented by: Stephanie Schech, M.P.H., Researcher, Center
for Health Care Policy and Evaluation, 12125 Technology Drive,
Eden Prairie, MN 55344; Tel: (952) 833-7085; Fax: (952) 8337090; E-mail: stephanie_d_schech@uhc.com
Research Objective: The objective of this research is to
examine differences in child characteristics and enrollment
patterns for Medicaid and commercially enrolled children in
the same managed care organization.
Study Design: We performed a cohort study using
administrative datasets maintained by the managed care
organization. Data was conducted using Stata (version 8.2)
and Excel. All confidence intervals have level 95%.
Population Studied: All children enrolled in the managed
care organization for any length of time from January 1, 2000
through December 31, 2002, who resided in one northeastern
state were included in the study. All enrollment days from all
enrollments during the study period until the day before the
18th birthday were included.
Principal Findings: There were 30,720 children enrolled in the
managed care plan commercially and 35,465 enrolled through
Medicaid. The Medicaid enrolled children were younger (7.14
years, CI 7.09-7.19) at the start of their first enrollment period
as compared to the commercially enrolled children (mean
8.69 years, CI 8.64-8.75). Children under four years of age
accounted for 40.59% of the Medicaid children as compared
to 28.34% of the commercially insured children. Children ten
years and older accounted for 32.53% of the Medicaid enrolled
children and 44.47% of the commercially enrolled children.
There was a small overall male predominance for both
Medicaid enrolled (50.28% male) and commercially enrolled
(51.11% male) children, with the gender proportions varying
somewhat by age group. The mean number of days of
enrollment was substantially greater for Medicaid enrolled
children (519.31 days, CI 516.81-521.80) as compared to
commercially enrolled children (428.27 days, CI 425.55430.99). The 25th, 50th and 75th percentile for days of
enrollment for the Medicaid enrolled group was 312 days, 625
days and 730 days respectively. The 25th, 50th and 75th
percentile for days of enrollment for the commercially enrolled
group was 214 days, 366 days and 730 days respectively.
Conclusions: Medicaid enrolled children were younger at the
start of their first enrollment and had more mean days of
enrollment as compared to children enrolled commercially in
the same managed care organization.
Implications for Policy, Delivery or Practice: While turnover
in enrollment of Medicaid enrolled children has been
identified as a concern, their time of enrollment in this
managed care organization was longer than among
commercially enrolled children. The specific findings of
Medicaid children being younger and having longer
enrollment periods may not be generalizeable to all managed
care plans serving both Medicaid and commercially enrolled
children. However, these differences do underscore the
importance of taking into account such factors when
comparing utilization patterns of Medicaid and commercially
enrolled children, even when both groups are enrolled in the
same managed care organization.
Primary Funding Source: Center for Health Care Strategies
● Mental Health Services for Children with Severe
Emotional Disturbance: Understanding Abuse Related
Characteristics
Christine Walrath, Ph.D., Angela Sheehan, M.P.A., Michele
Ybarra, Ph.D., Barbara J. Burns, Ph.D., E. Wayne Holden,
Ph.D.
Presented by: Angela Sheehan, M.P.A., Research Associate,
Applied Research Division, ORC Macro, 116 John Street, Floor
8, New York, NY 10038; Tel: (646) 695-8122;
Fax: (212) 941-7031; E-mail: Angela.K.Sheehan@orcmacro.com
Research Objective: Child abuse in this country remains an
alarming problem, with 2.3 children per 1,000 physically
abused and 1.2 children per 1,000 sexually abused (DHHS,
2002). Child abuse has been linked to various psychological
and psychosocial problems among children, including higher
rates of internalizing and externalizing problems, suicidality,
aggressive/criminal behavior, and addiction/risk behaviors.
The purpose of this study was to gain an understanding of the
unique characteristics associated with abuse in efforts to
inform policy-makers and service providers when making
treatment decisions for children with abuse histories seeking
community-based mental health services.
Study Design: This study used information collected during
the baseline assessment of children and their families who
participated in the National Evaluation of the Comprehensive
Community Mental Health Services for Children and Their
Families Program (CMHS, 1999). This mental health service
initiative funds local communities to develop systems of care
to serve children with severe emotional disturbance (SED).
Data used in the current study were collected between 1997
and 2003.
