Child Health
Call for Papers
Medicaid, SCHIP & Access to Care: National, State &
Local Perspectives
Chair: Paul Wise, Brigham and Women’s Hospital
Sunday, June 26 • 8:30 am – 10:00 am
●Changes in Children’s Mental Health Care, 1997-2002.
Tatiana Andreyeva, MA, MPHil, Roland Sturm, Ph.D.
Presented By: Tatiana Andreyeva, MA, MPHil, Doctoral
fellow, RAND Graduate School, 1776 Main Street, Santa
Monica, CA 90401; Tel: (310) 393-0411 x6047; Fax: (310) 2608155; Email: tatiana@rand.org
Research Objective: Multiple forces have changed the
practice of mental health care for children during the past
decade. Limited empirical data is available on the
consequences of these reforms for children's mental health
care. The objective of this study is to describe changes in
mental health care in a large representative sample of schoolage children over 1997-2002, and to examine differential rates
of change across socioeconomic populations and geographic
regions.
Study Design: The study uses data from the 1997, 1999 and
2002 cross-sectional rounds of the National Survey of
America’s Families, a nationally representative survey of
children, adults under the age of 65, and their families fielded
in 13 states and the balance of the nation for the Urban
Institute. The main outcome measures are: 1) utilization of
any mental health services and number of visits among users,
2) unmet need for mental health services (no service use
among children with identified need according to the Child
Behavior Checklist), and 3) need among users of mental
health services.
Population Studied: Nationally representative children ages
6-17 surveyed in 1997 (N = 21,824), 1999 (N = 23,423), and
2002 (N = 22,064).
Principal Findings: Utilization of mental health services
among school-age children increased significantly between
1997 and 2002, with most of the growth occurring between
1999 and 2002. While the average utilization of any mental
health services grew nationwide from 7.1% in 1997 to 8.9% in
2002, there was substantial variation in growth rates across
socioeconomic populations and geographic regions. Among
all socioeconomic groups examined, only uninsured children
had a decrease in utilization of mental health services over
1997-2002, from as low levels as about 2/3 of the national
average in 1997 to 1/2 of the national levels in 1999 and 2002.
Utilization rates for black children and children with public
insurance were the slowest to grow (1.3-1.4% annually),
whereas white children and children in high-income families
had the opposite extreme (5.6-6.0% annually). Changes in
overall means mask significant differences in trends across
states. Although all 13 states in the survey increased their use
of children’s mental health services between 1997 and 2002,
the slowest to grow (2.1-2.2% per year) were the states with
initial utilization levels well below the national average, e.g.
Alabama and Mississippi. Similar patterns occurred in unmet
need for mental health services and need among users.
Conclusions: Utilization of mental health services among
school-age children is increasing at substantially different
rates among socioeconomic populations and geographic
regions. As children with the highest need, predominantly
black children and children in low-income families, are
increasing utilization at a much lower rate than children
overall, the well-known and disturbing socioeconomic
disparities in health care may threaten to increase in the
future. We show multi-fold differences in the growth of
children’s mental health utilization across states (up to 5-fold)
that exceed the disparities in trends across race/ethnicity and
income groups.
Implications for Policy, Delivery, or Practice: Changes in
the practice of mental health care are associated with
disproportionate effects on children in already marginal
groups and lagging states. Providers can make a difference by
delivering mental care focused on children with the highest
needs rather than trying to increase the overall rates of service
use.
Primary Funding Source: National Institutes of Mental
Health
●Insurance Trends: Rural, Minority Children Lag Over 20
Years
Keith Elder, Ph.D., MPH, MPA, Janice Probst, Ph.D., Daniel
Patterson, MPH, Ph.D., Charity Moore, MSPH, Ph.D.
Presented By: Keith Elder, Ph.D., MPH, MPA, Assistant
Professor, Health Services Policy and Managment, University
of South Carolina Arnold School of Public Health, 800 Sumter
Street Health Sciences Building, Room 120, Columbia, SC
29208; Tel: (803) 777-5041; Fax: (803) 777-1836; Email:
kelder@gwm.sc.edu
Research Objective: Over the past decade, Medicaid
coverage for poor children has significantly expanded,
principally through SCHIP. We examined the degree to which
this expansion may have increased overall levels of insurance
coverage for children, with a focus on rural and minority
children (African American and Hispanic), across the period
1980-2000. We also assessed health care utilization patterns
over time among rural children and whether the patterns were
different for white and minority children.
Study Design: Data were drawn from the National Health
Interview Survey, a nationally representative household survey
conducted annually by the National Center for Health
Statistics. Public use data sets for the years from 1980
through 2001 were accessed. The dependent variables were
health insurance status, family poverty index, family structure
(one or two parents in household), highest education level in
the household, and doctor visits in past 12 months. All
analyses were stratified by race (white, African American,
Hispanic) and residence (urban, rural).
Population Studied: Children ages 0 –17. The number
observed varied by survey year, from a high of 35,196 children
in 1987 through 12,389 children in 1999. Rural was defined as
residing outside an SMSA.
Principal Findings: In 1979, the proportion of children who
lacked health insurance ranged from 10.4% among urban
whites to 36.3% among rural Hispanics. Among white
children, the proportion without insurance peaked in 1994 at
20.9% (urban), declining to 5.9% in 2001. By 2001, only 8.7%
of rural white children, 14.2% of rural African American
children, and 26.7% of rural Hispanic children remained
without coverage. Throughout the period, urban white
children were least likely to be uninsured. Within each
race/ethnicity, rural children were less likely to have insurance
coverage than urban children, a disparity that remained
unchanged across the period. The proportion of children with
no physician visit in the preceding year declined over the
period. Among urban whites, the proportion of children with
no visit declined from 22.4% in 1979 to 9.4% in 2001. Among
rural Hispanics, the most at-risk group, the proportion of
children with no visit declined from 40.2% in 1979 to 24.4% in
2001.
Conclusions: The proportion of children without insurance
declined between 1979 and 2001, with parallel declines in the
proportion of children with no access to health services.
However, racial disparities remain, with rural minority children
most likely to be uninsured and least likely to have seen a
physician within the past year.
Implications for Policy, Delivery, or Practice: The
proportion of rural children without insurance declined sharply
with the introduction of SCHIP in 1996. In the current
budgetary climate, however, states are unlikely to be able to
support Medicaid expansions without federal matching funds,
slated to expire in 2007. Given the erosion of private insurance
during the late 1990s and through the present, the proportion
of uninsured children is likely to increase across the next
decade, with adverse effects on children and the institutions
that serve them.
Primary Funding Source: HRSA, Federal Office of Rural
Health Policy
●Out-of-pocket Financial Burden for Low-income Families
with Children: Socioeconomic Disparities and Effects of
Insurance
Alison Galbraith, M.D., MPH, Sabrina T. Wong, RN, Ph.D.,
Sue E. Kim, Ph.D., MPH, Paul W. Newacheck, DrPH
Presented By: Alison Galbraith, M.D., MPH, 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)5099893; Fax: (617)859-8112; Email:
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
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 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
●The Effect of County Characteristics on Children’s
Participation in California’s Medicaid and SCHIP
Programs
Jennifer Kincheloe, Ph.D., MPH
Presented By: Jennifer Kincheloe, Ph.D., MPH, Research
Scientist, Health Services, UCLA Center for Health Policy
Research, UCLA School of Public Health, 845 Coronado Drive,
Glendale, CA 91206; Tel: (310)909-8725; Email:
jkinchel@ucla.edu
Research Objective: This study examines the impact of
county-level factors on children’s enrollment in California’s
Medicaid (Medi-Cal or MC) and SCHIP (Healthy Families or
HF) programs, while controlling for individual and family-level
factors. Among other factors, it examines the impact of
outreach funding, media expenditures, outstationed eligibility
workers, and county-sponsored health insurance expansion
initiatives (expansion initiatives) for undocumented children
and children whose families make slightly too much money to
qualify for HF.
Study Design: Cross-sectional; simple and hierarchical
multivariate logistic regression analysis. Independent variables
include family-level sociodemographic characteristics and
county characteristics such as money spent on outreach, the
number of outstationed eligibility workers, and whether there
was an expansion initiative.
Population Studied: Individual-level and family-level data
from the 2001 California Health Interview Survey (CHIS 2001)
were merged with county-level data from the California
Department of Health Services and Managed Risk Medical
Insurance Board, the Medi-Cal Policy Institute, and the 100%
Campaign. These included data on whether a county had an
expansion initiative, the number of outstationed eligibility
workers, and money dispersed to each county from the state
for various types of outreach in FY 1999-2000 and FY 20002001. The CHIS 2001 random-digit dial telephone survey
collected information from a representative sample of about
55,000 California households. The study focuses on children
ages 0-17 who were eligible for either the MC or the HF
program and had no private or employer-sponsored insurance
coverage.
Principal Findings: 1) Controlling for other factors, eligible
children who lived in counties with an expansion initiative had
three times the odds of enrolling in MC compared with those
who lived in counties without expansion initiatives (p=0.06).
There was no significant effect on HF enrollment, perhaps
because eligibility is administered at the state level while MC
eligibility is administered locally. 2) Among children eligible for
MC, the odds of being enrolled increase by 6% for each
additional dollar spent on outreach per eligible child in the
county, excluding media (p=0.08). Among HF eligible children
the odds increased by 7% for each additional dollar spent on
outreach per eligible child. 3) For each additional outstationed
eligibility worker per 1,000 eligible children in the county, the
odds of MC enrollment decreased by two thirds. 4) Media
dollars spent per eligible child had a negative impact on
enrollment in HF (OR .89).
Conclusions: This study demonstrates the positive “spillover
effect” that local expansion initiatives have on children’s
enrollment in the MC program and the importance of
outreach money in reducing uninsurance among program
eligible children. The spillover effect was not significant for
HF— perhaps because HF enrollment is administered at the
state level while MC enrollment is administered locally. The
study highlights the need to evaluate outreach strategies and
to dedicate scarce resources where they will have the greatest
impact. California’s “one size fits all” media campaign actually
had a negative effect on HF enrollment, as did outstationed
eligibility workers. The latter surprising result may be
explained by the fact that outstationing is expensive, diverting
resources away from other outreach programs, and that
eligibility workers in hospitals target high cost patients, not
children, in order to reduce bad debt.
Implications for Policy, Delivery, or Practice: States may
increase children’s enrollment in the Medicaid and SCHIP
programs by funding proven program outreach and through
expansion initiatives. Local administration of program
enrollment may have a positive effect on enrollment.
Primary Funding Source: California Program on Access to
Care
●Uninsurance Among Children Who Are Eligible for
SCHIP: Results from A Nationally Representative Survey
Hao Yu, Ph.D.
Presented By: Hao Yu, Ph.D., Health Policy Analyst, RAND,
201 North Craig Street, Suite 202, Pittsburgh, PA 15213; Tel:
(412)683-2300 x4460; Fax: (412)683-2800; Email:
hao_yu@rand.org
Research Objective: While studies in specific states have
examined children’s enrollment pattern in the State Children’s
Health Insurance Program (SCHIP), little is known at the
national level about those who are eligible for SCHIP but
uninsured. This study aims to assess the: (1). Proportion of
children eligible for SCHIP across the U.S., (2). Proportion of
SCHIP-eligible children who are uninsured, (3). Risk factors for
these children to be uninsured, and (4). Their parents’
knowledge of and experience with SCHIP.
Study Design: Data were from the first National Survey of
Children with Special Health Care Needs, which was
conducted in 2000-2001. Bivariate and multivariate analyses
were performed. SCHIP-eligibility was defined by age and
income according to state-specific policies as of October
2000. The uninsurance referred to being uninsured for the
past 12 months
Population Studied: 215,162 children sampled by the survey,
including 38,866 children with special health care needs.
Principal Findings: Nationally, 6% of children, or 4.3 million,
were eligible for SCHIP in 2000, and among these eligible
children, 36%, or 1.5 million, were uninsured. Substantial
variation existed across states in terms of SCHIP eligibility and
the proportion of eligible but uninsured children. After
controlling for other socio-demographic characteristics, older
children were more likely to be uninsured. Black children had
lower probability of being uninsured than white children.
Children from families, for which the interview language was
not English, were two times more likely to be uninsured than
those from English-speaking families. Children with special
health care needs were 50% less likely to be uninsured than
those without special needs. The main reasons for not having
insurance were “costs too much” (40%) and “can’t get
insurance through employer” (14%). Among the SCHIPeligible but uninsured children, 63% of their parents had
heard about SCHIP, compared with 88% of them hearing
about Medicaid. The top two sources that these parents first
heard about Medicaid/SCHIP were “friends and family
members” (28%) and “health care providers” (21%). Although
82% of these parents indicated that they would enroll their
child if told eligible, only 22% of them had ever applied for
SCHIP, and 19% of them perceived difficulty in completing
SCHIP application.
Conclusions: A substantial number of children nationally
were eligible for SCHIP but were uninsured, and their parents
had limited knowledge of SCHIP and had difficulty in applying
for SCHIP.
Implications for Policy, Delivery, or Practice: It may be
helpful for states with high uninsurance rates to review their
eligibility criteria, enrollment practices, and outreach
strategies. In particular, specific enrollment efforts should be
taken to target older children, white children, children from
non-English-speaking families, and children without special
health care needs. An implication for health care providers is
that many uninsured children may in fact be eligible for
SCHIP. Health care providers can play a role in educating
about SCHIP, and in helping families enroll.
Primary Funding Source: No Funding
Call for Papers
Organizational & Community Factors in Quality & Safety
of Care for Children
Chair: David Bergman, Stanford University
Sunday, June 26 • 10:30 am – 12:00 pm
●Outcomes at 6 Months Post-Admission to Pediatric
Intensive Care: Report of a National Study of Pediatric
Intensive Care Units in the United Kingdom.
Samantha Jones, BSc Pharmacology, GJ Parry, K Rantell, K
Stevens, C McCabe, K Rowan
Presented By: Samantha Jones, BSc Pharmacology, Research
Fellow, Health Services Research, ScHARR, University of
Sheffield, Regent Court, 30 Regent Street, Sheffield, England,
S1 4DA; Tel: 44 (0)114 222 0772; Fax: 44 (0)114 272 4095;
Email: sam.jones@sheffield.ac.uk
Research Objective: To measure the health status of children
using the Health Utilities Index (HUI2) 6 months after
admission to a pediatric intensive care unit in the United
Kingdom and to assess the relationship between long term
outcomes and measures of illness severity at admission to
pediatric intensive care.
Study Design: Prospective observational cohort study.
Population Studied: A total of 3551 patients admitted to 23
paediatric intensive care units in the United Kingdom between
March 2001 and February 2002.
Principal Findings: Consent forms agreeing to subject
participation were received from 3843 parents/guardians of
children admitted to pediatric intensive care. Following
exclusions due to eligibility checks, 2895 HUI2 questionnaires
were sent out to parents/guardians, and 2044 (71%) were
returned. No difference was found in the initial illness severity
of those children who consented to participate (versus those
who did not) and those for whom a HUI2 questionnaire was
returned (versus those for whom a questionnaire was not).
The primary outcomes measured by the HUI2 consist of six
dimensions: sensation, cognition, emotion, mobility, self-care
and pain. At 6 months post admission to pediatric intensive
care, the percentage of children in the highest (best possible
health status) category of the six HUI2 dimensions was 61%
for sensation, 70% for cognition, 66% for emotion, 71% for
mobility, 69% for self-care and 65% for pain. Overall, 28% of
children were in full health 6 month post admission to
pediatric intensive care, whilst 9% had some level of
impairment on all the outcome measures at 6 months post
admission. To assess the relationship between longer-term
outcomes and measures of illness severity at admission,
ordinal regression models were estimated for each of the
primary outcomes, using the illness severity measures
included in the Pediatric Index of Mortality (PIM) and the
Pediatric Risk of Mortality (PRISM, PRISM III-12 and PRISM
III-24) as explanatory variables. Only the illness severity
measures included in PIM were significantly related to
outcome at 6 months. The remaining measures were related
to some of the outcomes, but not all. None of the existing
illness severity measures provided satisfactory discriminatory
power for any of the health outcomes at 6 months.
Conclusions: At 6 months post admission to pediatric
intensive care, there is a significant sustained morbidity which
must be taken into account when examining strategies to
improve or optimize pediatric intensive care unit
configurations. Whilst the degree of morbidity appears to be
related to initial illness severity, this information alone is
insufficient to predict long term outcomes. Work is ongoing to
examine the predictive potential of other explanatory variables.
Implications for Policy, Delivery, or Practice: Mortality
following pediatric intensive care is currently only around 6%
in the United Kingdom. In determining the quality and
performance of pediatric intensive care units, it is important
to take into account variations in the health status of survivors
post discharge. However, these results suggest that illness
severity at admission has little impact on the longer-term
health status of children. In attempting to develop policies to
improve longer-term outcomes of children post pediatric
intensive care, it may be important to also take into account
other factors, such as pre-existing co-morbidities,
socioeconomic status and the quality of care received by
children following discharge from intensive care.
Primary Funding Source: Medical Research Council (MRC)
●The Impact of Chronic Care Coordination on Young
Children (Age 0 to 5) with Asthma: A Statewide Evaluation
of the California Community Asthma Intervention
Mina Lai, MPH, David Núñez, M.D., MPH, Toshi Hayashi,
Ph.D., Pradeep Gidwani, M.D., MPH
Presented By: Mina Lai, MPH, Research Analyst,
Epidemiology and Program Evaluation Unit, California
Department of Health Services, 1616 Capitol Avenue, Suite
74.317, P.O. Box 997413, MS 7212, Sacramento, CA 958997413; Tel: (916) 552-9870; Fax: (916) 552-9911; Email:
mlai@dhs.ca.gov
Research Objective: During the past two decades, the
prevalence of asthma increased dramatically, with the greatest
increase reported for children under age five. California’s
statewide Community Asthma Intervention (CAI) aims to
decrease asthma morbidity and improve the quality of life for
these children and their families. The objective of CAI is to
demonstrate that asthma care coordination is an effective
approach to alleviating the burden of asthma on young
children and their families.