Population Studied: This study was based on a sample of
children (n=4,358) with caregiver reported abuse history data,
who participated in the national evaluation. The majority of
the children in the study sample were male (68.2%), White
(56.0%), with an average age of 12.3. Based on caregiver
reports, 14.5% had a history of physical abuse, 10.2% of sexual
abuse, and 11.8% of co-occurring abuse.
Principal Findings: Children with a history of running away
and suicidality were each significantly more likely to have a
history of abuse after adjusting for other characteristics.
Substance abuse among caregivers was also associated with a
reported history of abuse. Clinically, children with
internalizing problems were more likely to have abuse
histories. Children with histories of multiple types of abuse
presented certain characteristics similar to children with
physical abuse only histories and certain characteristics
similar to children with sexual abuse only histories. Being
female and sexually abusive was each associated with a
reported history of sexual abuse and a reported history of
multiple types of abuse. Family history of domestic violence
appeared to be related to a child history of physical abuse and
multiple types of abuse.
Conclusions: The study results suggest that multiple abuse
history is as prevalent as physical and sexual abuse alone; that
a spectrum of characteristics are influential in discriminating
children as a function of their abuse history; and that children
reporting multiple abuse types demonstrate characteristics
similar to children who have experienced physical abuse alone
and other characteristics similar to children who have
experienced sexual abuse alone. In sum, while psychosocial
characteristics differentiate children with various abuse
histories, the current findings suggest that the most risky
behaviors (e.g., running away, suicide attempt) and negative
life experiences (e.g., exposure to domestic violence, family
mental illness) are associated with co-occurring abuse.
Implications for Policy, Delivery or Practice: Understanding
the unique characteristics associated with abuse histories is
key to developing individualized treatment plans for children
with reported histories of abuse and in identifying effective
and evidence-based practices available to treat children with
these complicated abuse experiences.
Primary Funding Source: Other Govt, SAMHSA, Center for
Mental Health Services
● School-Based Health Centers: What Services, For Whom
Debra Tennyson, Ph.D., M.B.A., M.T.(ASCP)
Presented by: Debra Tennyson, Ph.D., M.B.A., M.T.(ASCP),
Associate Professor, Health Service Administration, Our Lady
of the Lake College, 7443 Picardy Avenue, Baton Rouge, LA
70808; Tel: (225) 214-6969; Fax: (225) 768-0819;
E-mail: dtennyso@ololcollege.edu
Research Objective: To analyze the utilization and frequency
patterns, and population demographics of those who use
school-based health centers in a public school system. To
compare the demand among school-based health centers
which differ in student grade level and age of the clinic.
Study Design: Archival record review of multiple established
school-based health centers in a public school system during
academic year 2003-2004. Blanket permission forms were
sent to all school-enrolled parents for their child to use the
school-based health center.
Population Studied: The data of a Southern city’s public
school system which has school-based health centers. The
school-based health centers were established in different
years, ranging from two- to 16-year affiliations. All youths who
attended seven of the schools: three high schools, three
middle schools and one elementary school, and utilized the
affiliated health center were compiled and analyzed. School
demographics and health center age were also factors
included in the analysis.
Principal Findings: Approximately 53 percent of the 5,400
students enrolled at these seven schools utilized the schoolbased health center at least one time. The 2,788 students used
the clinic an average of five times over the academic year, with
a range of 1-41 visits per patient.
Out of the 14,684 visits, 76 percent were by AfricanAmericans, 56 percent were by those who were either
uninsured or on Medicaid, and 57 percent were females. An
overall compilation of the cases seen showed that the
categories titled general preventative medicine,23.6%, mental
health, 15.9%, head and central nervous system, 8.9%,
muscular skeletal/trauma, 8.3%, and nose/ear/throat, 7.8%
were the most common reasons for the visits. Health
counseling and education only comprised an overall average
of 4.3 percent of the visits, with a range of 0.2 percent in a
high school to a high of 19 percent in a middle school.
Further findings from combining insurance coverage, gender,
primary diagnosis group and frequency of visit were also
analyzed. Although the school with the newest, only two years,
affiliated health center had the lowest percentage of youths
utilizing its services, in general, there were no consistent
pattern differences between patient utilization, age of clinic
and school affiliation and school grades included in access.
Conclusions: School-based health centers prove to be an
important site for the delivery of health care, especially for
uninsured and Medicaid covered youths. Surprisingly, lifestyle
behavior-related reasons were least often seen conditions,
such as drug abuse, pregnancy, sexually transmitted diseases
and nutrition issues. This may be at least partially influenced
by what procedures are traditionally reimbursed. This finding
needs further study, as does the potential for school-based
health centers to be independently, financially viable.