Study Design: Community health workers and other health
professionals were established as Asthma Coordinators (ACs)
at eight project sites in California. The ACs were based in
both clinics and community organizations and worked with
the children, their parents, clinical practitioners, and childcare
providers to affect change in asthma management skills,
including elimination of home environmental asthma triggers.
To measure this change, the ACs conducted interviews at
enrollment with the parents of enrolled children. Follow-up
interviews were conducted at 6-month intervals and at time of
discharge. Outcome measures addressed in the interview
included: possession of an asthma management plan;
hospitalizations and emergency room visits; medication
usage; childcare or preschool days missed; and parent work
days missed. The Cochran-Mantel-Haenszel chi-square test
was performed, using results from the enrollment and latest
follow-up interviews.
Population Studied: Children age 0 to 5 with asthma,
residing in the nine counties served by CAI, were eligible for
enrollment in the program. 34% of enrollees resided in rural
or semi-rural communities. 92% had health insurance
coverage, with 68% enrolled in the state Medicaid program.
70% of enrollees were Latino, and 15% were African-American.
The data used in evaluation were based on 1,920 individuals,
out of 2,497 total enrollees, whose parents completed at least
two interviews. The number of individuals included in the
analyses varied for each outcome measure.
Principal Findings: Among other improvements in outcome
measures, there were significant increases in the proportion of
children who received asthma management plans from their
health care providers (39% to 81%); a decrease in children
who experienced daytime asthma symptoms more than twice
a week (54% to 13%); a decrease in asthma-related
hospitalizations (17% had one or more hospitalization in a sixmonth period, decreasing to 6%); and a decrease in missed
school days (57% of children attending childcare/preschool
missed at least one day or more due to asthma at enrollment,
decreasing to 27% at follow-up).
Conclusions: Chronic care coordination for children age 0 to
5 with asthma improves communication between healthcare
providers, childcare providers, and families; addresses issues
of cultural competency in asthma education; and enables
parents to take an active role in their child’s asthma care by
helping them to better understand the condition. The
resulting improvements in health and other important
outcomes demonstrate the success of the intervention.
Implications for Policy, Delivery, or Practice: Coordinating
asthma-related care for young children effectively addresses
the critical health issues that affect this age group. Efforts
should be made to integrate this model into current health
care delivery systems for young children with asthma.
Primary Funding Source: First 5 California
●Patient Safety for Infants and Children in Academic
Medical Center Hospitals: Organizational and Human
Factors Related to Harmful Medical Event Outcomes–
Evidence using Electronic Medical Error-Event Reporting
Systems
Sandra Magnetti, MS, DrPH, Raj Behal, M.D., MPH
Presented By: Sandra Magnetti, MS, DrPH, Post doctoral
fellow, Clinical Practice Advancement Center, University
HealthSystem Consortium, 2001 Spring Road, Oak Brook, IL
60523; Tel: (630) 954-1719; Fax: (630) 954-5879; Email:
magnetti@uhc.edu
Research Objective: To identify human and organizational
factors, which are significantly related to harmful vs. nonharmful medication events in infants and children.
Study Design: We analyzed medication error-event data
reported over a three-year period submitted by 23 academic
medical centers, which participated in a collaborative, on-line,
web based event reporting system. Front-line clinical staff
entered information on the events and scored the level of
harm using a progressive 10-point scale ranging from near
miss to patient death due to the event. Unit managers had the
option to review the report and comment on factors that
contributed to the event. The input screen format allowed
them to select one or more of 36 human and organizational
factors, depending on their perception of the event. We used
the nurse unit manager’s report to correlate these human and
organizational factors with a harm/no harm score. The score
was developed by dichotomizing the progressive 10-point
scale into those events that caused harm to the patient
ranging from temporary harm requiring extra intervention to
patient death versus those events that caused no harm to the
patient. The Fisher’s exact test was used to evaluate these
relationships using a p value <= 0.05. We analyzed the
children’s and infant’s data separately.
Population Studied: Medication error-event data from
“children” (inpatients between one month and 18 years) and
“infants” (inpatients from birth to less than one month of age)
were utilized. The data came from 23 academic medical center
hospitals’ web based reporting systems for years 2001-2004.
Principal Findings: We found that of the medication events
in “children” between one month and 18 years (N=4208),
6.5% were related to harm; in “infants” from birth to less than
30 days of age (N=757), 6.9% were related to harmful events.
The remaining reported events did not reach the patients or
require additional treatment. Of the 36 human and
organizational factors available for selection, the following
were significantly related to the harmful events for “children”:
“insufficient staffing”, “inadequate resident supervision”, “bed
availability”, and “language barrier”. For “infants”, “shift
change, equipment malfunction, “equipment availability” and
“no 24-hour pharmacy were listed as related to some form of
harm.
Conclusions: This study reveals that there are specific human
and organizational factors related to medication error-events,
which, either necessitated additional treatment measures,
were life threatening, or resulted in death. It also indicates that
these factors may differ in treatment of infants versus
children.
Implications for Policy, Delivery, or Practice: This project
provides information as to which events are more closely
associated with harm to the infants and children being treated
in hospitals. Endeavors to target error-event prevention
programs should take note of possible differences in
organizational factors related to children versus infants.
Primary Funding Source: No Funding
●Nurse Staffing and Pediatric Quality of Care
Barbara Mark, Ph.D., Wallace F. Berman, M.D., David W.
Harless, Ph.D.
Presented By: Barbara Mark, Ph.D., Professor, School of
Nursing, University of North Carolina at Chapel Hill,
Carrington Hall CB#7460, Chapel Hill, NC 27599; Tel: (919)
843-6209; Fax: (919)843-3168; Email: bmark@email.unc.edu
Research Objective: Recent research has demonstrated the
relationship between hospital nurse staffing and various
measures of quality and patient safety, but this research has
focused almost exclusively on adult, rather than pediatric
patients, despite the estimated $1 billion in excess charges
due to adverse pediatric safety events. Two studies of inpatient pediatric acute care incidentally included a measure of
nurse staffing and came to different conclusions,
demonstrating the need for targeted investigation of nurse
staffing and pediatric quality of care. The purpose of our study
is specifically to examine the relationship between nurse
staffing and pediatric patient safety outcomes (mortality,
complications, and failure to rescue). We control for
community level characteristics that can affect demand for
hospital care (per capita income, hospital use, population,
race, infant mortality rate), market characteristics (managed
care penetration), and hospital characteristics (hospital size,
technological complexity, ownership, teaching status, pediatric
patient volume, and net income).
Study Design: A longitudinal panel study of 200 general acute
care hospitals in California from 1996 – 2001. Data are from:
the Area Resource Files, American Hospital Association’s
annual survey of hospitals, InterStudy, and the California
Office of Statewide Health Planning and Development’s
financial, utilization, and patient discharge files. Risk
adjustment was conducted by MEDSTAT.
We apply a dynamic panel data regression model for count
data. Differential levels of patient acuity are accounted for by
using the expected number of mortalities, complications, and
failures to rescue as the measures of exposure for a hospital in
a particular time period. The fixed effects specification
controls for differences in initial conditions by including the
initial count of outcomes as a regressor in addition to the
value of the lagged count of outcomes. Staffing levels are
measured using RN FTEs per 1,000 expected- mortality-indexadjusted inpatient days.
Population Studied: Approximately 3 million pediatric patient
discharges from 200 general acute care hospitals.
Principal Findings: In our initial models, although the point
estimates were not significant (i.e., p < .05), for a hospital with
the mean level of expected mortalities per one thousand
inpatient days, parameter estimates suggest that: 1) the
number of mortalities decreases 0.1% per 1% increase in RN
FTEs per one-thousand inpatient days; 2) the number of
incidents of failure to rescue decreases by 0.09% per 1%
increase in RN FTEs per one-thousand inpatient days; 3) the
number of complications decreases by 0.03 per 1% increase in
RN FTEs per one-thousand inpatient days; and 4) for-profit
hospitals and teaching hospitals had significantly lower failure
to rescue rates than not for profit and non-teaching hospitals.
Conclusions: The relationship between nurse staffing and
pediatric quality of care was not statistically significant in the
models tested. However, other variables related to nurse
staffing (i.e., tenure, experience, turnover) are not captured in
the data set. Amplified models that include race and infant
mortality, as well as additional nursing variables (extent of
agency personnel) are being developed.
Implications for Policy, Delivery, or Practice: These results
do not support changing nurse staffing ratios to improve
quality of care for pediatric patients in California – the only US
state that currently has mandated minimum nurse staffing
ratios.
Primary Funding Source: AHRQ
●Follow-Up Care for Children Prescribed Attention Deficit
Hyperactivity (ADHD) Medication
Sally Turbyville, MA, Phil Renner, MBA, Russell Mardon,
Ph.D., Shaheen Halim, MA, Richard Herman, M.D., Christy L.
Beaudin, Ph.D.
Presented By: Sally Turbyville, MA, Senior Health Care
Analyst, Quality Measurement, NCQA, 2000 L Street, Suite
500, Washington, DC 20036; Tel: (202)955-1756; Fax: (202)
955-3599; Email: turbyville@ncqa.org
Research Objective: To assess follow-up care for children
with a new prescription for Attention Deficit Hyperactivity
Disorder,ADHD, and to determine the validity of using
administrative pharmacy data to identify the study population.
ADHD is one of the more common chronic conditions of
childhood.
Study Design: Observational study conducted in six health
plans. All submitted administrative claims and pharmacy data
for commercial plan members and three submitted Medicaid
data. For this measure, children were identified as having
ADHD if they had one new prescription claim for an ADHD
specifc drug. These drugs were specified on a NDC code list
based on expert panel’s recommendations. Diagnosis of
ADHD in administrative data was not required to qualify for
the study population. Analyses were run to calculate follow-up
rates, and to determine the validity of administrative data as
compared to the medical record and the ability of pharmacy
data to accurately capture ADHD diagnosis.
Population Studied: The study population included 5,288
children ages 6 to 12 years. Medical records were examined
for 867 patients.
Principal Findings: The validation study showed that of
children confirmed with a new medication treatment episode
a diagnosis of ADHD was present for nearly all patients
identified by pharmacy data (average: 96.8 percent).
Approximately 43 percent of the children in the study
population enrolled in a commercial plan and 45 percent of
children enrolled in Medicaid had an initiation visit (i.e., a
follow-up visit within 30 days after the ADHD medication was
dispensed). Approximately 40 percent of the children in the
study population enrolled in a commercial plan and 42
percent of children enrolled in Medicaid had at least two
additional follow-up visits with a provider within 11 months of
their initiation visit. There is moderate variation among health
plans, and none had follow-up rates greater than 50 percent,
indicating significant room for improvement. Requiring an
ADHD diagnosis to be captured in the follow-up claim to
count toward numerator compliance, the initiation visit rates
drop to 19 percent and 23 percent for commercial and
Medicaid, respectively. The continuation and maintenance
follow-up visits (at least two additional visits) rates drop as
well, to an average of 14 percent (commercial) and 16 percent
(Medicaid). Children enrolled in Medicaid and commercial
plans had similar rates.
Conclusions: Low rates of follow-up for children with a new
ADHD medication prescription were observed in commercial
and Medicaid populations. Pharmacy data in commercial and
Medicaid populations accurately identified children with
ADHD on medication.
Implications for Policy, Delivery, or Practice: Despite the
guidelines recommending timely follow-up care for children
dispensed medication for ADHD this study shows variation
and significant room for improvement. Performance
measurement for follow-up through NCQA HEDIS®
measurement for children on ADHD medication can be used
to demonstrate variable follow-up rates and improve data
capture for population management.
Primary Funding Source: Unrestricted Educational grants
and SAMHSA grant
Call for Papers
Childhood Obesity & New Data & Findings for Children
with Special Health Care Needs
Chair: Jonathan Klein, University of Rochester
Monday, June 27 • 9:00 am – 10:30 am
●Comparing and Interpreting Findings on the Prevalence
and Health and Health Care Service Need Characteristics
of Children and Youth with Special Health Care Needs
(CYSHCN) Across Three new National Data sets
Christina Bethell, Ph.D., MBA, MPH, Debra Read, MPH, Paul
Newacheck, DrPH, Stephen Blumberg, Ph.D.
Presented By: Christina Bethell, Ph.D., MPH, MBA, Associate
Professor, Department of Pediatrics, Oregon Health & Science
University, Mailcode CDRC-P, 707 SW Gaines Street, Portland,
OR 97239; Tel: (503)494-1892; Fax: (503)494-2475; Email:
bethellc@ohsu.edu
Research Objective: To compare findings on the prevalence
and health and health care service need characteristics of
children and youth with special health care needs
(CYSHCN)identified using the same screening method
(CSHCN Screener) in the 2001 National Survey of Children
with Special Health Care Needs (NS-CSHCN), the 2000
Medical Expenditures Panel Survey (MEPS) and the 20032004 National Survey of Children's Health (NSCH).
Study Design: Data from the NS-CSHCN, MEPS and NSCH
are used to calculate the proportion of children meeting
criteria for having one or more type of special health care need
using the standardized CSHCN Screener. Child health and
health care service needs as well as sociodemographic
characteristics of CYSHCN are compared to further
understand similarities and differences in the prevalence and
profile of CYSHCN provided by each of these datasets. Several
analyses consider whether differences observed may be due to
variations across surveys in (1) sampling (random vs.
oversampling; household vs. target child interview; English vs.
Non-English language), (2) administration (survey
introduction, order of items, incentives, survey length) and (3)
weighting. Differences in shifts in practice patterns between
survey years (2000 to 2004), such as increased use of
prescription medication among children and higher rates of
provider identification of children with mental or behavioral
health problems (e.g. ADHD), are also considered. In
addition, differences in characteristics of CYSHCN identified
using alternative methods (CSHCN Screener vs. condition
checklists) are compared to further understand the overall
performance of the non-condition specific, consequencesbased CSHCN Screener across these three new national data
sets.
Population Studied: Children age 0-17 who met standardized
parent-reported criteria for having a special health care need in
the NS-CSHCN, MEPS and the NSCH. (N= 68,217)
Principal Findings: The rate of CYSCHN in the 2001 NSCSHCN is 13.6 (13.4-13.9) vs. 16.2 (14.7-17.7) for 2000 MEPS
for English language cases (MEPS English only) and 17.6%
(17.2-18.0) for the 2004 NSCH. Once identified, CYSHCN
identified in each survey do not vary dramatically in the health
and health care service need consequences they experience.
We hypothesize that higher rates of identification for the
MEPS and NSCH vs. NS-CSHCN are due to variations in
sampling and administration of this surveys and real shifts in
practice patterns in recent years. We also hypothesize that
significantly fewer children will be identified using the CSHCN
Screener vs. a chronic condition check-list in both MEPS and
the NSCH and that these children experience more
functioning and health service need consequences compared
to children only identified using a condition check-list.
Conclusions: Important differences in the profile of CYSHCN
provided across the new national data sets exist and involve
differences in methodology as well as potentially real
differences due to shifts in practice patterns and epidemiology
of CYSHCN between survey years.
Implications for Policy, Delivery, or Practice: Users of the
new national data sets need to understand differences in
methods used across surveys in order to validly interpret
findings on CYSHCN emerging from the NS-CSHCN, MEPS
and the soon to be released NSCH.
Primary Funding Source: HRSA
●Access to Care for Adolescents with Special Health Care
Needs
Debra Lotstein, M.D., Nicole Garro, MA, Moira Inkelas, Ph.D.
Presented By: Debra Lotstein, M.D., Assistant Professor,
Pediatrics, UCLA, 10833 Le Conte Avenue 12-358 MDCC, Los
Angeles, CA 90095; Tel: (310)825-9346; Email:
dlotstein@mednet.ucla.edu
Research Objective: Multiple studies of the general
population have found that adolescents have poorer access to
care than younger children. Studies of youth using various
definitions of disability also suggest poorer access to care
among teenagers with disabilities. It is unknown if this agerelated pattern applies to the new broadly defined population
of children with special health care needs (CSHCN). The
objective of this study is to determine if the prevalence and
predictors of unmet health care needs differ for adolescents
compared to younger children with special health care needs.
Study Design: Data are from the 2001 National Survey of
Children with Special Health Care Needs, a nationally
representative telephone survey conducted by the CDC. Our
main dependent variable is unmet need, defined as having at
least one unmet need for a health service (from a list of 18
types) in the last 12 months. We compute the prevalence of
unmet need by age group (0-1, 2-5, 6-11, and 12-17 years old),
and compare the odds of having unmet need controlling for
insurance coverage, type of health care need and condition
severity. Next, we compare predictors of unmet need for
health services using age-stratified logistic regression
analyses, adjusting for predisposing, enabling and need
factors associated with access to care in prior studies.
Population Studied: Parents of 38,866 children with a chronic
health condition that has lasted or is expected to last at least
one year.
Principal Findings: Prevalence of unmet need increases with
age, reaching 18.9% for teens from about 16% for younger
children. Even after controlling for structural and health need
factors, adolescents have 1.2 times the odds of school-age
children of having an unmet need (95% CI 1.06-1.36). Lack of
insurance coverage, less stable health care needs and having a
condition requiring emotional/behavioral or developmental
services are common predictors of unmet need in all age
groups. Yet among teenagers alone, increased odds of unmet
need are found for females and non-white CSHCN.
Conclusions: Adolescents with special health care needs have
poorer access to health care compared with younger children,
even accounting for their lower insurance rates and different
types of health care need. Gender and race/ethnicity are of
unique importance for teenagers’ access to care.
Implications for Policy, Delivery, or Practice: Adolescents
with special health care needs require enhanced services and
supports to ensure access to comprehensive care. Creative
clinical and policy solutions are needed to meet the unique
needs of this adolescent population.
Primary Funding Source: RWJF
●Physical Education and the Incidence of Overweight
among Adolescents
Chad Meyerhoefer, Ph.D., John Cawley, Ph.D., David
Newhouse, Ph.D.
Presented By: Chad Meyerhoefer, Ph.D., Economist, Center
for Financing, Access and Cost Trends, Agency for Healthcare
Research and Quality, 540 Gaither Road, Rockville, MD 20850;
Tel: (301)427-1664; Fax: (301)427-1276; Email:
cmeyerhoe@ahrq.gov
Research Objective: To determine whether the time spent in
physical education (PE) classes affects adolescent Body Mass
Index (BMI) and clinical weight classification. Based on
measurements taken during the National Health and
Nutrition Examination Surveys, the incidence of overweight
has grown rapidly among children and adolescents, increasing
from 6.5 percent in the late 1970s to 15 percent in 1999-2000.
Overweight status in childhood or adolescence has been
linked to adult obesity and to subsequent adverse health
impacts. There is now widespread recognition that the
prevention and reduction of overweight among children and
adolescents is an important public health objective. Among
the changes under consideration by state policy makers is
increasing primary and secondary school PE requirements.
This research will indicate whether this policy holds promise
for reducing overweight, as we test whether the time spent in
PE classes impacts adolescent BMI and the probability of
becoming overweight.
Study Design: Height and weight data are used to calculate
BMI for individuals in the Youth Risk Behavior Surveillance
System (YRBSS) in order to investigate the relationship
between PE classes and BMI. Multivariate regressions are
used to determine the impact of minutes of exercise during PE
classes on BMI, controlling for age, race, gender, level of
urbanization, and consumption of certain food groups.
Categorical regression methods are used to measure the
impact of minutes of exercise during PE classes on the
probability of being overweight or at risk of overweight. In
addition, the impact of PE on different reported exercise levels
is investigated to determine whether PE promotes more active
lifestyles and a higher propensity to engage in physical activity
outside of the school day. One concern is that minutes of
exercise in PE may be correlated with unobserved
socioeconomic characteristics of the school district, which
may in turn be correlated with BMI; this would lead to omitted
variable bias in our coefficients on minutes of exercise in PE.
To address this possible bias, we estimate models of
instrumental variables. Our instruments are the state
requirements for PE.
Population Studied: This study uses data from the 1999,
2001, and 2003 Youth Risk Behavior Surveillance System
(YRBSS), a nationally representative survey of the U.S. high
school student population.
Principal Findings: Results from models of instrumental
variables indicate that PE participation has a significant and
negative impact on both BMI and the probability of being
overweight. Our first-stage regressions in the IV models
indicate that minutes of exercise in PE classes is strongly
influenced by state-level PE requirements as well as the
enforcement of those requirements.
Conclusions: Raising the number of minutes that children are
active in school PE classes would likely reduce BMI and is a
promising method to reduce the prevalence of overweight
among children and adolescents.
Implications for Policy, Delivery, or Practice: Policymakers
are searching for interventions to prevent and reduce
overweight among adolescents. These results suggest that
increasing the minutes of exercise during PE class time is one
promising method. These results can also be used in
conjunction with other information, such as the cost of
increasing PE class offerings, to establish a cost-effective PE
curriculum.
Primary Funding Source: AHRQ
●Arkansas’s Response to Childhood Obesity: Year Two
Assessment
Joseph Thompson, M.D., MPH, James E. Bost, MS, Ph.D.,
Jennifer L. Shaw, MAP, MPH, Kevin W. Ryan, JD, MA
Presented By: Joseph Thompson, M.D., MPH, Director,
University of Arkansas for Medical Sciences, Arkansas Center
for Health Improvement, 5800 West 10th Street, Suite 410,
Little Rock, AR 72204; Tel: (501) 660-7551; Fax: (501) 660-7543;
Email: thompsonjosephw@uams.edu
Research Objective: The prevalence of obesity among U.S.
children has reached epidemic proportions. To combat
problems associated with childhood obesity, the Arkansas
General Assembly passed Act 1220 in 2003 that includes a
wide range of activities. Included in the Act is a requirement
for all public school students to annually have their body mass
index (BMI) for age assessed and reported to their parents. In
the 2003-2004 school years, the Arkansas Center for Health
Improvement (ACHI) undertook statewide implementation of
BMI assessment and reporting for approximately 450,000
students. The continued BMI assessment for the 2004-2005
school year will yield comparable data to the first year’s
statistics.
Study Design: The data gathering and reporting on 421,973
students for the 2003-2004 school year was completed by
ACHI in the summer of 2004. A 91% student match was
found from 2003-2004 school year to the 2004-2005 school
year. A comparative analysis of student and demographic data
over the 2 school years will indicate improvement or
regression.
Population Studied: Arkansas school students for the past
two years, and citizens of Arkansas are affected by Act 1220
through results and community-level changes may benefit
societal efforts to combat obesity.
Principal Findings: Based on BMI-for-age calculations, the
2003-2004 school year data showed that 21% of Arkansas
school children were overweight, 17% were at risk for being
overweight, 2% were underweight, and 60% were normal
weight, using weight categories defined by the Centers for
Disease Control and Prevention. The demographic
distribution of results showed that both genders had similar
percentages among weight classifications. African-American
and Hispanic students had slightly higher percentages for
overweight (24% and 26%, respectively) and at risk for
overweight (17% and 20%, respectively) classifications than
Caucasians (20% overweight, 17%, at risk for overweight).
The results for the first statewide assessment in the nation
indicate that Arkansas has a higher than estimated percentage
of children and adolescents with weight problems than
predicted by the NHANES sample of more than 7000
children.
Conclusions: The Arkansas BMI assessment has revealed a
more severe problem than anticipated, with the state having
38% of its children in the 2 highest risk weight categories.
Implications for Policy, Delivery, or Practice: Analysis of the
2004-2005 school year data will be an initial indicator of
trends associated with obesity and will enable longitudinal
studies on factors that can influence the epidemic of obesity
among our nation’s children.
Primary Funding Source: RWJF
●User-Friendly Strategies to Expand the Use of new
National Data Sets on Children's Health by Policymakers
and Consumer and Health Care System Leaders
Nora Wells, MEd, Christina Bethell, Ph.D., MBA, MPH, Debra
Read, MPH
Presented By: Nora Wells, M.Ed, Director of Research and
Education, Federation of Children with Special Needs/Family
Voices, 1135 Tremont Street, Boston, MA 21210; Tel: (617)2367210; Fax: (617)572-2094; Email: nwells@fcsn.org
Research Objective: To develop and evaluate the use of an
online data query tool to expand the use of the National
Survey on Children with Special Health Care Needs (NSCSHCN)and the 2003-2004 National Survey on Children's
Health among federal and state policymakers and program
leaders and family and health care system leaders.
Study Design: Federal and state policymakers and program
administrators and family leaders across the US were engaged
in a five phase process to assess interest, capacity and
support needed to use data resulting from the NS-CSHCN
and other similar data sets (n= 72 representing 36 states).
Phases included (1) in-person focus groups, (2)a standardized
self-reported survey, (3) in-depth structured interviews to
identify preferred features and content for an online data query
tool and resource center and (4) a workshop to further discuss
needs and options for designing the Data Resource Center
(DRC) and (5) an in-person website demonstration and
evaluation session. Input obtained during ten in-person
educational workshops on the DRC and the use of the DRC by
over 12,000 users (65,000 hits)was evaluated to assess the
usability and value of the DRC in expanding the use of
national data sets by non-research audiences essential to
engage in the use of data to inform and stimulate the design
of health care programs and policies for children and youth.
Population Studied: Federal and state Title V leaders in the
area of children and youth with special health care needs
(CYSHCN) and family CYSHCN leaders participating in the
Family Voices consortium. (N = 72 for pretest; N = approx.
12,000 for beta test)
Principal Findings: Over 85% of participants indicated that
they were "extremely interested" in being able learn about and
directly access and query national and state level child health
and health care quality data sets. Over 83% indicated that
they would be "extremely likley" to routinely use a Data
Resource Center website designed to assist them in learning
about and easily using this data. Over 60,000 hits to the DRC
were recorded during the nine month start up period of the
DRC. The vast majority of visits were to use the online
interactive data query tool. Examples of uses of data findings
derived from the DRC include grant applications, legislative
testimony, popular press public education, stakeholder
education and engagement and state block grant needs and
performance assessments as well as many other applications.
E-mail and telephone technical assistance are central to the
success of any DRC-like effort as well as in-person and other
more in-depth trainings on how to think about, query and
communicate data findings in a scientifically valid and
effective manner.
Conclusions: State and federal policymakers and health care
program leaders as well as family/consumer leaders have a
strong interest in being able to directly access and validly use
data findings from national and state surveys on child and
adolescent health and health care.
Implications for Policy, Delivery, or Practice: Without a
DRC-like resource it is unlikely that essential policy, consumer
and health system leaders will make use of the new national
and state data on child and adolescent health and health care
will. Design of any DRC-like resource must be developed with
ongoing and in-depth input from target users. If US health
care policy continues to emphasize consumer engagement it
will be even more important to provide publicly available, nonproprietary DRC-like resources to assist consumers,
policymakers and others to easily access data they would
otherwise not have the skills, capacity or resources to use.
Primary Funding Source: HRSA
Related Posters
Poster Session A
Sunday, June 26 • 2:00 pm – 3:15 pm
●Parent Reports of Patient-Centered Communication with
Pediatric Providers: Implications for Quality Improvement
Melinda Abrams, MS, Susanne E Tanski, M.D., Peggy Auinger,
MS, Michael Weitzman, M.D.
Presented By: Melinda Abrams, MS, Senior Program Officer,
The Commonwealth Fund, One East 75th Street, New York,
NY 10021; Tel: (212) 606-3831; Fax: (212) 249-1276; Email:
mka@cmwf.org
Research Objective: To assess patient-centered
communication between mothers of young children and their
child’s primary care clinician in order to identify opportunities
for improving the quality of preventive pediatric care.
Study Design: Data from the 2001 and 2002 Child Preventive
Health Supplement Section to the Medical Expenditures Panel
Survey (MEPS) were analyzed to assess child and family
characteristics associated with maternal reports of patientcentered communication, specifically how well the clinician
listened, explained things, had respect for what the parent had
to say and spent enough time with the child. A composite
“overall communication” scale combining these four areas
was created, with an answer of “always” = 3, “usually” = 2,
“sometimes” = 1, and “never” = 0 for each area. A score of 06 was termed inadequate, 7-11 adequate and of 12 excellent.
Maternal physical health and mental health were determined
from the SF-12 within the MEPS. Bivariate and regression
analyses were conducted.
Population Studied: A nationally representative sample of
4450 parents of children under 5 years of age.
Principal Findings: Estimates of internal consistency among
the four communication questions was high (Cronbach’s a =
.89). Overall, 58.7% of parents reported receiving “excellent”
patient-centered communication and 6.5% “inadequate”.
Poorer communication was associated with worse child health
status, with 20.9% of parents of children with fair/poor health,
11.6% with good health and 6.3% with very good health and
4.7% with excellent health (p<.001) reporting inadequate
communication. In multivariate regression, fair/poor child
health was independently associated with having inadequate
communication with the child’s practitioners, adjusted OR 5.9
(95% CI 2.7, 12.7), as was poor maternal mental health OR 2.3
(1.31, 4.05) and poor maternal physical health OR 1.8 (1.7,
2.94). There were no significant associations between
communication and child’s age, race, ethnicity, health
insurance, or single parent household.
Conclusions: The majority of parents of young children report
excellent patient-centered communication with their child’s
pediatric clinician. However, mothers of children with poor
health status report inadequate communication, as do
mothers with poor physical or mental health.
Implications for Policy, Delivery, or Practice: The
association between poor health status and inadequate
communication suggests opportunities for quality
improvement. Screening children and parents for physical and
mental health in advance of preventive care encounters could
help clinicians identify families in need of additional time for
anticipatory guidance and counseling. Such an approach
could lead to variation in payment for preventive services
based on family health status. Additional strategies to improve
patient-centered communication include enhanced training of
clinicians’ communications skills, development of materials to
help parents communicate concerns and distribution of
parent education materials about health care conditions and
issues. To implement suggested changes requires restructuring preventive health care encounters at the parent,
provider, practice and system levels.
Primary Funding Source: CWF
●Association Between Remitted, Current and Chronic
Maternal Depression and Behavior in 3- Year-Old Children
Melissa Azur, MS, Philip Leaf, Ph.D., Anne Duggan, Sc.D.
Presented By: Melissa Azur, MS, NIMH Predoctoral Fellow,
Mental Health, Johns Hopkins Bloomberg School of Public
Health, 624 North Broadway, 8th Floor, Baltimore, MD 21205;
Tel: (410)719-6172; Email: mazur@jhsph.edu
Research Objective: To investigate the association between
remitted, current and chronic maternal depression and
internalizing behavior problems, externalizing behavior
problems and adaptive behavior in three-year-old children.
Second, to investigate the role of maternal social support in
moderating this association.
Study Design: The data come from a randomized
longitudinal study of an early home visitation program in
Hawaii. Maternal depression was measured using the CES-D.
Internalizing behavior and externalizing behavior were
measured based on maternal reports from the CBCL, and
adaptive behavior was measured using the Vineland Adaptive
Behavior Scale. Logistic regression was used to assess the
association between maternal depression and each of the
child outcomes. Interactions between maternal depression
and maternal social support were explored and the models
controlled for poverty, maternal education, teen parenthood,
race, and child’s gender.
Population Studied: The study sample consisted of 583
families participating in the larger randomized longitudinal
study. These families were identified as at risk for child abuse
and child maltreatment at the time of entry into the original
study. The study sample was limited to families where the
mother completed the interview when the target child was 3
years old.
Principal Findings: Maternal depression was highly prevalent
with 35% of women reporting current or chronic symptoms of
depression and an additional 23% of women reporting
remitted depression. There was an increasing trend in the
odds of having internalizing problems among children with
remitted, currently depressed and chronically depressed
mothers. Children living below the poverty line and children of
teen mothers were even more likely to experience internalizing
problems. Remitted maternal depression and chronic
maternal depression were also associated with externalizing
problems. Once we controlled for maternal social support and
child’s gender, there was no association between maternal
depression and adaptive behavior. There were no significant
interactions between social support and maternal depression.
Conclusions: Children with depressed mothers are at
increased risk for internalizing and externalizing behavior
problems and this risk continues after the depression has
remitted. Children born to adolescent mothers and children
living in poverty may be at particular risk of internalizing
problems.
Implications for Policy, Delivery, or Practice: Pediatricians
should consider a family-centered approach in treating
children and consider screening mothers for a history of
depression. Children living in poverty and children born to
adolescent mothers may be at particular risk for internalizing
problems. If depression is detected, support and treatment
should be provided to both the parent and the child.
Primary Funding Source: Other Government Funding
●Physical Activity Among Adolescents: The Role of
Physical Education
Susan Babey, Ph.D., Allison L. Diamant, M.D., MSHS, Theresa
Hastert, E. Richard Brown, Ph.D.
Presented By: Susan Babey, Ph.D., Research Scientist, UCLA
Center for Health Policy Research, 10911 Weyburn Avenue,
Suite 300, Los Angeles, CA 90024; Tel: (310)794-6961; Fax:
(310)794-2686; Email: sbabey@ucla.edu
Research Objective: To estimate the prevalence of regular
physical activity and physical inactivity and to examine the
relationship between physical education (PE) requirements
and physical activity among adolescents in California.
Study Design: We used data from the 2001 and 2003
California Health Interview Survey (CHIS). CHIS, a randomdigit dial (RDD) telephone survey of households drawn from
every county in California, completed interviews with over
55,000 households in 2001 and 42,000 households in 2003.
Bivariate and multivariate analyses were used to examine the
relationship between PE and level of physical activity. Other
factors examined include age, gender, race/ethnicity, and
income.
Population Studied: We analyzed responses from 5,858
adolescents age 12-17 interviewed for CHIS 2001 and 4,010
adolescents interviewed for CHIS 2003.
Principal Findings: In 2003, 7.3% of adolescents were
physically inactive, a significant increase from 2001 when 5.2%
were inactive (p<0.01). Inactivity among adolescent girls
nearly doubled from 2001 (9.2% vs. 5.0%, p<0.001) whereas
prevalence of inactivity among boys remained about the same.
Latino, African American, and Asian adolescents were less
active than white adolescents. Level of physical activity also
varied with PE requirements. The prevalence of regular
physical activity was higher among adolescents whose schools
require PE (73.0%) than among those whose schools do not
require or do not offer PE (59.4%, p<0.001); and the
prevalence of physical inactivity was nearly twice as high
among adolescents whose schools do not offer or do not
require PE (11.8% vs. 6.2%, p<0.01). Furthermore, the
prevalence of regular physical activity varied dramatically by
race/ethnicity and PE requirements. Among adolescents
whose schools do not require PE, two-thirds (67.9%) of white
adolescents engage in regular physical activity compared with
less than half of Asian adolescents (43.0%, p<0.05), and less
than one-third of African American adolescents (29.0%,
p<0.001). Although there was significant variation in physical
activity by race/ethnicity among adolescents whose schools
require PE, the differences were considerably smaller, ranging
from 65.4% among African Americans to 78.3% among
whites. PE requirements had a differential impact on boys’
and girls’ physical activity. Boys whose schools require PE
have a lower prevalence of inactivity than girls (4.4% vs. 8.1%,
p<0.01). However, there were no significant differences
between boys’ and girls’ prevalence of physical inactivity when
their schools did not offer or did not require PE (11.1% vs.
12.4%).
Conclusions: These findings suggest that physical education
requirements at school are an important factor related to
adolescent’s participation in physical activity and may be a
promising area for intervention efforts for groups that are less
active.
Implications for Policy, Delivery, or Practice: Physical
inactivity contributes to complications and death from chronic
conditions such as type 2 diabetes, coronary heart disease,
obesity, and hypertension. Despite the well-documented
benefits of physical activity, many California adolescents do
not get regular physical activity or get no activity at all.
Identification of factors, particularly environmental factors,
related to physical activity among adolescents can aid in the
development of effective interventions to increase physical
activity and help adolescents establish a lifetime of healthy
activity behaviors.
Primary Funding Source: The California Endowment
●Correct Identification of Childhood Obesity and its
Association with Reported Practice Behavior
Sarah E. Barlow, M.D., MPH, Michael P. Elliott, Ph.D., Sonal
Bobra, MPH
Presented By: Sarah E. Barlow, M.D., MPH, Assistant
Professor, Pediatrics, Saint Louis University, 1465 South Grand
Boulevard, Saint Louis, MO 63104; Tel: (314) 577-5647; Fax:
(314) 268-2775; Email: barlowse@slu.edu
Research Objective: To determine how often pediatricians
correctly identify overweight/obesity during health supervision
visits of children 6 to 17 years. To assess the association of
overweight/obesity identification with evaluation for obesityrelated medical conditions and with reported health behavior
counseling.