Implications for Policy, Delivery or Practice: School-based
health centers are well-positioned sources of health care
delivery to vulnerable, dependent, school-age youths.
Although school-based health centers provide a valuable
service in the delivery of health care, their role appears to have
potential to be more influential and pivotal in caring and
educating our youth.
Primary Funding Source: No Funding
● Do Ambulatory Care Use Patterns Explain the Greater
Emergency Department (ED) Use for Medicaid Enrolled
Children as Compared to Commercially Enrolled Children
in the Same Managed Care Organization?
Patrick Vivier, M.D., Ph.D., Jeffrey D. Blume, Ph.D., Stephanie
D. Schech, M.P.H., William J. Lewander, M.D., James G.
Linakis, Ph.D., M.D.
Presented by: Patrick Vivier, M.D., Ph.D., Associate Professor
of Community Health and Pediatrics, Community Health,
Brown University/Brown Medical School, Box G-A4, Brown
University, Providence, RI 02912; Tel: (401) 863-2034;
Fax: (401) 863-3699; E-mail: Patrick_Vivier@Brown.edu
Research Objective: Previous work determined that ED use
rates were twice as high among Medicaid enrolled children as
compared to commercially enrolled children in the same
managed care organization, while ambulatory use was
somewhat less for Medicaid enrolled children. The objective
of the research presented in this abstract is to examine
ambulatory care use as a potential explanatory factor for the
greater ED use among Medicaid enrolled children as
compared to commercially enrolled children in the same
managed care organization.
Study Design: We performed a cohort study using
administrative datasets maintained by the managed care
organizations. Data was conducted using Stata (version 8.2)
and Excel. All confidence intervals have level 95%.
Multivariate regression analyses were performed using an
over-dispersed Poisson regression model.
Population Studied: All children enrolled in the managed
care organization for any length of time from January 1, 2000
through December 31, 2002, who resided in one northeastern
state were included in the study. All enrollment days from all
enrollments during the study period until the day before the
18th birthday were included. All ED and ambulatory visits that
occurred during the study period, prior to the child’s 18th
birthday were included.
Principal Findings: In the multivariate analysis controlling for
ambulatory use rates, as well as for age and gender the ED
use rate of Medicaid enrolled children was still more than
twice that of the commercially enrolled children (rate ratio
2.30, CI 2.23-2.37).
Conclusions: Differences in ambulatory use rates do not
explain the greater ED use by Medicaid enrolled as compared
to commercially enrolled children in the same managed care
organization.
Implications for Policy, Delivery or Practice: It is not the
case that low ambulatory use rates explain the greater ED use
among Medicaid enrolled children. Primary care factors that
need to be further investigated include the timing of
ambulatory visits, sources of primary care and issues related
to the quality of ambulatory care. Additional work must also
focus on whether greater health care needs of Medicaid
enrolled children may explain ED use differences.
Primary Funding Source: none, Center for Health Care
Strategies
● Healthcare Costs and Patterns of Illness in Military
Dependants: Identifying Children at Risk
Kathleen Walsh, M.D., Arlene S. Ash, Ph.D., Jennifer R. Fonda,
M.A., Thomas V. Williams, Ph.D.
Presented by: Kathleen Walsh, M.D., Fellow, Pediatrics,
Boston Medical Center, 91 E Concord Street, Maternity 4104,
Boston, MA 02118; Tel: (617) 414-5736; Fax: (617) 414-3679;
E-mail: kathleen.walsh@bmc.org
Research Objective: The U.S. Department of Defense
manages the military health system (MHS), one of the largest
integrated health care systems in the world, offering care to
almost 2 million children under age 18. Nearly two thirds of
these eligible children are enrolled in TRICARE Prime, a pointof-service health plan that delivers care through clinics and
hospitals operated by the MHS or its civilian contractors. A
small fraction of these children have special health care needs
or are chronically ill, and use a large proportion of healthcare
resources. Improved understanding of these vulnerable child
beneficiaries will indicate how the MHS can best meet their
needs and improve the quality of their care. Our first objective
was to describe the patient and family demographics and
diseases of the top 5% of pediatric healthcare utilizers among
military dependant children in 2002. Our second objective
was to use demographic and diagnostic information to
predict, among all military dependant children in 2001, which
would be high utilizers in 2002.
Study Design: This was a retrospective cohort study of
military dependant children under 18 years of age in fiscal
years 2001 and 2002. High utilization is defined as having
total annual healthcare costs above the 95th percentile in
2002. The total annual healthcare cost for each patient was
the sum of the costs of inpatient and outpatient treatment
plus medications. Demographic variables included rank and
branch of service of parent sponsor, region of the country,
urban/suburban/rural location, and proximity to military
healthcare facilities (that is, living within the “catchment area”
of a medical treatment facility). Administrative diagnostic
codes (ICD-9-CM) were used to identify illness burden. For
our second objective, we used Diagnostic Cost Group models
(applied to 2001 age, sex and diagnoses) and total spending
in 2001 to predict total cost in 2002.
Population Studied: We used the Defense Eligibility and
Enrollment Reporting System, which describes each person
eligible to receive benefits through the MHS, to identify the
study population. We included dependents of active duty and
retired members of the armed forces who were under age 18
as of 30 Sept 2001, residents of the continental U.S., Alaska,
or Hawaii, and were enrolled in TRICARE Prime throughout
the study period of FY2001-2002.
Principal Findings: There were 775,329 children in this study.
Of these children, 5% were under 1 year old as of 30
September 2001, 19% were 2-4 years old, and 49% were 5-12
years old. Parents of this population were 36% Army, 30% Air
Force, and 32% Navy with ranks of 7% Jr Enlist, 71% Sr Enlist,
7% Jr Officer, 13% Sr Officer, and 2% Warrant. Most (68%)
lived close to military healthcare facilities (within a military
treatment facility “catchment area”) and 83% lived in urban
areas, 14% suburban. Heath care costs for these children
totaled $758 million in 2002 (average cost=$978). Children
with total annual healthcare costs above the 95th percentile
cost $320 million in 2002 (average = $8,275), and absorbed
42% of the total population costs. In bivariate analyses, high
utilizers were significantly more likely to be in the 0-1 or 13-17
year age groups, to be female, to live in proximity to military
healthcare, and to be Air Force dependants. The most
common diagnoses in 2001 were the same for both the 2002
high utilizers and others, with the top two categories being
“screening” and “other ENT.”
Our best model to prospectively identify high cost cases in
2002 located a high risk group (the 5% with the highest
predicted 2002 cost) with average costs of $4,960 (more than
5 times the population average); 50% of the high risk group
had costs over $2,105, 36% actually had costs in the top 5%
(>$3,130) and 10% had costs over $9,250.
Conclusions: Children in the youngest and oldest quartile,
females, and children living in proximity to military treatment
facilities were more likely to be in the top 5% of healthcare
utilizers. The most frequent disease codes for high utilizers in
2002 and the lower-cost 95% of the population did not differ
in 2001; however, we were able to prospectively identify a
group with highly elevated risk of being costly in the following
year (well over 1/3 of our high risk group ended up in the 5%
of the population with the highest costs in 2002).
Implications for Policy, Delivery or Practice: Although most
of the children in our study were healthy, and some high costs
were “surprises,” we were able to find a group with sufficiently
serious medical problems in 2001, and expectations of high
utilization in 2002, to justify proactive management. Familybased outreach programs and appropriate case management
of such high-risk children will likely achieve more efficient and
effective health care.
Primary Funding Source: Other Govt.
● Risks and Resilience: A Conceptual Model for Pediatric
Patient Safety
Donna Woods, Ed.M., Ph.D., Jane L Holl, M.D., M.P.H.,
Munisha Mehra, M.D., Edward Ogata, M.D., M.M., Kevin B
Weiss, M.D., M.P.H.
Presented by: Donna Woods, Ed.M., Ph.D., Fellow, Institute
for Health Services Research and Policy Studies, Feinberg
School of Medicine, Norhtwsestern University, 339 E Chicago
Avenue, Room 717, Chicago, IL 60611; Tel: 847-571-2593; Fax:
312-503-2936; E-mail: woods@northwestern.edu
Research Objective: Children are different than adults in
many ways, but which of these differences is meaningful and
impactful in the context of patient safety? This study seeks to
discern and describe which differences are meaningful and
must be attended to in the design and implementation of
patient safety interventions.