Study Design: Pediatricians at federally-funded health centers
and a random sample in private practice in Saint Louis,
Missouri were asked to provide information from up to 30
visits as part of a study of care of chronic conditions during
health supervision visits of children 6 to 17 years. Participants
returned a copy of the visit note and the growth chart and
completed a questionnaire about patient demographics and
visit evaluation and treatment. The pediatricians checked
current conditions from a list that included overweight/obesity
(OW/OB) and hypertension. For 7 health behaviors,
pediatricians reported none, brief, or >/= 2 minutes
counseling
Population Studied: 55 pediatricians were contacted and 22
returned information from a total of 564 visits. 51.3% of
patients were 6-11 years old, 50.1% were male, 47.2% were
Caucasian, and 49.2 were African-American. 27.3% of visits
occurred in federally-funded health centers, and 54.0% were
covered by Medicaid.
Principal Findings: Based on height and weight recorded in
554 visits, 17.1% of children were at risk of overweight (BMI
85th-94th percentile) and 22.4% were overweight or obese
(BMI >/= 95th percentile). Pediatricians identified OW/OB in
26.1% of children in the at-risk category and 83.1% of children
with BMI >/= 95th percentile. Reported physician behavior
was examined in three visit categories: identified obesity (BMI
>/=95th with OW/OB identified) n=98; missed obesity (BMI
>/= 95th with no OW/OB identified) n=20; and normal weight
(BMI < 85th percentile) n=335. Cholesterol was ordered in
36.1% identified obesity visits, 15.0% missed obesity visits,
and 10.7% normal weight visits (identified vs. missed p=.05).
Glucose was ordered in 16.4% identified obesity visits, 0
missed obesity visits and 2.2% of normal weight visits
(identified vs. missed NS). Blood pressure was recorded in
more than 95% of visits with no difference among the three
groups. Pediatricians reported hypertension in 8.5% identified
obesity visits, 0 missed obesity visits, and 2.0% normal weight
visit (identified vs. missed NS). Diet counseling >/=2 minutes
was more common among identified obesity visits compared
with normal weight and missed obesity visits (81.3% versus
25.9% and 31.3%, p < .001). Similarly, exercise counseling >/=
2 minutes was more common among identified obesity visits
(70.5% versus 20.0% and 24.4%, p < .001). Counseling for
behavior management and for growth and development did
not differ among the groups, nor did counseling for family
planning, HIV/STD, and tobacco
Conclusions: Pediatricians missed obesity in 16.9% of obese
children. The higher rates of diet and exercise counseling and
the trend toward higher cholesterol screening when obesity is
identified suggest that improved recognition could improve
practice patterns.
Implications for Policy, Delivery, or Practice: Helping
pediatricians identify all overweight children could lead to
improved medical care and more intensive diet and exercise
counseling. Further work is needed to assure the quality and
effectiveness of the counseling.
Primary Funding Source: AHRQ
●The Impact of Gaps in Health Insurance Coverage on
Immunization Status for Young Children
Lynn A. Blewett, Ph.D., Lynn A. Blewett, Ph.D., Gestur
Davidson, Ph.D., Holly Rodin, MPA, Mark L. Messonnier, MS,
Ph.D.
Presented By: Lynn A. Blewett, Ph.D., Associate Professor,
School of Public Health, University of Minnesota, 420
Delaware Street, MMC 729, Minneapolis, MN 55455; Tel:
(612)626-4739; Email: blewe001@umn.edu
Research Objective: To estimate the impact of gaps in public
and private health insurance coverage on young children’s
rates of immunization receipt.
Study Design: We use multivariate logistic regression models
to assess the impact of health insurance coverage on the
probability of being up-to-date (UTD) on 10 recommended
childhood immunizations. We look specifically at the impact
of gaps in coverage by comparing full-year and part-year
private and public (Medicaid/SCHIP) health insurance
coverage on whether immunizations are UTD controlling for
other factors that might affect immunization. Covariates
include characteristics of both children and their parents
(including employment status, income, race/ethnicity). We
worked with CDC to obtain a unique data file that linked
responses from 8,886 non-special needs children with
insurance coverage data from the 2001 SLAITS/CSHCN with
provider verified immunization status on age-eligible children
from the 2000-2002 National Immunization Survey (NIS).
Population Studied: A nationally representative sample of
8,886 children age 19-35 months.
Principal Findings: We found that children with private-partyear coverage were less likely to be up-to-date (UTD) across all
10 immunizations and statistically significantly lower for 6 of
the 10 immunizations compared to children with private-fullyear coverage. On average, children with gaps in private
coverage were 9% less likely to be UTD than children with fullyear covereage. Children with private-full-year coverage were
not statistically different in UTD status from children with
public-part-year coverage for any of the immunizations, and in
4/10 immunizations their likelihood of being UTD was
marginally higher. We found children with public-full-year
coverage were significantly more likely to be UTD in 2/10
immunizations compared to children with private-full-year
coverage. Children who were uninsured the whole year were
not significantly different in their likelihood of being UTD for
any of the immunizations, compared to children on privatefull-year coverage.
Conclusions: This study provides important new information
on the impact type and duration of health insurance coverage
has on childhood immunization rates. Specifically gaps in
private coverage increases the likelihood that children are not
UTD in their immunizations. Even children with part-year
public coverage do as well or better on obtaining
recommended immunizations on time than children with
gaps in private coverage. Gaps in private health insurance
coverage may have an important impact in children delaying
or foregoing immunizations.
Implications for Policy, Delivery, or Practice: While
immunization coverage among children is at an all-time high
in the US, 20 percent or more of children between 19 and 35
months of age are still missing one or more recommended
immunizations. Gaps in private health insurance coverage
may be an important barrier to obtaining recommended
immunizations. Policy strategies that enhance continuity of
coverage for children may improve immunization coverage.
In addition, steps should be taken to ensure that both families
and providers understand that the current federal Vaccine for
Children Program (VCP) provides for free vaccines to
uninsured children including those that lose coverage during
the year.
Primary Funding Source: CDC
●When the Bough Breaks: Provider-Initiated
Comprehensive Care is More Effective and Less Expensive
for Sole-Support Parents on Social Assistance
Gina Browne, Ph.D., RN, Carolyn Byrne, Ph.D., RN, Jacqueline
Roberts, MSc, RN., Amiram Gafni, Ph.D., Susan Whittaker,
MSc, BSc, BA
Presented By: Gina Browne, Ph.D., RN, Founder & Director,
System-Linked Research Unit on Health and Social Service
Utilizaton; Professor, Nursing & C.E.&B., School of Nursing,
McMaster University, Faculty of Health Sciences, 75 Frid
Street, Building T30, Hamilton, Ontario, L8P4M3; Tel: (905)
525-9140 x22293; Fax: (905)528-5099; Email:
browneg@mcmaster.ca
Research Objective: This five-year study conducted in
Ontario, Canada is designed to assess the effects and expense
of adding a mix of provider-initiated interventions to the
health and social services typically used in a self-directed
manner by sole-support parents and their children receiving
social assistance in a national system of health and social
insurance.
Study Design: Families were randomized to receive proactive
in-home visits by nurses, employment retraining, and age
appropriate childcare, recreation, skills development for all
children in the household alone or combined and further
compared to their own self-directed use of services.
Population Studied: This was a five-arm prospective
randomized trial of 765 single parents on social assistance
and their 1330 children (aged 0 - 24 years).
Principal Findings: Results from a two-year interim analysis
show that providing social assistance families with proactive
comprehensive care (health promotion, employment
retraining, and recreation activities for children) compared to
allowing families to fend for themselves in a self-directed
manner, results in 15% more exits from social assistance
within one year and substantial savings to society in terms of
social assistance payouts.
Conclusions: It is more effective and creates more savings,
yet no more expensive to provide health and social services in
a comprehensive fashion to parents and all children in a
household on social assistance.
Implications for Policy, Delivery, or Practice: This study
funded by Health Canada presents clear evidence that
providing comprehensive care to social assistance recipients
produces tremendous short and long term financial gains and
societal benefits.
Primary Funding Source: Health Canada
●Nurse Staffing and Healthcare-Associated Bloodstream
Infections in the Neonatal ICU
Jeannie Cimiotti, DNS, Janet P. Haas, MS, Kevin D. Roberts,
Ph.D., Elaine L. Larson, Ph.D.
Presented By: Jeannie Cimiotti, DNS, Research Associate,
School of Nursing, University of Pennsylvania, 420 Guardian
Drive 327R NEB, Philadelphia, PA 19104-6096; Tel: (215) 8984989; Fax: (215) 573-2062; Email: jcimiott@nursing.upenn.edu
Research Objective: Healthcare-associated infections (HAIs)
are a cause of significant morbidity and mortality among
infants in the neonatal intensive care unit (NICU). Few studies
have examined the association between nurse staffing and
HAIs in infants; furthermore, no prospective studies have
examined the association between nurse staffing and
bloodstream infections (BSIs) in the NICU.
Study Design: This prospective correlational study examined
the association between nurse staffing and healthcareassociated BSI among infants in two, high risk NICUs in New
York City. An experienced epidemiologist collected data on
BSIs, defined per CDC criteria. Four risk factors associated
with BSI in infants were examined: birthweight, intravascular
catheterization, major surgery, and total parenteral nutrition
(TPN). Birthweight was stratified into four groups: 1)
<1000gm, 2) 1000-1500 gm, 3) 1501-2500 gm, and 4)
>2500gm. Catheters were classified as umbilical, tunneled
(Hickman or Broviac), peripheral inserted central (PICC) and
extracorporal oxygenation membrane (ECMO); TPN was
defined as days of TPN to infection or discharge. Registered
nurse (RN) hours were RN care hours per day, adjusted for
case mix based on DRG. RN staffing data were ranked into
quartiles with the first and fourth quartile indicating low and
high staffing, respectively. Risk factors with a p-value <0.10
were included in a multivariate model and data were analyzed
using a Weibull accelerated failure-time model to determine
those covariates associated with BSI.
Population Studied: Data were collected on all nurses who
provided direct patient care and on all infants admitted to the
NICU from March 2001 through January 2003.
Principal Findings: During the study 2,675 infants were
admitted to the NICU for >48 hours. Infants were 53% male
and gestational age ranged from 23 to 42 weeks. A total of 309
(12%) infants had a birthweight <1000gm, 330 (12%) 10001500 gm, 812 (30%) 1501-2500 gm and 1,224 (46%) >2500
gm. Catheters were inserted in 1,603 infants: 783 (49%) were
umbilical, 60 (4%) tunneled, 737 (46%) PICC and 23 (1%)
ECMO. Additionally, 467 (17%) infants had surgery and 1,284
(48%) received TPN during their hospitalization. A total of 224
(8%) infants had an infection that met the study definition of
BSI. In a multivariate analysis, the risk factors associated with
BSI were birthweight <1000 (p<.0001) and 1000-1500 gm
(p=<0.019), umbilical catheter days (p=0.02) and low hours of
care provided by RNs (p<0.0001).
Conclusions: Infants had an increased risk of BSI when RN
care hours were low. These results are consistent with studies
on nurse staffing in other populations and provide evidence of
a causal link between nurse staffing and BSI. We hypothesize
that inadequate nurse staffing results in poor hand hygiene
compliance, breaks in aseptic technique or compromises in
practice that might increase the risk of transmitting infection.
Implications for Policy, Delivery, or Practice: These findings
underscore the importance of active surveillance and adequate
nurse staffing in healthcare facilities to potentially reduce
HAIs, improve the quality of patient care and reduce the
economic burden on our healthcare system.
Primary Funding Source: NIH/NINR
●Factors Associated with Children’s Participation in
Shared Decision Making
Elizabeth Cox, M.D., MS, , , Maureen Smith, MD, MPH, PhD,
Roger Brown, PhD, Mary Anne Fitzpatrick, PhD, , , ,
Presented By: Elizabeth Cox, M.D., MS, Clinical Assistant
Professor, Population Health Sciences and The Center for
Women's Health & Research, University of WisconsinMadison Medical School, 610 Walnut Street, 634 WARF
Building, Madison, WI 53726; Tel: (608)263-9104; Fax:
(608)263-2820; Email: ecox@wisc.edu
Research Objective: Due to its ability to produce improved
health outcomes in adults, shared decision-making (SDM)
has become a preferred method for reaching treatment
decisions with adults. Among adults, males, minorities, and
those less educated are less likely to desire SDM and less
likely to participate in their healthcare. No work has examined
how such characteristics impact children’s participation in key
SDM tasks. We examine how the child, parent and physician
share visit talk with children of differing ages and how child
and parent factors influence child participation in key SDM
tasks (relationship building and information exchange).
Study Design: We analyzed videotapes of children’s medical
visits as well as physician/participant surveys of
demographics, practice characteristics and healthcare
utilization. Using the Roter Interaction Analysis System,
utterances were coded and aggregated to reflect relationship
building and information exchange (information giving and
information gathering). Negative binomial models were used
to analyze the association between the child’s participation in
key SDM tasks and parent factors (education and gender of
the accompanying parent) or child factors (age, gender, and
race), adjusting for visit length and physician factors, as well
as clustering by physician.
Population Studied: 100 children and their parent(s) visiting
1 of 15 family physicians or pediatricians for acute concerns.
Principal Findings: Children’s mean age was 5.4 years (sd
5.0, range 0-18). Physicians spoke 63% of visit talk, parents
spoke 31% of visit talk and children spoke the remaining 6% of
visit talk. The amount of physician talk did not change with
child age, but parent talk decreased with child age, p<0.001,
while child talk tended to increase, p<0.06. For relationship
building talk, children of college graduates spoke 5 times more
than children of less educated parents, while girls spoke 3
times more than boys, both p<0.02. Children gave 8% more
information for each year of child age, p<0.05. Children of
college graduates did twice as much information giving than
children of less educated parents, p<0.05. Only 15 of the
children gathered any information during the visit.
Conclusions: In pediatric visits, children talked at the expense
of parent talk while the amount of physician talk remained
unchanged across child age. Increased child participation in
key tasks of SDM is seen with higher parental education and
among female children.
Implications for Policy, Delivery, or Practice: Patterns of
participation in key SDM tasks among children appear similar
to those of adults, suggesting that such patterns begin early in
life. Future work should examine how these patterns are
established as a step toward identifying mutable factors that
encourage patient participation in SDM.
Primary Funding Source: AHRQ
●Explaining Disparities in Patient Centeredness Between
Hispanic and Non-Hispanic Children
Denise Dougherty, Ph.D., Frances Chevarley, Ph.D., Darryl
Gray, M.D., Sc.D., Lisa Simpson, MB, BCh, MPH, Melissa
Romaire, MPH, Marc Zodet, MS
Presented By: Denise Dougherty, Ph.D., Senior Advisor, Child
Health and Quality Improvement, Office of Extramural
Research, Education, and Priority Populations, Agency for
Healthcare Research and Quality, 540 Gaither Road, Room
2010, Rockville, MD 20850; Tel: (301) 427-1868; Fax: (301) 4271562; Email: ddougher@ahrq.gov
Research Objective: To explain Hispanic versus NonHispanic disparities in the parent-provider communication
experience using factors in addition to those used in previous
studies of this topic (urbanicity, region, child’s country of
birth, and CAHMI special health care need measure).
Study Design: We used data from the 2002 Medical
Expenditure Panel Survey (MEPS), a nationally representative
survey, in a series of regression analyses designed to explain
differences in parent-clinician communication between
Hispanics and non-Hispanics. The outcome variables were
two CAHPS® measures of communication: 1) whether the
provider always listened carefully to the parent and 2) whether
the provider always explained things clearly to the parent
regarding the child’s health. Logistic regression examined
whether disparities in communication between Hispanics and
non-Hispanics persisted after controlling for individual, family,
and contextual variables (age, race, health status, insurance
status, usual source of care (USC); child born in the U.S.,
language of interview, education of interviewee, family
income; region, urbanicity, and area density of practicing
physicians).
Population Studied: The study sample consisted of 11,097
children aged 0-17 for whom there was complete information
from the Child Supplement section in the 2002 MEPS.
Principal Findings: Unadjusted estimates suggest that
Hispanic children were less likely than non-Hispanic children
to have parents report that providers always listened carefully
to them (68.7% v. 72.8%) and always explained things clearly
to them (70.7% v. 76.5%). However, after controlling for other
covariates using multiple logistic regression, the differences in
reported communication between Hispanic children’s and
non-Hispanic children’s parents were no longer significant for
either measure [i.e., always listening carefully OR
0.89[0.71,1.11], and always explaining clearly OR 0.96
[0.76,1.22]). Living outside the Northeast, with reports of
other than excellent child health status, and of being
poor/near poor poverty status are associated with a decreased
likelihood of reports that the provider always listened carefully
or explained things clearly. Children residing in less populated
“micro” areas (10,000-50,000 population) have an increased
likelihood of positive responses on both measures of
communication. Black children have an increased likelihood
of reports that the provider always explained things clearly
while multiple races and not having a USC are associated
with a decreased likelihood of providers always listening
carefully. For age, only <1 year is associated with a positive
response for providers always listening carefully. Insurance
status, language, born in the U.S., and education had no
independent effect.
Conclusions: In using CAHPS® communication-related
questions as a measure of patient-centered care and a
nationally representative survey, factors other than Hispanic
ethnicity likely exert a strong influence on the quality of the
child and parent health care experience.
Implications for Policy, Delivery, or Practice: Initiatives to
improve communication for Hispanics may be more similar to
those for non-Hispanics than expected. However, our data
are limited and unable to test a full range of plausible factors
explaining disparities in parent-clinician communication.
More research is needed to assess whether cultural
competence programs for providers who treat Hispanic
children will improve parents’ ratings of communications. To
reach Hispanics and non-Hispanics, efforts to improve
patient-centeredness might be focused outside the Northeast,
in non-micro residential areas, and among poor families.
Primary Funding Source: No Funding Source
●Social Cognitive, Behavioral, and Psychosocial Predictors
of Young Children’s Oral HealthB
Tracy Finlayson, BS, Kristine Siefert, Ph.D., MPH, MSW, Amid
Ismail, BDS, MPH, DrPH
Presented By: Tracy Finlayson, BS, Research Assistant, Health
Management and Policy, University of Michigan School of
Public Health, 109 South Observatory, Ann Arbor, MI 481092029; Tel: (734)615-5131; Email: tfinlays@umich.edu
Research Objective: Dental caries is the most common
disease affecting children and is disproportionately high
among lower-income African-American children in Detroit.
This study seeks to advance knowledge of the social
determinants of oral health, by examining how several specific
maternal health beliefs, behaviors, and psychosocial factors
relate to young children's dental outcomes and practices in
this population.
Study Design: Survey and dental exam data are from the
Detroit Dental Health Project (DDHP; NIDCR grant U-54
14261-01). Social Cognitive Theory guided the study design
and selection of predictor variables. Health belief scales
reflecting mothers’ self-efficacy, feelings of fatalism, attitudes
about dental disease and knowledge about bottle use were
constructed based on exploratory factor analysis of survey
questions. Mothers’ brushing habits and psychosocial
measures of depressive symptoms (CES-D), parenting stress,
availability of instrumental social support and traditional
background factors were also predictors. The outcomes were
children’s brushing frequency, severity of Early Childhood
Caries (ECC), and a subjective oral health rating. Descriptive
and multivariable regression analyses were conducted with
SUDAAN.
Population Studied: A population-based sample of 719
African American children aged 1-5 and their mothers living in
Detroit who participated in the DDHP in 2002-2003 were
studied. 1-3 and 4-5 year olds were examined separately, to
account for developmental differences.
Principal Findings: The constructed health belief scales were
reliable and internally consistent. Maternal ratings of child
oral health status as fair/poor were quite congruent with
whether or not the child had disease as determined by dental
examinations. The regression analyses revealed that maternal
self-efficacy, attitudes, fatalism, brushing behavior and social
support were significantly associated with 1-3 year old
children’s one-week brushing frequency. Efficacy, attitudes,
brushing behavior and dental insurance coverage were
significant in the model for 4-5 year old children. Among 4-5
year olds, having dental insurance, more education and less
bottle knowledge reduced their likelihood of a fair/poor rating,
while negative attitudes about disease and help with errands
increased the likelihood. Higher parenting stress was
inversely related to disease severity for all children. Fatalistic
and negative disease attitudes increased the likelihood of
having ECC for 4-5 year olds, while more education reduced
the likelihood. Restorative dental treatment among 1-3 year
olds increased the likelihood of ECC, while higher income
reduced the likelihood.
Conclusions: Although some findings are counterintuitive
and warrant further exploration, mothers’ social cognitive and
psychosocial characteristics are important factors that affect
her child’s brushing frequency and dental health status in
earliest childhood.
Implications for Policy, Delivery, or Practice: Behaviors and
cognitions are potentially modifiable, and this study’s findings
can inform the design of tailored interventions. Such
interventions could enhance mothers’ sense of efficacy and
educate her about dental disease and caring for young
children’s teeth, thus boosting her motivation to positively
affect her child’s oral health. Mothers’ regular brushing could
also be encouraged, to model a desirable preventive hygiene
habit.
Primary Funding Source: NIH NIDCR grant U-54 14261-01
●Risk Factors for Failing Oral Amoxicillin Treatment of
Severe Pneumonia in Children
Linda Fu, M.D., Robin Ruthazer, MPH, Ira Wilson, M.D.,
M.Sc., Archana Patel, MB, DNB, MSCE, Donald Thea, M.D.,
Patricia Hibberd, M.D., Ph.D.
Presented By: Linda Fu, M.D., Clinical Research Fellow,
Institute for Clinical Research & Health Policy Studies, TuftsNew England Medical Center, 750 Washington Street Box 63,
Boston, MA 02111; Tel: (617) 636-8028; Fax: (617) 636-5025;
Email: lfu@tufts-nemc.org
Research Objective: Oral amoxicillin was found to be
equivalent in a recent trial to intramuscular penicillin, the
currently recommended treatment for WHO-defined severe
pneumonia (lower chest indrawing [LCI]) in children. Since
oral therapy may eliminate the need for hospitalization, our
goal was to determine which children were likely to fail oral
amoxicillin treatment based on presenting characteristics and
early response to therapy.
Study Design: This is a retrospective cohort study within a
previously completed randomized controlled trial conducted
at tertiary care centers in 8 countries.
Population Studied: Information was analyzed for the 857
participants ages 3-59 months who received oral amoxicillin
for severe pneumonia. Patient information was obtained upon
enrollment (T0), as well as 12 hours (T12) and 24 hours (T24)
after the first dose of amoxicillin. Treatment failure was
defined as persistence of LCI or development of danger signs
after 48 hours of therapy.
Principal Findings: Treatment failure occurred in 18%. Four
multi-level multivariate logistic regression models, each
including enrollment site as a random effect, were created to
predict failure depending on the duration of observation and
whether variables related to blood oxygen saturation were
included, as pulse oximetry is not always available. In the first
model, which assumed only 12 hours of observation and no
access to pulse oximetry, infancy [age<6 months] (OR 4.0,
95% CI 2.4-6.6), very fast breathing [>69 breaths per minute if
<12 months and >59 breaths per minute if >=12 months] (6.9,
2.9-16.5), and increasing respiratory rate (1.2, 1.1-1.3) predicted
failure with an ROC area of 0.68. In the second model, which
assumed 12 hours of observation with access to pulse
oximetry, infancy (3.9, 2.2-6.8), very fast breathing at T0 (6.3,
2.4-16.4), low blood oxygen saturation at T0 [<90% in room
air for all sites at sea level and <88% for Columbia and
Mexico] (4.0, 1.8-8.9), increasing respiratory rate (1.1, 1.0-2.9)
and decreasing oxygen saturation (1.2, 1.1-1.2) predicted failure
with an ROC area of 0.72. In the third model, which assumed
24 hours of observation and no pulse oximetry, infancy (4.5,
2.6-7.7), very fast breathing at T0 (12.2, 4.8-31.2), higher
temperature at T0 (1.8, 1.3-2.6), increasing respiratory rate (1.3,
1.0-1.4), increasing temperature (2.0, 1.4-2.7) and wheezing at
T24 (2.2, 1.2-3.9) predicted failure with an ROC area of 0.73. In
the fourth model which assumed 24 hours of observation with
access to pulse oximetry, infancy (3.9, 2.3-6.6), very fast
breathing at T0 (11.2, 4.5-27.6), low oxygen saturation at T0
(3.8, 1.8-8.1), increasing respiratory rate (1.3, 1.2-1.4),
decreasing oxygen saturation (1.2, 1.1-1.3) and wheezing at T24
(2.1, 1.2-3.6) predicted failure with an ROC area of 0.76.
Conclusions: Age and routine vital signs obtained during the
first 24 hours of treatment of severe pneumonia with oral
amoxicillin can be used to determine with reasonable accuracy
which children are at risk for treatment failure. Data from
pulse oximetry is needed to achieve similar predictive ability
after only 12 hours of observation.
Implications for Policy, Delivery, or Practice: These findings
may assist with decision-making about the need for
hospitalization or duration of observation, but need to be
evaluated in further studies.
Primary Funding Source: AHRQ
●Parents’ and Guardians' Influence on Children's Use of
Mental Health Care
Darrell J. Gaskin, Ph.D., Anthony Kouzis, Ph.D.
Presented By: Darrell J. Gaskin, Ph.D., Associate Professor,
Health Policy and Management, Johns Hopkins Bloomberg
School of Public Health, 624 North Broadway Room 441,
Baltimore, MD 21205; Tel: (443)287-5297; Fax: (410)614-8964;
Email: dgaskin@jhsph.edu
Research Objective: While 16 to 22% of children have a
diagnosable mental/addictive disorder during a year, most do
not seek or receive treatment. This study attempted to
understand how parent’s/guardian’s characteristics influenced
children’s use of mental health services. We were interested in
how four factors influenced children's use of mental health
services: parents’/guardians’ mental health status and general
health status, family structure, family’s dependency on
government assistance and socio-economic status.
Study Design: This is a cross sectional analysis. We used
logistic regression models to predict for children the odds of
having a mental health visit and the odds of having a needed
mental health visit delayed/postponed. We used a negative
binomial regression to predict the number of visits during the
year.
Population Studied: We examined the mental health service
use of 20,000 children whose families participated in the 1997
National Survey of American Families.
Principal Findings: We found that parents’/guardians’
mental health status seemed to have a paradoxical effect on
children’s use of mental health services. Having a
parent/guardian with poor mental health status was
associated with increased mental health service use.
However, it also was associated with a greater likelihood of
delaying/postponing needed mental health services. A
possible explanation is that parents with poor mental health
status were more likely to use mental health services for their
children. However, parent’s poor mental health status may
have been an access barrier because it made in more difficult
for parents to navigate the health care system. We also found
that children in blended, single-parent, or foster families were
at greater risk of using mental health services. Financial
factors increased the odds of using a mental health service
and the number of mental health visits during the year but did
not affect the odds of a needed mental health service being
delayed or postponed.
Conclusions: The health status of parents and guardian
influences their children's access to care. Any effort to
improve children's access to mental health services is
incomplete if it does not address the health needs of their
parents and guardians.
Implications for Policy, Delivery, or Practice: Advocates for
expanding access to care for children should not forget about
their parents and guardians. Also, future research should
explore why children in blended, single-parent, or foster
families were at greater risk of using mental health services,
and in particular, why those in blended and single-parent
families were more likely to experience barriers to care.
Primary Funding Source: NIMH
●Population-Based Volumes, Rates and Resource Use for
Pediatric Cardiac Procedures
Darryl Gray, M.D., Sc.D.
Presented By: Darryl Gray, M.D., Sc.D., Medical Officer,
Center for Quality Improvement and Patient Safety, Agency for
Healthcare Research and Quality, 540 Gaither Road 3rd floor,
Rockville, MD 20850; Tel: (301) 427-1326; Fax: (301) 427-1341;
Email: dgray@ahrq.gov
Research Objective: Congenital malformations of the heart
and great vessels affect roughly one million Americans.
Acquired conditions (generally of infectious origin) add to the
growing burden of pediatric heart disease seen in children and
adults. While relevant diagnostic and therapeutic options are
expanding, little is known in aggregate about the resulting
frequencies of procedures used to treat these conditions.
Administrative data were used to estimate population-based
volumes, rates, and resource use for inpatient cases, which
have been estimated to comprise ~90% of pediatric cardiac
interventional procedures
Study Design: For a retrospective descriptive study,
International Classification of Diseases-Clinical Modification
(Ninth Revision) principal procedure codes for therapeutic
(rather than purely diagnostic) cardiac procedures performed
via surgical or transcatheter approaches were determined.
Publicly-available aggregate data on inpatient admissions were
obtained from the Kids' Inpatient Database (KID) and the
National Inpatient Sample (NIS) of the Agency for Healthcare
Research and Quality‘s Healthcare Cost and Utilization Project
(HCUP). Hospital charges, which exceed costs but do not
include physician fees, were expressed in 2002 dollars based
on the Consumer Price Index. Volume figures were combined
with Census data to generate population-based rates.
Population Studied: Weighted, nationally representative
samples of admissions of 0-17 year olds (YOs)
Principal Findings: KID data from 1997 indicate that infants
(i.e., patients < 1 year old) accounted for 15,024 admissions
(384.6/100,000 infants). A mean length of stay (LOS) of 23.0
days generated charges of $147,091/admission. Among 1-17
YOs, KID estimated that there were 14,607 cases
(21.9/100,000), where mean LOS=6.1 days and charges
averaged $61,458/admission. For 0-17 YOs, aggregate
charges (discharge volumes X mean hospital charges) were
$3.1 billion. For that year, NIS projected 12,827 infant
admissions, an LOS of 21.9 days and charges averaging
$128,359/case. For 1-17 YOs, 14,067 admissions averaging 6.4
days generated charges of $48,984/case. Aggregate charges
for 0-17 YOs were $ 2.3 billion. The mean LOS figures and
the relative contributions of infants vs older children to
admission volumes and to charges remained relatively stable
over time and across databases. However, for all ages, NIS
absolute volumes for 1998-2002 rose from 20,657 in 1998 to
32,368 in 1999. Subsequent volumes and variation decreased,
with 24,691 cases estimated for 2002. Aggregate charges
were $1.6 billion in 1998, $3.0 billion in 1999 and $3.1 billion in
2002. In 2000, NIS and KID volumes were 23,400 and 30,861
respectively. However, adjusted aggregate charges were
similar at $2.3 billion versus $2.4 billion.
Conclusions: Observed pediatric cardiac procedure
admission volumes and resource use exceed prior estimates.
Infants (including newborns) account for roughly ½ the
admissions and >2/3 of the charges. While NIS appears
annually, its estimates may fluctuate. KID (released for 1997
and 2000; 2003 pending) may better reflect pediatrics care.
Implications for Policy, Delivery, or Practice: The
considerable volumes and costs associated with pediatric
cardiac prccedures indicate the societal importance of these
interventions, and argue for increased population-based
research on care patterns and outcomes, especially for infants.
Such research should use data from HCUP and other sources
to distinguish the effects of sampling variation or artifact from
those of major changes in actual procedure volume and/or
resource use.
Primary Funding Source: National Heart, Lung and Blood
Insttiute
●Is Cost-sharing Associated with Seeing Out-of-Network
Physicians among Children with Diabetes?
David Grembowski, Ph.D., William Trejo, BS, Paula Diehr,
PhD, Frederick Connell, M.D., MPH, James Stout, M.D., MPH
Presented By: David Grembowski, Ph.D., Professor, Health
Services, University of Washington, Box 357660, Seattle, WA
98195; Tel: (206) 616-2921; Fax: (206) 543-3964; Email:
grem@u.washington.edu
Research Objective: To determine the association between
out-of-network cost-sharing and the likelihood of seeing an
out-of-network physician among insured children with
diabetes. The single, common element across all types of
managed care organizations, or MCOs, is a provider network.
To control their costs, MCOs often build networks composed
of physicians with lower fees and/or lower-cost practice styles,
and then route enrollees to network physicians through
greater out-of-network cost-sharing. Because children with
chronic conditions have greater needs and see multiple
physicians, it is unclear whether greater out-of-network costsharing reduces the likelihood of seeing an out-of-network
physician, and whether this matters in terms of expenditures
and quality of care.
Study Design: Cross-sectional cohort study.
Population Studied: 225,748 children/adolescents with 2
years of continuous coverage, from July 1999 to June 2001, in
two insurance companies in Washington state. Of these, 476
children met eligibility criteria for diabetes: at least one
diagnosis for diabetes or 2+ insulin prescriptions. Costsharing was measured by out-of-network and in-network costsharing indexes for the child’s health plan. Other data sources
include medical claims, physician network directories, enrollee
eligibility information, American Medical Association
Masterfile, and sociodemographic characteristics of the child’s
Zip code tabulation area.
Principal Findings: 224 children had diabetes both years,
who are prevalence cases, and 217 children had diabetes only
in Year 2, or incidence cases. Average age was 12.6 years.
About 49% were female, and 19% had other chronic
conditions. Children saw an average of 4.17 physicians,
excluding anesthesiologists, radiologists and emergency room
physicians; about 43% had emergency room visits and 26%
were hospitalized. About 18% of children saw an out-ofnetwork physician, and these children saw an average of 1.06
out-of-network physicians. About 59% of the out-of-network
physicians had primary care specialties, 24% had
endocrinology, diabetes, neurology, ophthalmology, or
podiatry specialties, and 13% had other specialties.
Regression analyses revealed that the cost-sharing indexes
were not associated significantly with seeing an out-of-network
physician. Age, gender, incidence vs. prevalence, and chronic
conditions also were not associated with seeing out-ofnetwork physicians. HMOs have greater cost-sharing for outof-network care and smaller provider networks, and we also
found that use of out-of-network physicians was similar for
children in HMOs vs. other managed plans. Allowed
ambulatory expenditures in the 2-year period were higher for
children seeing out-of-network physicians, avg $3832, than
children seeing only in-network physicians, avg $2966; p =
.009.
Conclusions: Cost-sharing is not associated with seeing an
out-of-network physician among children with diabetes in
health plans with provider networks.
Implications for Policy, Delivery, or Practice: For children
with diabetes, cost-sharing does not appear to be a barrier to
seeing out-of-network physicians. Out-of-network utilization
may be relatively high because of low access to quality care
from in-network physicians, and we are examining the quality
of care for children seeing only in-network physicians vs.
children seeing both in-network and out-of-network
physicians.
Primary Funding Source: AHRQ
●Direct Medical Costs of Autism in a Privately Insured
Population – 2002
Scott D. Grosse, Ph.D., Tom T. Shimabukuro, M.D., MPH,
MBA
Presented By: Scott D. Grosse, Ph.D., Health Economist,
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)4983074; Fax: (404)498-3070; Email: SGrosse@cdc.gov
Research Objective: Autism spectrum disorder (ASD) is a
group of childhood-onset neurobehavioral disorders that is
being diagnosed in the U.S. with increasing frequency. We
calculated (1) the magnitude of incremental direct medical
costs of ASD, (2) the ratio of direct medical costs for
individuals with ASD versus those without ASD, and (3) the
structure of the individual components: costs for inpatient,
outpatient, and pharmaceutical services.
Study Design: We used data from the 2002 Medstat
MarketScan® Research Databases. The databases included
claims for a diverse group of enrollees from large self-insured
U.S. companies. We used International Classification of
Diseases, Ninth Revision diagnosis codes 299.0x and 299.8x
to identify individuals with ASD. We calculated incremental
direct medical costs by subtracting the average direct medical
costs for enrollees without ASD from that of those with ASD
(i.e., the difference in average direct medical costs); we
calculated cost ratios by dividing average direct medical costs
for those with ASD by those without ASD; and finally we
calculated the individual component costs for inpatient,
outpatient, and pharmaceutical services as percentages of
total direct medical costs.