Study Design: Extensive review of the formal and informal
pediatric literature, including pediatric texts, published
reports, peer reviewed literature, websites of pediatric
healthcare professional organizations, conference
presentations and proceedings, was performed to identify
factors specific to children and/or children’s healthcare that
could contribute to patient safety problems in children’s
medical care. This review focused on specific characteristics
of children, the adaptations made by pediatrics to compensate
for these differences, and the different types of contact that
children have with the health care system (e.g., differences in
epidemiology of illnesses and treatments), as well as pediatric
patient safety studies. These factors were then assessed to
understand their impact on factors that have been shown to
increase the risk of error.
Population Studied: Children, birth through 20 years of age.
Principal Findings: Analysis of three epidemiologic studies of
pediatric patient safety each employing different source data
and methodologies together suggest specific contexts of risk.
Additionally, child-specific-factors contribute to patient safety
risk.
These child-specific-factors include:
I. Physical Characteristics
A. Small size, weight and morphology.
B. Varied physical characteristics
II. Development
A. Physiological development and growth:
B. Cognitive social emotional development
III. Minor Legal Status
A. Decision-making and consent
B. Parental responsibility for medical
management:
C. Confidentiality:
D. Supervision requirements.
These child-specific-factors create the following conditions
that have been shown to increase error risk. 1) Increased
variability (medication dosages, equipment and devise sizes,
in signs and symptoms, examination of infants versus
adolescents), 2) visual difficulty distinguishing differences in
sizes and amounts (i.e., equipment, devises, medications) 3)
increased complexity in medical care processes (medication
ordering, dispensing and administration), 4) decreased
response time for communication and coordination (increase
physiological volatility), 5) decreased information (children’s
limited ability to communicate), 6) increased technical
difficulty (insertion of intravenous line).
In addition, child-specific-resiliency-factors were identified.
Children’s physiological resilience and healing ability can
protect children in the context of increased error risk. Most
hospitalized children’s underlying health status is essentially
healthy, which leads to a physiological resilience that protects
from cascading failure of multiple physiologic systems.
However, those children with multiple co-morbidities lose this
resilience and are at a greater risk for error related injuries.
This review demonstrated differences in children’s
epidemiology of illness and intervention. Procedures shown
to be high risk in adults are infrequently if ever performed in
children.
Conclusions: This review identifies specific characteristics in
children and children’s health care that contribute to patient
safety risks in children. These factors must be accounted for in
the design and implementation of patient safety improvement
interventions.
Implications for Policy, Delivery or Practice: The more we
learn through pediatric patient safety research, the more we
find that in order to successfully improve the safety of
children’s medical care, specific attention must be paid to
designing safe practices with the special characteristics of
children in mind.
Primary Funding Source: AHRQ
● Health Care Utilization of Children With Muscular
Dystrophy
Byung-Kwang Yoo, M.D., Ph.D., Scott Grosse, Ph.D.
Presented by: Byung-Kwang Yoo, M.D., Ph.D., Fellow,
National Center on Birth Defects and Developmental
Disabilities, Centers for Disease Control and Prevention, 1600
Clifton Road, Mail Stop E-87, Atlanta, GA 30333;
Tel: (404) 498-3553; Fax: (404)-498-3070;
E-mail: ddz7@cdc.gov
Research Objective: To assess health care utilization of
children with Muscular dystrophy (MD). MD includes a group
of genetic disorders characterized by progressive muscle
weakness and varying degrees of paralysis. Different kinds of
MD have different genetic causes, affect people at different
ages, and affect different muscles. The different types of MD,
e.g., Duchenne MD, do not have separate ICD-9 codes, which
limits the usefulness of administrative data for assigning costs
to specific etiologies. Because MD is rare, with a prevalence
of perhaps 2 cases per 10,000 people, it is not possible to
assess costs using national survey data. In this analysis we
used data from an administrative dataset covering a privately
insured population.
Study Design: Secondary data analysis, using the 2002
Medstat MarketScan® Health Insurance Claims Database.
Direct medical expenditures were calculated among MD
patients, defined by ICD-9 codes 359.0 or 359.1. This database
consists of 45 large self-insured employers and 100 payers.
Health care utilization among children, 19 years of age or
younger, was calculated for children enrolled in a plan for an
entire year. Additional estimates were made for
subpopulations based on sex, age, and three types of
insurance plans (health maintenance organization (HMO)
plans, plans with other types of partial or full capitation, and
non-capitated plans).
Population Studied: (Defined in Study Design)
Principal Findings: Out of 1,608,954 total child enrollees, 183
children with a diagnosis of MD had non-zero cost claims.
Means for outpatient care, prescribed medications, and
inpatient care were $15,600, $1,270, and $6,500, respectively.
Because of a skewed expenditure distribution, medians were
lower, $5,200, $210, and $0, respectively. Mean age-specific
medical expenditures for 2002 were as follows: 1-through-4year-olds: MD $31,100, no MD $1,200; 5-through-9-year-olds:
MD $16,000, no MD $900; 10-through-4-year-olds: MD
$12,100, no MD $1,100; 15-through-19-year-olds: MD $37,300,
no MD $1,500. Incremental costs ranged from $11,000 to
$35,000 per year. Total medical expenditures per child with
MD were 10 to 25 times higher than for children without MD.
Comparing the 25th, 50th, and 75th percentiles of medical
expenditures, children in HMO (n=19) and non-capitated
plans (n=134) had the lowest and highest expenditures,
respectively, among the three types of insurance plans.
Conclusions: Privately insured children with MD utilize a
substantially greater amount of medical expenditures than
those without MD. The 10:1 to 25:1 ratio of medical costs
between MD-affected and unaffected children is high
compared with the threefold difference recently reported for all
children with or without disabilities in Medical Expenditure
Panel Survey (MEPS), a nationally representative survey, data.
Among MD patients, expenditure distributions were skewed to
the right, reflecting heterogeneity in the severity and the
progress of MD. Because of the small number of hospitalized
patients in our dataset, estimates for hospitalization
expenditures cannot be precisely estimated. The higher
expenditures among subjects in fee-for-service insurance
plans probably more accurately reflected actual utilization,
because of underreporting in capitated plans.
Implications for Policy, Delivery or Practice: A large private
insurance claims dataset is useful to assess health care
utilization of children with a rare disease like MD, though it is
not nationally representative.
Primary Funding Source: CDC
● Incremental Cost of Providing SCHIP Coverage for
Children with Special Health Care Needs
Hao Yu, Ph.D., Andrew Dick, Ph.D., Peter Szilagyi, M.D.
Presented by: Hao Yu, Ph.D., RAND, 201 North Craig Street,
Pittsburgh, PA 15213; Tel: (412)683-2300 ext4460;
E-mail: hao_yu@rand.org
Research Objective: In spite of evidence on the beneficial
effects of providing health insurance for uninsured children,
few studies have focused on children with special health care
needs (CSHCN). This study aims to inform policy-making by
providing new information about two issues of health care
financing for CSHCN:
(1). How does enrollment in the State Children’s
Health Insurance Program (SCHIP) affect utilization and
expenditures by CSHCN?
(2). What is the incremental cost to society of
providing SCHIP coverage for those CSHCN who are eligible
but uninsured?
Study Design: The study has four components. The first one
identifies the number of CSHCN who are eligible for SCHIP
but uninsured. The second one investigates change in
utilization after CSHCN become enrolled in Child Health Plus
(CHPlus), the SCHIP program in New York State. The third
one examines contribution to total annual expenditures by
different types of utilization. Putting together the first three
components, a simulation analysis is run to estimate the
incremental cost to society of providing the CHPlus-type
SCHIP coverage for the eligible but uninsured CSHCN.
Three major datasets are used in the study, including the 2001
National Survey of Children with Special Health Care Needs
(NSCSHCN), the 2000 Medical Expenditure Panel Survey
(MEPS), and a survey of the New York State’s CHPlus, a
relatively mature SCHIP program with the nation’s largest
number of SCHIP enrollees in 2002.
Population Studied: 38,866 CSHCN interviewed by the
NSCSHCN, 973 CSHCN identified by the MEPS, and 567
CSHCN who were newly enrolled in the CHPlus, and were
randomly selected by the survey of CHPlus.
Principal Findings: Nationally, there were 141,464 CSHCN
who were eligible for SCHIP but uninsured in 2000. Their
annual expenditures on health care were 223.3 million, or
$1,581 per CSHCN per year. Enrollment in CHPlus resulted in
more utilization of all types of health services, except visits to
emergency room. If all the eligible but uninsured CSHCN
become enrolled in a SCHIP program similar to CHPlus, the
incremental cost to society was $31.7 million, or $224 per
CSHCN per year. In other words, on average, one CSHCN
who were SCHIP-eligible but uninsured had an annual
expenditure of $1,581, and after enrollment in SCHIP, his/her
annual expenditure would increase by $224. The incremental
cost represented an increase of 14.2% in the societal cost, or
12.4% in government budgetary cost.