Population Studied: Privately insured children and
adolescents 1-19 years old in the 2002 MarketScan® Research
Databases and enrolled in the same health plan for the entire
year.
Principal Findings: Of 773,653 enrollees aged 1-19 years, 1,336
had a diagnosis of ASD. Average direct medical costs for
2002 were as follows: (a) 1-4-year olds: ASD $6,000, no ASD
$1,200, incremental cost of ASD $4,800; (b) 5-9-year olds:
ASD $5,200, no ASD $900, incremental cost of ASD $4,300;
(c) 10-14-year olds: ASD $5,700, no ASD $1,100, incremental
cost of ASD $4,600, (d) 15-19-year olds: ASD $6,700, no ASD
$1,500, incremental cost of ASD $5,200. When comparing
those with ASD to those without ASD, on average 1-4-year
olds with ASD incurred 5.0 times more direct medical costs
than those without ASD, 5-9-year olds incurred 5.8 times
more, 10-14-year olds 5.2 times more, and 15-19-year olds 4.5
times more. For individuals with ASD, outpatient costs as a
percentage of total direct medical costs decreased from 86%
in 1-4-year olds to 35% in 15-19-year olds while pharmaceutical
costs as a percentage of total direct medical costs increased
from 7% in 1-4-year olds to 37% in 15-19-year olds. Individuals
without ASD exhibited a similar but smaller trend for
outpatient costs while drug costs did not change appreciably.
Conclusions: Children and adolescents with ASD incurred
greater direct medical costs than children without ASD, with
the incremental costs ranging from $4,300 to $5,200. On
average, individuals with ASD incurred 4.5 to 5.8 times more
direct medical costs than those without ASD. In addition, for
individuals with ASD, component costs appeared to shift from
outpatient services in younger age groups to pharmaceuticals
in older age groups, suggesting that individuals with ASD
require increasingly intense pharmacotherapy to control
behavioral symptoms as they grow older.
Implications for Policy, Delivery, or Practice: ASD imposes
a substantial economic burden on the health system with
pharmaceutical costs appearing to becoming more prominent
with age.
Primary Funding Source: No Funding Source
●The Impact of Potentially Avoidable Post-Surgical
Complications on Pediatric Patient Outcomes
Samuel Hohmann, Ph.D.
Presented By: Samuel Hohmann, Ph.D., Senior Research
Specialist, Information Architecture, University HealthSystem
Consortium, 2001 Spring Road, Suite 700, Oak Brook, IL
60523; Tel: (630) 954-1740; Fax: (630) 954-4730; Email:
hohmann@uhc.edu
Research Objective: Demonstrate the magnitude of impact
that post-surgical complications have on pediatric patient
outcomes (length of stay, in-hospital mortality, ICU utilization,
cost and use of particular services).
Study Design: Retrospective review of hospital inpatient
discharge billing abstracts (UB-92). Patient outcomes of
cohorts of hospital pediatric inpatients who had no
documented and coded potentially avoidable complications
were compared with outcomes of cohorts having
complications. The University HealthSystem Consortium
(UHC) uses 25 categroies of potentially avoidable
complications, and cases are flagged based on the presence of
the defining ICD-9 codes in the discharge abstract. Only
cases who had a surgical procedure within 48 hours of
admission are including the process of flagging cases for
complications. Complications associated with patients having
their first procedure later in their stays may not be the result of
the procedure and are therefore excluded from the risk pool.
Cases were stratified by UHC-defined product lines, and
further stratification was performed by DRG.
Population Studied: Pediatric patients having an operating
room procedure within 48 hours of admission to an academic
medical center (AMC). The study included discharges
between July 1, 2003, and June 30, 2004. Of 284,682 pediatric
discharges in the UHC database in that period (including
newborns), there were 58,577 in the post procedure risk pool.
The latter were used for comparison of outcomes with and
without complications.
Principal Findings: Overall, there were 6,651 discharges that
had at least one potentially avoidable complication
documented and coded in their discharge billing abstracts.
This amounted to an overall complication rate of 11.4 percent.
Nine UHC-defined product lines accounted for 77.7 percent of
the risk pool cases and 84.9 percent of the cases with
complications. The highest complication rates were among
ventilator support cases (52.2 percent), cardiothoracic surgery
cases (25.3 percent), and trauma cases (24.3 percent). The
most frequently occurring complication categories were postoperative pulmonary compromise, post-procedure
hemorrhage or hematoma, mechanical complications due to
implants, and post-operative pneumonia. (Iatrogenic
potentially complications, a less specific category, were
excluded from the analysis.)
The impact was generally a doubling or more of the outcome
measure - average length of stay (ALOS), in-hospital mortality
(in percent), ICU average length of stay, etc. For example,
among cardiothoracic surgery discharges, ALOS was 6.3 days
without complications vs. 16.5 days with complications; cases
using ICU - 63.6 percent vs. 79.7 percent; ICU ALOS - 4.5 days
vs. 11.7 days; in-hospital mortality - 1.3 percent vs. 6.6 percent.
Although cardiothoracic surgery is a more homogenous group
than all cases combined, the case mix index (CMI) for the two
groups was different - 4.4 without complications vs. 5.0 with
compications. CMI was not a factor at the DRG level. An
example at the DRG level was DRG 105 (cardiac valve
procedures without catheterization). For DRG 105, ALOS
without complications was 6.3 days vs. 13.8 days with
complicaitons; ICU use was higher for cases with
complications (84.7 percent vs. 74.7 percent) and ICU ALOS
was longer (11.1 days vs. 3.4 days); mortality was 2.4 percent
vs. 10.6 percent. Other analysis demonstrated similar impacts
on overall cost and cost of particular services
(accommodations, medical/surgical supplies, laboratory,
blood, pharmacy, etc.).
Conclusions: Complications increase the duration of stays,
having an impact on patients and allocation of institutional
resources. Interventions should focus on efforts to
reduce/prevent post-surgical complicaitons in pediatric
populations. Performance improvement teams should review
cases with documented and coded potentially avoidable
complications and strategize on prevention and management
when complications occur.
Implications for Policy, Delivery, or Practice: Ascertaining
the extent of added cost, resource utilization, degradation of
patient safety and patient satisfaction, etc. should drive budget
decisions on allocating resources to prevent potentially
avoidable post procedure complications. Hospital
administrators should embrace performance improvement
initiatives to address patient safety, patient satisfaction, cost
and resource allocation.
Primary Funding Source: No Funding Source
logistic regression analysis, adjusting for demographics and
months of enrollment in Medicaid prior to the fatal event.
Population Studied: All Medicaid children under age 10 and
victims of homicide as identified through the cause of death
documented in the DC, were included in the analysis (n=138).
Principal Findings: The yearly average of violence induced
fatalities (VIF) during the study period was 27.6 deaths. The
majority of decedents had no prior contact for injury-related
services (70%) and 86% were between ages 0 and 4 years old.
Fatal child abuse, fatal assault, and death by firearms were
listed as the cause of death on the death certificate
respectively for 64 (46%), 51 (37%), and 23 (17%) of the
victims. Children age 0-4 were more likely than their older
counterparts not to have had previous contact with the health
care system for injury-related services after controlling for
demographics and length of enrollment in Medicaid prior to
the fatal event (adjusted odds ratio (AOR): 4.11; 95%
Confidence Interval (CI) = 1.03-16.5). Those residing in
Metropolitan, Appalachian, and Suburban counties were 14.8
(95% CI = 3.2-69.1) times more likely not to have received
injury-related services when compared to those living in rural
counties.
Conclusions: We estimated that a rather small proportion
(30%) of children may have been in contact with the health
care system prior to the fatal event for injury-related services –
a statistic that translates into a limited window of opportunity
for health care providers to prevent such events from
happening.
Implications for Policy, Delivery, or Practice: The analysis of
patterns of use of injury-related services in the period
preceding the fatal event may be used to develop a riskassessment tool for health practitioners to identify children at
risk for becoming victims of homicide, and hopefully prevent
VIFs. Although our study indicated that a rather small
proportion of children have any contact with the health care
system for injury-related services, this finding should by no
means impede further research efforts in this direction, as all
such deaths are preventable.
Primary Funding Source: Ohio Department of Public Safety
●Children Victims of Homicide are Unlikely to Use InjuryRelated Health Services Prior to the Fatal Event
Angelique Stubblefield, BSN, MPH, Siran Koroukian, Ph.D.
●Georgia's Foster Care Children and Medicaid
Glenn Landers, MBA, MHA, Mei Zhou, MS, MA
Presented By: Siran Koroukian, Ph.D, Professor,
Epidemiology and Biostatistics, Case Western Reserve
University, School of Medicine, 10900 Euclid Avenue,
Cleveland, OH 44106-4945; Tel: (216)368-3197; Fax: (216)3683970; Email: skoroukian@case.edu
Research Objective: Numerous studies have reported
increased incidence of violence-induced fatalities (VIF) among
socio-economically disadvantaged subgroups of the
population, especially among children. However, the extent to
which victims of violence could be identified through their
pattern of utilization of health services is unknown. This study
aims at describing patterns of use of injury-related services by
Ohio Medicaid children victims of homicide, in the period
preceding the fatal event.
Study Design: This was a retrospective study using linked
Ohio Medicaid and death certificate (DC) files, 1992-1996.
Bivariate associations were tested using chi-square tests to
assess statistical significance in the difference between
proportions. Odds ratios were obtained using multivariable
Presented By: Glenn Landers, MBA, MHA, Senior Research
Associate, Georgia Health Policy Center, 14 Marietta Street,
Atlanta, GA 30303; Tel: (404)463-9562; Fax: (404)651-3147;
Email: glanders@gsu.edu
Research Objective: Compare the conditions, Medicaid
utilization, and costs of Georgia's foster child children with
those of other Medicaid children.
Study Design: Retrospective cohort analysis; logistic
regression of Georgia Medicaid claims data.
Population Studied: All Georgia foster children and other
Medicaid children with three years continuous enrollment for
the years 2000, 2001, and 2002.
Principal Findings: 1. Georgia foster children and other
Medicaid children have higher rates of mental health
conditions than reported nationally - 60 and 35 percent
respectively. 2. Fewer Georgia foster children experience
inpatient admissions, ER visits, and prescription drug claims,
and more experience dental visits, EPSDT screenings, and
outpatient visits than other Medicaid children - all contrary to
national reporting. 3. Of those children who utilize services,
Georgia foster children experience more outpatient visits,
EPSDT screenings, dental visits, and prescription drug
utilization than other Mediciad children. 4. About equal
numbers of Georgia foster children and other Medicaid
children visited physicians, but more foster children visited
specialists. 5. More foster children showed evidence of lapses
in prescription drug use for mental health conditions over
three years, and some children in each group showed
evidence of mental health prescription drug use without an
associated mental health diagnosis.
Conclusions: The results for Georgia foster children
described in this analysis, in comparison to the general
Medicaid child population, are encouraging in many areas,
particularly in preventive care.
Implications for Policy, Delivery, or Practice: Policy makers
may be concerned with the high proportions of mental health
diagnoses, lapses in prescription drug claims for mental
health conditions, and the presence of mental health drug
claims in the Medicaid data without an associated mental
health diagnosis. While the proportion of mental health
conditions in the foster child population is not surprising, it
indicates that any reduction in mental health services to foster
children might place foster children at even greater risk than
they are currently. Understanding why the foster child
population uses preventive services more frequently may
benefit the overall population of Medicaid children.
Primary Funding Source: Georgia Health Foundation
●Social Inequalities in Perinatal Mortality in Belo
Horizonte, Brazil: The Role of Hospital Care
Sonia Lansky, M.D., MPH, Ichiro Kawachi, M.D., Ph.D.,
Elisabeth Franca, M.D., Ph.D.
Presented By: Sonia Lansky, M.D., MPH, Research Fellow,
Society,Human Development and Health, Harvard School of
Public Health, 26 Harding Avenue, Belmont, MA 02478; Tel:
(617)4893801; Email: slansky@hsph.harvard.edu
Research Objective: Few studies have examined socioeconomic inequalities in perinatal mortality in Brazil, a country
with high infant mortality rates (33 per 1,000 live births). The
majority of births (97%) and perinatal deaths take place in
hospitals, most of the deaths occurring within the first hours
after birth. Yet, quality hospital care has not been assessed. As
there are marked socio-economic differences in the types of
facilities used by mothers, this study’s main goal is to analyze
perinatal outcomes between hospital categories in relation to
the Public Unified Health System (SUS), which assists almost
80% of the population in the country.
Study Design: We examined all live births and perinatal
deaths that occurred in Belo Horizonte City in 1999. Mortality
surveillance was carried out in 36 hospitals. Data were
collected by hospital chart review and linkage of individual
records to the National Live Birth Information System and the
National Death Information System, yielding 775 perinatal
deaths. Information gathered included maternal education,
birth weight, cause of death (Wigglesworth classification), and
type of hospital (public, philanthropic, private hospitals
contracting their services to SUS versus private non-SUS
hospitals). Birth-weight specific mortality rates were compared
among hospital categories adjusted for maternal education.
Antepartum deaths (before the onset of labor) were excluded,
as hospital care could not change birth outcomes in these
cases.
Population Studied: All 826 perinatal deaths (fetal and early
neonatal death) and 40,531 live births of Belo Horizonte
residents were assessed. Fetal deaths were stillbirth with birth
weight of 500 g or more and/or gestational of 22 weeks or
more. Early neonatal deaths were all infant deaths up to 7 days
of life, birth weight of 500 g or more and/or gestational age of
22 weeks or more.
Principal Findings: Although public hospitals had the highest
proportion of low birth-weight babies (20.8%), this group of
hospitals showed the lowest birth-specific mortality rates
among SUS-hospitals. On the other hand, private-SUS
hospitals had the highest mortality rate for each birth weight
category, despite having the lowest proportion of low birthweight babies (5.9%). Perinatal mortality rates for babies with
normal birth weight were high (2.8 to 5.2/1000) for hospitals
contracted to SUS, contrasting to the rate for private hospitals
(1.2/1000). After controlling for maternal education and birth
weight, private-SUS hospitals showed the highest mortality
rates in every situation. Intrapartum asphyxia predominated as
the cause of death in private-SUS hospitals.
Conclusions: Outcomes for SUS hospitals were worse
compared to private non-SUS hospitals, reflecting their
inadequate capacity to intervene during labor/child birth (and
child care after birth) for low birth-weight and premature
babies as well as adequate birth-weight children. Our findings
illustrate the inverse equity hypothesis: child health inequities
increase with the greater access to medical technology by
those of higher socio-economic status.
Implications for Policy, Delivery, or Practice: In Brazil more
than 50% of the hospitals that constitute the Unified Public
Health System are privately contracted to SUS, and account
for the majority of births occurring to mothers with low socioeconomic status. Complications of delivery and childbirth are
expected – but not predictable – in nearly 15% of all
childbirths, even for low risk pregnancies. This means that
every setting should be prepared to respond adequately in
situations such as perinatal intra-partum asphyxia, which can
be controlled by appropriate and timely health care. This study
demonstrates the urgent necessity to improve hospital health
care that could reduce a significant number of deaths
considered preventable - especially in the private-SUS
hospitals that showed the worst perinatal outcomes.
Primary Funding Source: PAHO/WHO
●Preventable Perinatal Deaths in Belo Horizonte, Brazil,
1999: a Hospital Care Evaluation
Sonia Lansky, M.D., MPH, Maria do Carmo Leal, Ph.D., Cibele
Comini Cesar, Ph.D., Luiz Costa Monteiro Neto, BcH,
Elisabeth Franca, Ph.D.
Presented By: Sonia Lansky, M.D., MPH, Research Fellow,
Society,Human Development and Health, Harvard School of
Public Health, 26 Harding Avenue, Belmont, MA 02478; Tel:
(617)4893801; Email: slansky@hsph.harvard.edu
Research Objective: Evaluation of perinatal health care,
particularly delivery and birth assistance, is necessary to
reduce perinatal morbidity and mortality rates in Brazil. Most
births take place at hospitals (97%) and with doctors’
assistance (77%), a context that should provide a safe
environment for women and children. Nonetheless, perinatal
mortality rates and maternal mortality are still high in the
country. Although the majority of deaths take place within
hospitals, few studies have been conducted to examine the
role of hospital health care in reducing perinatal mortality. The
main purpose of this study is to analyze the possible
association between perinatal mortality and factors related to
hospital care during birth, since most of these deaths can be
prevented by prompt access to quality health care.
Study Design: A population-based case-control was
conducted, considering all births (40,351) and all perinatal
deaths (826) in 1999 in Belo Horizonte, the third largest city in
Brazil with a population of 2 million. Multiple regression
analysis was conducted to examine association between
selected medical procedures during birth as well as the level of
hospital, adjusted by maternal and newborn potential
confounders.
Population Studied: 118 perinatal deaths (cases) and 492
births (controls) of residents in the city took part in the study.
Cases and controls were recruited in hospitals participating in
the Unified Health System (SUS) that provides health care for
around 70-80% of the population in the country. Data were
collected by hospital chart review and linkage of individual
records to the National Live Birth Information System and the
National Death Information System.
Principal Findings: Bivariate analysis showed that male sex,
prematurity, pathologies during pregnancy, low birth weight,
newborn pathologies, lack of prenatal care, no use of the
partograph during labor, and less than one fetus assessment
per hour during labor were associated (p< 0,05) with
perinatal death. Multiple regression analysis demonstrated
that no use of the partograph during labor (adjusted OR 2,79)
and low quality level hospitals (adjusted OR 4,96) are
independent health care factors associated with perinatal
death.
Conclusions: Besides the need to build a strong,
comprehensive and regionalized perinatal health system, this
study indicates that improvement in hospital quality care at
childbirth is essential to provide safe care and reduce perinatal
mortality due to preventable causes.
Implications for Policy, Delivery, or Practice: Improving
hospital quality care is essential to reduce the high rates of
perinatal preventable deaths in Brazil, as most of them occur
at the hospital level. More than 50% of the births in the city, as
well as in the country, take place in type 1 hospitals (low
quality level),which were associated to perinatal death after
controlling for confounders. In addition to birth technology,
like neonatal intensive care, basic practices must be improved
- such as the use of the partograph and adequate maternal
and fetal assessment during labor - to change child and
maternal adverse indicators in the country.
Primary Funding Source: PAHO/WHO
●The Impact of Family Income Gradients on the Health
and Health Care of Young Children
Kandyce Larson, M.S.W., Neal Halfon, M.D., MPH
Presented By: Kandyce Larson, MS., Research Associate,
School of Public Health, UCLA Center for Healthier Children,
Families, and Communities, 1100 Glendon Avenue, Suite 850,
Los Angeles, CA 90024; Tel: (310)794-0981; Fax: (310)7942728; Email: kandyce@ucla.edu
Research Objective: Health is not equally distributed across
the income distribution. Despite the significance of the early
childhood period in providing the foundation of human health
and development, research on social class gradients in
childhood is limited compared with that in adulthood. The
objective of this study is to examine income gradients in early
childhood health and health care in a nationally representative
sample.
Study Design: The 2000 National Survey of Early Childhood
Health is a telephone survey of a national sample of parents
with young children. Differences in selected health and health
care measures are examined across four categories of
household income: less than 17,501, 17,501-35,000, 35,00160,000, more than 60,000 dollars. Bivariate associations are
examined using linear polynomial testing. Gradient measures
that show significant linear associations with income are
examined using multivariate logistic regression.
Population Studied: Parents of 2,608 U.S. children aged 4 to
35 months.
Principal Findings: The percentage of respondents reporting
better health increases across income categories for six
indicators of child health. Low birth weight and acute health
conditions show no graded relationship with income.
Controlling for maternal race/ethnicity, maternal age, child
age, and child gender in multivariate logistic regression
analyses, a one unit change to a higher income level increases
the odds of parent reported excellent child health by 31 percent
OR: 1.31, CI: 1.12-1.52; decreases the odds of asthma OR: 0.61,
CI: 0.48-0.79, parent concern about child emotional/behavior
problems OR: 0.78, CI: 0.67-0.91, parent concern about the
child’s preschool skills OR: 0.83, CI: 0.69-0.99, and low
maternal mental health OR: 0.75, CI: 0.63-0.88; and has no
effect on parent concerns about child speech development.
Controlling for insurance status and child and family
demographics in multivariate analyses, household income
predicts global satisfaction with health care, satisfaction with
the health care provider, and the type of usual location for well
child care.
Conclusions: The results of this study confirm the existence
of substantial income gradients in the developmental health of
children in the first few years of life. Income gradients are
particularly steep for developmental, behavioral, and mental
health concerns.
Implications for Policy, Delivery, or Practice: Analyzing
health and health services outcomes in relation to income
gradients leads to different conclusions and policy
implications than traditional analyses that dichotomize
income impacts as poor vs. non poor.
Primary Funding Source: CWF
●Looking Behind HEDIS: The Timing of Childhood
Immunization Matters
Ann Lawthers, Sc.D., SM, Jianying Zhang, MPH, MS, M.D.,
Katharine Willrich-Nordahl, MS, Louise Bannister, BSN, JD,
Jay Himmelstein, M.D., MPH, Lawrence Kleinman, M.D.
Presented By: Ann Lawthers, Sc.D., SM, Assistant Professor,
Center for Health Policy and Research, University of
Massachusetts Medical School, 222 Maple Avenue,
Shrewsbury, MA 01545; Tel: (508)856-1531; Email:
ann.lawthers@umassmed.edu
Research Objective: This project presents a detailed study of
immunization rates offering a “look behind” the Health Plan
Employer Data and Information Set (HEDIS) performance in
four Medicaid managed care plans in Massachusetts. We
assess how well HEDIS measures reflect a child’s
immunization status and identify factors affecting
completeness rates so that payers and plans may identify
potentially fruitful opportunities when allocating scarce quality
improvement resources.
Study Design: Retrospective chart review and administrative
data analyses conducted in 1999 and 2002. The dates of all
visits, immunizations, immunization contraindications and
diagnoses at each visit were captured. Immunization
completeness at age two was assessed using the CDC’s
4:3:1:3:3 combination, HEDIS 2002 combination two, and the
Massachusetts Department of Public Health (MDPH) 2001
standard.
Population Studied: Randomly selected HEDIS eligible two
year-olds (n=1,618) enrolled in four capitated Medicaid
managed care plans in Massachusetts.
Principal Findings: By 2001, overall completeness at age two
had both increased and decreased, depending on the
completeness standard and method of counting
immunizations. Counting immunizations delivered, changes
from 1998 to 2001 were mixed, e.g. HEDIS rates increased
from 57% to 74% while the CDC rates dropped from 87% to
79%. Completeness by counting only appropriately timed
immunizations yielded completeness rates 13 percentage
points lower for all three standards. Logistic regression
modeling showed that children with fewer late immunizations,
missed opportunity visits, and invalid shots were more likely
to be complete by age two as were children at one plan with a
major quality improvement initiative on childhood
immunization.
Conclusions: Childhood immunization status is dynamic and
the use of snapshot measurement tools, such as HEDIS, may
be less useful for quality improvement purposes than
methods that describe the dynamic nature of immunization.
The HEDIS Childhood Immunization measure may be best
construed as a population health status measure that
assesses the level of protection against disease in the
community.
Implications for Policy, Delivery, or Practice: HEDIS has
become the national standard for measuring the adequacy of
immunization in managed care. Using this standard,
Medicaid managed care immunization rates appear to lag
behind those in commercial plans. “Looking behind” HEDIS
provides a valuable approach to targeting quality activities.
We demonstrate both the feasibility and value of transforming
a regulatory mechanism, in this case the annual clinically
focused study, into a constructive and actionable quality
improvement tool which produces demonstrable impacts on
child health status.
Primary Funding Source: Other Government Funding
●Factors Associated with Family-Centered Care for
Children with Special Health Care Needs (CSHCN)
Gregory Liptak, M.D., MPH, Jacalyn Yingling, MS, Monica
Serdinow, AuD, Mark Orlando, Ph.D., Karen Nolan, PT, MS,
PCS, Amy Luvera, MSPT, Emily Kuschner, MA
Presented By: Gregory Liptak, M.D., MPH, Professor of
Pediatrics, University of Rochester Medical Center, 601
Elmwood Avenue, Rochester, NY 14642; Tel: (585)275-5962;
Fax: (585)275-3366; Email: 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 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: DHHS: Maternal and Child Health
Bureau; Leadership Education for Neurodevelopmental and
Related Disabilities
●Short-Term Rehospitalization Following Discharge from
the NICU: The Influence of Age at Discharge
Scott Lorch, M.D., Scott A. Lorch, M.D., MSCE, Marla N.
Gardner, MA, John D. Greene, MA, Yanli Wang, MS, Jeffrey H.
Silber, M.D., Ph.D.
Presented By: Scott Lorch, M.D., Systems Research Institute
and Perinatal Research Unit, Kaiser Permanente Division of
Research, 2000 Broadway, 2nd floor, Oakland, CA 94612; Tel:
(510) 891-3502; Fax: (510) 891-3508; Email:
Gabriel.Escobar@kp.org
Research Objective: In the period immediately following
discharge home from the NICU, premature infants are two to
three times as likely to be rehospitalized as infants born at
term gestation. However, rehospitalization rates have been
calculated based on the date of discharge without accounting
for post menstrual age (PMA) at discharge.
Study Design: As part of the Infant Functional Status (IFS)
Study, we grouped the population according to PMA at
discharge (<35 vs. >35 weeks). For each group we developed 2
separate logit models to predict readmission, one for
readmission within 2 weeks of discharge and one for
readmission within 3 months. Each model included
gestational age (GA), SNAP-II, race, sex, SGA, maternal age,
NICU site, and presence of follow-up visit within 72 hours. We
also constructed a dummy variable interaction model to test
whether the coefficients on these variables differed across
PMA group.
Population Studied: All infants (N=894) born less than 32
weeks gestational age (GA) at a Northern California Kaiser
Permanente hospital between 1998 and 2001 were eligible. To
supplement the cohort, 543 infants of 33-34 weeks GA were
added. Infants were excluded for congenital anomalies, home
ventilation, need for a VP shunt, or loss to follow-up.
Principal Findings: Of the 1437 infants, 646 were discharged
at a PMA < 35 weeks, and 791 were discharged after 35 weeks.
Patients discharged after 35 weeks were more premature, had
lower birthweight, had greater severity as measured by SNAPII and were more likely to be SGA. The < 35 week group had a
2-week readmission rate of 1.85% vs. 4.24% in the >35 group
(p = 0.006), and similarly, 3-month readmission rates were
8.66% vs.14.79% (P < 0.001). The c-statistic for predicting 2week readmission was 0.868 in the < 35 week group versus
0.777 in the >35 week group, and for 3-month readmission
models, the c-statistics were 0.733 vs. 0.683 respectively.
Using the interaction model, there were no differences in the
coefficients on risk factors between the two groups.
Conclusions: There are higher rates of readmission in infants
discharged greater than 35 weeks PMA vs. those discharged
before because only the healthiest children who are eligible for
discharge fall into the < 35 week group. The lower
discrimination observed in the >35 week group suggests that
unobserved variation in physiologic status plays a larger role
in these infants.
Implications for Policy, Delivery, or Practice:
Understanding the increased risk of rehospitalization in
premature infants requires physicians and policy makers to
consider factors beyond PMA and other time based variables
commonly collected in claims data. Utilizing physiologic state
at or around the time of discharge, as well as demographic
and health services variables, may improve our ability to
predict these undesired events.
Primary Funding Source: HRSA, MCHB R40-MC00238
●Analyzing Pre-Discharge Costs to Predict Subsequent
Resource Use in Premature Infants
Scott A. Lorch, M.D., MSCE, Gabriel J. Escobar, M.D., Orit
Even-Shoshan, MS, Justin I. Mathew, BA, Jeffrey H. Silber,
M.D., Ph.D.
Presented By: Scott A. Lorch, M.D., MSCE, Assistant
Professor of Pediatrics, Division of Neonatology, The
Children's Hospital of Philadelphia, 3535 Market Street, Suite
1029, Philadelphia, PA 19104; Tel: (215) 590-1714; Fax: (215)
590-2378; Email: lorch@email.chop.edu
Research Objective: The timing of discharge of a premature
infant may influence subsequent use of medical resources.
Because the average daily cost of care in the last 2 weeks
before discharge (L2W-ADC) declines as neonates remain
hospitalized, this variable may help to identify sicker infants
who are discharged too early from the neonatal intensive care
unit (NICU). The objective of this project was (1) to
determine the relationship between the L2W-ADC, hospital
readmissions and medical costs 1 year after discharge from
the NICU in a managed care system and (2) to explore
alternative methods for analyzing cost data in this population.
Study Design: As part of the Infant Functional Study, all
infants born less than 32 weeks gestational age (GA) at a
Northern California Kaiser Permanente hospital between 1998
and 2001 were eligible. To supplement the cohort, 543 infants
of 33-34 weeks GA were added. Exclusions included
congenital anomalies, home ventilation, need for a VP shunt,
or loss to follow-up. A readmission was defined as any
hospitalization within one year of discharge. Costs were
calculated from resources used by the child in 2001 dollars.
Logistic regression models determined the association
between readmission and L2W-ADC after controlling for GA
and common neonatal complications. Three models (OLS,
logarithmic-transformed linear regression, and log-linear
variance regression) were constructed to determine the effect
of L2W-ADC on 1 year medical costs after controlling for
medical complications.
Population Studied: 1437 infants delivered at one of six
Northern California Kaiser Permanente hospitals between
1998 and 2001. 265 (18.4%) were born less than 28 weeks GA
and 629 (43.8%) were born between 29 and 32 weeks GA.
Principal Findings: The median L2W-ADC was $294.66
(intraquartile range $269.48-$321.95). L2W-ADC was increased
with bronchopulmonary dysplasia ($33±5), necrotizing
enterocolitis ($38±14), and history of ductus arteriosis ($11±4).
After controlling for GA, race, sex, and common neonatal
conditions, L2W-ADC was not significantly associated with a
hospital readmission; a $50 increase in L2W-ADC was
associated with only an odds ratio of 1.12 for readmission
(95% CI 0.975-1.287). Of the 3 cost regression models, the
log-linear variance regression had the lowest and most
consistent residual plots across expected cost, followed by the
log-transformed model. The log-linear variance model found
that a $50 increase in L2W-ADC was associated with a $46 ±
13 increase in post-discharge costs (P=0.0005). The same
increase in L2W-ADC was associated with a 6.6% increase in
post-discharge costs (95% CI 1.4%-12.1%). The L2W-ADC
decreased with later discharge from the NICU after controlling
for medical complications and GA.
Conclusions: Increases in the L2W-ADC were associated with
increased costs after discharge from the NICU using all three
models. However, the log-linear variance model displayed the
best residual analysis. L2W-ADC decreased with later
discharge from the NICU.
Implications for Policy, Delivery, or Practice: As daily costs
of a NICU stay fall for each added day a patient remains
hospitalized, our results suggest that early discharge of
premature infants may lead to increased medical use in the
year after discharge. However, the causal pathway for these
increased costs remains to be determined.
Primary Funding Source: HRSA, MCHB R40-MC00238
●Building Block to Literacy: Efficacy of a Phonetic,
Multisensory Therapy Model
Maureen K. Martin, Ph.D.
Presented By: Maureen K. Martin, Ph.D., Director, DuBard
School for Language Disorders, The University of Southern
Mississippi, 118 College Drive #10035, Hattiesburg, MS
39406-0001; Tel: (601) 266-5223; Fax: (601) 266-6763; Email:
maureen.martin@usm.edu
Research Objective: To determine the efficacy of a
specialized phonetic, multisensory therapy approach for
children with dyslexia. Currently understood as a language
disorder (Catts, 1989; Shaywitz, 2003), dyslexia varies in
degree of severity, is often familial, and persists into
adulthood. Studies have shown that skill in the phonological
system, the sounds of the language, at a preschool age is a
strong predictor of later success in developing reading skills
(Shaywitz, 2003). Conversely, lack of such skill results in poor
ability to decode, the first component required in reading
development. As a result, the second component of reading,
comprehension, may be greatly diminished or nonexistent.
Study Design: Subjects’ skills were measured on the
Decoding Skills Test (Richardson & DiBenedetto, 1985), and a
criterion referenced checklist of single phonemes, prior to the
implementation of a phonetic, multisensory therapy program.
The program was delivered by speech-language pathologists
in a resource schedule of service delivery averaging two onehour sessions per week. Pretest and post-test scores were
compared to evaluate efficacy.
Population Studied: The population consisted of 15 children
diagnosed with dyslexia, some of whom had a concomitant
diagnosis of Attention Deficit Hyperactivity Disorder (ADHD).
Principal Findings: Dyslexia is characterized by a deficit in
utilizing the phonological system—the system of sounds
which are combined to form words for speech and which are
also a critical component in developing reading skills. A
phonetic, multisensory therapy approach was delivered on a
resource therapy schedule in a university-based program and
resulted in significant gains in phonological skills.
Conclusions: Pre-test and post-test scores on a standardized
measure of decoding skills, the Decoding Skills Test
(Richardson & DiBenedetto, 1985), indicated that students
challenged with dyslexia made significant improvements
through phonetic, multisensory therapy. Paired sample t-tests
on three subtests resulted in -4.022, df of 11, and significance
at .002, -5.760, df of 14, and significance at .001, and -4.232,
df of 9, and .002. In addition, on a criterion referenced
measure of oral recall of single phonemes, pre- and post-tests
showed statistically significant results on a paired t-test: -2.373,
df of 14, and significance at .033. The results indicate that
dyslexic students are able to effectively and efficiently acquire
critical decoding skills when a phonetic, multisensory
structured approach is implemented through a resource
model of service delivery.
Implications for Policy, Delivery, or Practice: These results
illustrate the efficacy of a phonetic, multisensory therapy
approach for significantly improving phonological skills
necessary for reading success. It may be considered that such
an approach delivered to all students, including those
considered at-risk, as well as those diagnosed with the
language disorder of dyslexia, could potentially reduce the
nation’s 20% rate of reading failure. Effective intervention
may be expected to reduce the incidence of learning
disabilities and potentially the self-esteem and social skill
problems which are prevalent in those challenged with this
disability. In addition, the incidence of learning disabilities
among prison inmates has been estimated at between 30-50%
(Corley, 1996). Enhancement of literacy skills may be
expected to result in greater academic success, fewer social
and self-esteem issues, and potential reduction in criminal
activity.
Primary Funding Source: Other Foundation Funding
●Efficacy of an Intensive, Multisensory Therapy Model for
Children Challenged With Developmental Apraxia of
Speech
Maureen K. Martin, Ph.D.
Presented By: Maureen K. Martin, Ph.D., Director, DuBard
School for Language Disorders, The University of Southern
Mississippi, 118 College Drive #10035, Hattiesburg, MS
39406-0001; Tel: (601) 266-5223; Fax: (601) 266-6763; Email:
maureen.martin@usm.edu
Research Objective: To determine the efficacy of an intensive,
non-traditional model of speech-language therapy for children
challenged with developmental apraxia of speech (DAS). This
motor speech disorder (Vogel & Cannito, 2001; Yorkston et al,
1999) may be characterized by a wide range of neurological
soft signs; however, a specific neuroanatomical site of lesion
has not been identified for DAS. The condition results in a
severe articulation disorder which does not respond well to
traditional speech-language therapy and often results in the
need for assistive communication devices and/or sign
language.
Study Design: Articulation skills were measured on the
Arizona Articulation Proficiency Scale (Fudala & Reynolds,
1989, 1994; Fudala, 2001) prior to the implementation of
intensive speech-language therapy in a university-based
clinical program. A phonetic, multisensory program was
delivered by speech-language pathologists in a full-day nontraditional model of therapy. Pretest and post-test scores
were compared to evaluate efficacy.
Population Studied: The population consisted of 14 children
with the severe motor speech disorder known as
developmental apraxia of speech (DAS). In addition, some
students' concomitant diagnoses included language
disorders, cognitive deficits, autism, and attention deficit
hyperactivity disorder.