Conclusions: This study found that providing SCHIP coverage
to CSHCN, which help improve their access to health care,
would result in relatively small incremental cost to society, or
to government budget.
Implications for Policy, Delivery or Practice: For policymakers concerned with health care financing, it is worth
noting that it is a good investment to provide SCHIP coverage
for the eligible but uninsured CSHCN because this group of
children will have improved access to health care with limited
increase both in the societal cost and in the government
budget. Moreover, because the additional health services used
by the newly enrolled CSHCN tends to have substantial longterm benefits, the provision of public coverage may be viewed
as “an investment in the future”.
Primary Funding Source: Other, Maternal and Child Health
Bureau
● Consultation in Child Care Centers: Supporting Young
Children's Healthy Development
Maggie Zraly, M.S., S.M., Jeffrey Longhofer, Ph.D., L.I.S.W.,
Barbara Streeter, M.S., L.P.C.C., Thomas Barrett, Ph.D., Mara
Buchbinder, M.A.
Presented by: Maggie Zraly, M.S., S.M., Research Fellow,
Hanna Perkins Center for Child Development, 19910 Malvern
Road, Shaker Heights, OH 44122; Tel: (216) 225-4907;
Fax: (216) 991-5472; E-mail: maggie.zraly@case.edu
Research Objective: Previous studies of consultation
practices in child care centers have found that consultation
services can support healthy social and emotional
development among young children by increasing the overall
quality of centers. However, the causal relationships between
consultation practices and outcomes for children have not yet
been elucidated. The primary research objective of this study
was to examine how the National Child Care Consultation
Alliance (NCCCA) consultation practice related to the
processes of consultation and caregiving in child care centers
in order to identify potential pathways of these causal
relationships.
Study Design: The NCCCA consultation practice is designed
to promote the healthy social and emotional development of
young children by improving the quality of child care centers.
The NCCCA model is grounded in multiple consultation
theories: organizational, psychodynamic, constructivist
learning, social learning, and diffusion of innovations. In 1993,
the Early Childhood Intervention Alliance (ECIA) initiative
implemented the NCCCA model at five child care center sites.
During 1999 and 2000, evaluation research was conducted to
assess the emerging outcomes of the ECIA initiative. In order
to investigate: 1) how consultation affects changes in child
care center quality, and 2) how these changes support young
children’s healthy development, this study used the evaluation
research data to examine the experiences and perceptions of
NCCCA consultation processes and outcomes among the
ECIA initiative study population.
Population Studied: The five ECIA child care center sites were
located in: Utica, MI; San Diego, CA; San Bernardino, CA;
Huntsville, AL; and Scotsdale, AZ. The study population was
composed of the child care center caregivers, child care center
directors, and the NCCCA child care center consultants at
each of the five sites.
Principal Findings: Qualitative data on the emerging
outcomes were collected through four research methods: 1)
focus groups of caregivers at each site, 2) a focus group of the
directors from all of the sites, 3) a focus group of the
consultants from all of the sites, and 4) open-ended
questionnaires with consultants. The data collected through
each of these methods were entered into Altas.ti software and
systematically coded to analyze the themes related to the
processes and outcomes of consultation. By triangulating the
coded themes across sites, participant professions, and
methods, the results of this analysis indicate that NCCCA
consultation was associated with: 1) understanding children’s
behavior as communication, 2) developing trusting
relationships with parents, and 3) elevating the
professionalism of caregivers.
Conclusions: NCCCA consultation involves attitudinal shifts,
conceptual change, collaboration, culture and empowerment.
The pathways between these processes and understanding
children’s behavior, developing trusting relationships, and
elevating the professionalism of caregivers play a role in
improving child care center quality. These pathways may
prove to be important for supporting young children’s healthy
social and emotional development in child care centers.
Implications for Policy, Delivery or Practice: This research
on the ECIA initiative supports the literature that
demonstrates the efficacy and impact of consultation in child
care centers for young children’s mental health and future
learning. It also suggests that the provision of consultation
may be most efficacious at specific moments of the “daily
rounds” of the center day.
Primary Funding Source: Other Foundation, The TRW
Foundation