Principal Findings: Children with developmental apraxia of
speech (DAS) are a subgroup of those affected with
articulation disorders. Often, these students are limited to
assistive communication devices and sign language as modes
of communication due to a poor response to traditional
therapy approaches. Through an intensive, non-traditional
therapy approach used in a university-based program,
students achieved not only speech intelligibility but additional
critical academic skills as well.
Conclusions: Pre-test and post-test scores on measures of
articulation intelligibility indicated that students challenged
with DAS made significant improvements in speech skills
when an intensive, non-traditional model and approach to
therapy was utilized. A paired sample t-test resulted in
-8.910, df of 13, and significance at .001 on standardized
measures of articulation intelligibility. The results indicate
that severely apraxic children can acquire highly intelligible
speech skills through a relatively short period of speechlanguage therapy when a phonetic, multisensory structured
approach is implemented on an intensive basis as part of a
total educational program. In addition, students acquired
reading, spelling, cursive handwriting, and acoustic skills in
addition to their improvements in articulation. Through
traditional therapy approaches, DAS students may require
years of therapy and suffer the challenges of inadequate oral
communication skills with the related effects of diminished
interpersonal and social skills, as well as critical academic
skills such as reading.
Implications for Policy, Delivery, or Practice: These results
illustrate the efficacy of a non-traditional model for service
delivery which resulted in significantly improved speech skills,
avoidance of the need for alternative communication
strategies such as assistive devices or sign language, and
provided the added benefit of enhancing reading, writing, and
other academic skills.
●Malaria Prevention and Control Among Primary School
Children in Kenya
Thadeus Odenyo, BSc,MPH, Orago Alloys, BSc, MSc, Ph.D.,
Michael Otieno, BSc, MSc, Ph.D., Syprine Otieno, BSc, MSc,
Ph.D.
Presented By: Thadeus Odenyo, BSC, MPH, Student, Health
Sciences, Kenyatta University, PO box 43844, Nairobi, 168; Tel:
(254)-722885904; Fax: (254)-2-810901; Email:
thadeusoba@yahoo.com
Research Objective: a) To establish the knowledge levels of
school pupils in Busia District on malaria. b) To investigate
the effect of knowledge level on the perceptions and beliefs of
school children towards prevention and control of malaria. c )
To investigate the practices of school pupils towards malaria
prevention and control.
Study Design: Descriptive Crosssectional Study
Population Studied: Primary School Children
Principal Findings: Results show that in spite of good
knowledge among school children, there was a
disproportionate balance between knowledge and practice The
mean knowledge score was 60.99± 0.6 (95 % CI). Respondent
who had good knowledge on the etiology of malaria were
94.14 % (n = 649). While pupils sought treatment from health
facilities when having clinical malaria, compliance with
prescribed dosage was low. At the same time there was
disparity between net ownership (93.83 %, n = 649) and net
use (54.69 %, n = 649). Net ownership and use appeared to
be positively related. In fact, respondents who had nets were
36 times more likely to use them (c2= 330.8, p < 0.001). In
this study it appeared that knowledge on malaria was to a
great extent academic. It is hence surmised that this
contributed to poor malaria communication at the family level.
It was also evident that malaria related instructions failed to
alight due to instructor incompetence, in the light of which we
recommend instructor capacity building on malaria. Visiting a
health facility did not significantly influence the perception
that mosquito nets can prevent malaria (c2= 2.7, p > 0.05), at
the same time perception that treated nets are better than
untreated nets appeared to be independent of visiting a health
facility (c2= 0.6, p > 0.05). Respondents who visited a health
facility were not likely to undertake environmental sanitation
as a way of controlling malaria (c2= 1.04, p > 0.05) and were
less likely to perceive insecticides as a control tool for malaria
(c2= 0.9, p > 0.05). Class of respondent (c2= 7.3, p <0.01)
and knowledge on malaria etiology were related to perceptions
on visiting a health facility (c2= 11.95, p < 0.001).
Nevertheless, having been taught about malaria (c2= 0.04, p
> 0.05), number of bouts experienced by a respondent (c2=
0.34, p > 0.05), and perceived distance from a health facility
(c2= 1.63, p > 0.05) failed to have any significant relationship
Conclusions: We conclude that knowledge, beliefs and
perceptions as well as practices form a labyrinth
interdependent body. Ingeniously coordinated approaches are
needed to overcome the negative impacts of this
interdependence.
Implications for Policy, Delivery, or Practice:
Recommendations
Operational recommendations
Information, Education and Communication: There is need to
tailor a malaria package for use in malaria endemic zones of
the country. The package may be transmitted through the
school radio program since pupils seem to regard information
coming over the radio positively. Policy Formulation:
Education programs aimed at increasing awareness among
the pupils on malaria transmission might promote the use of
personal protection against mosquitoes. Evaluation and
Monitoring: The role of the government in coordination,
monitoring and evaluation of malaria prevention and control
activities in the context of stakeholder involvement should be
strengthened. It is recommended that capacity building
should be undertaken among government officials charged
with the management of malaria matters. Such training
should be undertaken regularly to ensure that extant capacities
can cope with emerging malaria challenges. Coordination of
Intersectoral collaboration: Paramount of all, the ministry of
health should be at the frontier of malaria prevention and
control. By mobilising the community through the school as a
fundamental unit of the framework, children will appreciate
the impacts of malaria on them and consequently conceive
the advances that target malaria.
Suggestions for future work: i) There is need to carry out
research to determine the socio-cultural determinants causing
the disparity between ownership and net use among pupils in
the District. ii) There is need to investigate the deteminants
culminating with non-compliance to prescribed dosage on
malaria among pupils in Busia district. iii) There is need to
follow-up knowledge evaluation on malaria with practices
instituted by respondents to prevent malaria. iv) It is
imperative to investigate the relationship between
respondents buying nets and their use as compared to
recepients of nets as donations. General recommendation:
Parents, teachers and children must be sensitized on malaria
prevention and control and children charged with the
obligation to undertake practices that will protect them and
the wider community from malaria.
Primary Funding Source: Doris Morgan Trust
●Assessment, Optimization and Use of Mortality
Prediction Tools for Admissions to Pediatric Intensive
Care in the United Kingdom
Gareth Parry, BSc, MSc, Ph.D., Sam Jones, BSc, David
Harrison, Ph.D., Stephanie Black, MSc, Gale Pearson, M.D.,
Kathy Rowan, Ph.D.
Presented By: Gareth Parry, BSc MSc Ph.D., Reader in Health
Services Research, Health Services Research, University of
Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA;
Tel: 44 114 2220798; Fax: 44 114 2724095; Email:
g.parry@sheffield.ac.uk
Research Objective: To assess the published tools currently
proposed for use in comparing the risk-adjusted mortality of
children following admission for pediatric intensive care.
Study Design: The US developed Pediatric Risk of Mortality
(PRISM, PRISM III-12 and PRISM III-24) systems which use
information up to 24 hours post admission were compared
with the primarily Australian Pediatric Index of Mortality (PIM
and PIM2) systems which use information up to 1 hour post
admission. Predicted probability of PICU mortality was
calculated using the published algorithms for PIM, PIM2 and
PRISM and compared to observed mortality. These scores
along with PRISM III-12 and PRISM III-24 (whose algorithms
are not published) were optimized for a UK setting. Statistical
process control charts in the form of funnel plots of the
resulting risk-adjusted mortality were constructed to assess
the impact of comparing performance using each of the tools.
Population Studied: Data were collected from 23 of 27 (85%)
pediatric intensive care units identified in the United Kingdom
on 10197 (98%) of 10,385 admissions between 1st March 2001
and 28th February 2002.
Principal Findings: Overall, 45% of eligible admissions had
complete data for PIM and only 9% for PRISM. Following the
published rules for missing values in each scoring system, all
cases were eligible for inclusion in the analysis. PIM2 had the
best calibration and discrimination using published
coefficients but still showed evidence of significant miscalibration (c-index=0.84, 0.81, 0.82 and Hosmer-Lemeshow
Chi square = 39.8, 86.7, 549.1 all P<0.001 for PIM2, PIM and
PRISM respectively). Following estimation of UK specific
coefficients, PRISM III-24 had the best discrimination (cindex=0.88) and marginally superior calibration (HosmerLemeshow Chi square = 13.2) compared to PIM2 (cindex=0.84, Hosmer-Lemeshow Chi square = 14.5).
The funnel plots for all the re-calibrated models indicated that
the risk-adjusted mortality for all units was consistent with
random variation.
Conclusions: In the UK both the PRISM III and PIM2 systems
provided very similar assessment diagnostics and provided
similar conclusions in assessing the distribution of riskadjusted mortality in pediatric intensive care units. PIM2
benefits from greater ease of data collection compared to
PRISM III.
Implications for Policy, Delivery, or Practice: This study
confirms that risk adjustment methods primarily developed in
other countries require validation before being used to provide
risk-adjusted outcomes of pediatric intensive care unit
mortality for units within a new health care setting. It is also
important that the calibration of these tools are reassessed
periodically in order to ensure their continued validity. Since
similar conclusions on the distribution of risk-adjusted
mortality were achieved with all the scoring systems and that
good discrimination and calibration are achievable without
using information obtained after the first hour in a pediatric
intensive care unit, there is evidence to suggest that the PIM2
system may be preferable. However, any variation in riskadjusted pediatric intensive care unit mortality needs to be
tempered by an assessment of variation in longer term
outcome.
Primary Funding Source: United Kingdom Medical Research
Council
●The Role of Public/Private Partnerships in Communitybased Efforts to Improve the Effectiveness of School
Health Programs
MaryAnn Phillips, MPH, Bernette McColley, BA, James
Emshoff, Ph.D., Bobbi Cleveland, BS
Presented By: MaryAnn Phillips, MPH, Senior Research
Associate, Georgia Health Policy Center, 14 Marietta Street,
Atlanta, GA 30303; Tel: (404)651-1643; Fax: (404)651-3147;
Email: mphillips2@gsu.edu
Research Objective: To determine if public/private
partnerships are effective in expanding sustained access to
care for low income and medically underserved school-aged
children.
Study Design: To facilitate achievement of model school
health programs, Georgia’s Department of Community Health
and the Philanthropic Collaborative for a Healthy Georgia
pooled financial resources to develop and evaluate a
competitive grant program to encourage school districts to
establish coordinated school health programs.
Population Studied: School-aged children in 13 Georgia
communities.
Principal Findings: School health grants were funded for one,
two, or three years beginning in 2001 and concluding in 2004.
Preliminary results indicate that access to health services has
improved, school faculty and staff skills have been enhanced,
overall attendance has increased, and local community
support for school health programs is strong. In addition, the
project has advanced the knowledge about successful health
efforts at the state and national levels by sponsoring a
technical assistance conference, preparing a training video
distributed to all school health programs in Georgia and
broadcast on the statewide education-related network, and
participating in a pilot training program for the National
Association of School Nurses on the treatment of asthma in
the schools. A thorough evaluation of the effort is currently
underway.
Conclusions: Georgia has developed an innovative model for
improving school health programs that may be replicable in
other states. Its success reflects the generosity and
commitment of 20 Georgia private and corporate foundations
whose initial contribution was matched by the State
Department of Community Health and then leveraged even
further with local and federal dollars. There are advantages to
public/private partnerships that accrue to all elements of the
program: pooling resources allows foundations to have
greater reach and impact, local communities receive funding
to improve access to care for low income children, and
technical assistance and best practice information receive
statewide and national dissemination.
Implications for Policy, Delivery, or Practice: The evaluation
of this effort will provide best practice information that will
impact state policies regarding the provision of health care in
Georgia schools; identify new methods of collaboration for
providing access to care for low income children; and promote
additional opportunities for public/private partnerships
around common health care priorities.
Primary Funding Source: Georgia Department of
Community Health and the Philanthropic Collaborative for a
Healthy Georgia
●Utilization of Nasal Airway for EGD in Children
George Russell, M.D., Alex Flores, M.D., Pacifico Tuason,
M.D., William Denman, M.D., Audrius Zibaitis, M.D.
Presented By: George Russell, M.D., Fellow, Pediatric
GI/Clinical Care Research, Institute for Health Policy Studies
and Clinical Research, Tufts-New England Medical Center, 750
Washington Street, NEMC #213, Boston, MA 02111; Tel: (617)
636-3083; Fax: (617) 636-8718; Email: grussell@tufts-nemc.org
Research Objective: In a patient population undegoing
endoscopy (EGD), general anesthesia is commonly required
to provide an optimal working environment for successful
completion of endoscopic examination. We have revisited an
old technique utilizing nasal airways to deliver oxygen and
inhaled anesthetics for EGD and evaluated its effectiveness
and safety profile.
Study Design: Retrospective Case Series
Population Studied: Two hundred charts of pediatric patients
who have undergone EGD in our intitution between 20012003 were identified. We selected 112 charts where EGD alone
or in combination with another procedure (e.g., colonoscopy)
were performed. Patients were anesthetized by either inhaled
anesthetics alone, total intravenous anesthetics (TIVA), or a
combination of both. The emphasis of our data collection was
to compare the safety profile and efficiency of the nasal airway
technique to other techniques by looking at the peri-procedure
complication rates and operating room (OR) turnover times.
Principal Findings: The age of patients ranged from 7
months to 20 years (mean, 9.8 years). Fifty-four were female
(48%). 56 patients used the nasal airway with a mean time to
leave the OR at 8.2 min +/- 4.8 min and a mean time to
discharge of 85.4 min +/- 35 min. 44 patients used the mask
airway with a mean time to leave the OR at 7.6 min +/- 4.1 min
and a mean time to discharge of 88.4 min +/- 55 min. 12
patient underwent endotracheal intubation with a mean time
to leave the OR at 22.6 min +/- 14 min and a mean time to
discharge at 91.6 min =/- 56 min. The average time to leaving
the OR was significantly lower in the nasal airway group
compared to endotracheal intubation (p value <.001).
Discharge times between three comparison groups did not
significantly differ. There were a total of 11 peri-operative
adverse events among the three groups. No aspiration
episodes occured and no event had long-lasting sequelae. The
complication rates were 5% for nasal airway, 14% for mask
airway, and 17% for endotracheal intubation.
Conclusions: In our study, nasal airway provided us with a
satisfactory means of maintaining patent airway during EGD.
The complication rate in the nasal airway group was lower
than in other evaluated groups. The nasal airway group
exhibited no increased risk of aspiration. Our finding suggest
that a nasal airway method is a safe, non-invasive alternative
to endotracheal intubation when used for EGD. OR turnover
times were superior in the nasal airway group in comparison
to patients being intubated.
Implications for Policy, Delivery, or Practice: More study is
needed but instituting the nasal airway as standard of care in
place of endotracheal intubation for EGD could substantially
lower the cost of time spent in the OR and reduce patient
waiting times for important diagnostic procedures.
Primary Funding Source: AHRQ
●Just One More Visit: Achieving >90% Vaccination
Coverage and Reducing Racial Disparities with one Catchup Visit
Tom T. Shimabukuro, M.D., MPH, MBA, Elizabeth T. Luman,
Ph.D., MS, Richard A. Schieber, M.D.,. MPH, Carla A.
Winston, Ph.D., MA
Presented By: Richard A. Schieber, M.D., MPH, Medical
Epidemiologist, Health Services Research and Evaluation
Branch, Immunization Services Division, National
Immunization Program, Centers for Disease Control and
Prevention, 1600 Clifton Road, MS E-52, Atlanta, GA 30333;
Tel: (404)639-6228; Fax: (404)639-8614; Email:
RSchieber@cdc.gov
Research Objective: Achieving and maintaining the Healthy
People 2010 objective of at least 90% coverage for universally
recommended vaccines among young children and reducing
racial/ethnic disparities in vaccination coverage are important
national health priorities. We projected the potential
improvement in up-to-date (UTD) coverage achieved by one
simulated additional provider visit for catch-up vaccinations.
Study Design: We used data from the 2003 National
Immunization Survey, a nationally representative randomdigit-dial survey of households with children 19-35 months of
age. We calculated crude baseline UTD vaccination coverage
levels and stratified levels by race/ethnicity and state among
24-month olds for the 4:3:1:3:3:1 (four diphtheria-tetanuspertussis, three poliovirus, one measles, three Haemophilus
influenza type b, three hepatitis B, and one varicella) and
4:3:1:3:3:1:4 (includes four pneumococcal vaccinations
recommended since 2000) combined series. We then
simulated coverage if incompletely vaccinated children were to
receive one additional provider visit to obtain up to four
missing vaccinations.
Population Studied: Children 24-months of age in the 2003
National Immunization Survey
Principal Findings: Overall baseline UTD coverage for the
4:3:1:3:3:1 series was 69.1% (95% confidence interval [CI],
67.9%-70.4%). Among incompletely vaccinated children,
79.0% became UTD with only one additional visit, of which
63.5% required only one vaccination during that visit. With
that simulated visit, overall UTD coverage increased 24
percentage points to 93.5% (95% CI, 92.8%-94.2%). Coverage
increased significantly within each racial/ethnic group: nonHispanic whites, from 71.7% to 94.6%; non-Hispanic blacks,
from 62.9% to 92.2%; and Hispanics, from 66.8% to 92.1%.
Baseline coverage in the 50 states and District of Columbia
ranged from 50.8% to 84.4% (median 68.5%); following the
simulated additional visit, all but 6 of these achieved >90%
UTD coverage (range 88.9% to 98.8%, median 93.9%).
For the 4:3:1:3:3:1:4 series, overall baseline UTD coverage was
35.1% (95% CI, 33.8%-36.3%). Among incompletely vaccinated
children, 88.4% became UTD with only one additional visit, of
which 68.2% required only one vaccination during that visit.
For this series, the simulated visit increased overall UTD
coverage 57 percentage points to 92.5% (95% CI, 91.7%93.2%). Coverage increased significantly within each
racial/ethnic group: non-Hispanic whites, from 37.8% to
93.8%; non-Hispanic blacks, from 28.9% to 90.4%; and
Hispanics, from 31.1% to 91.2%. Although still statistically
significant, differences in final coverage levels among
racial/ethnic groups following one simulated additional visit,
for both vaccination series, are minimal. For the 4:3:1:3:3:1:4:
series, baseline coverage in the 50 states and District of
Columbia ranged from 13.2% to 56.1% (median 32.3%);
following the simulated additional visit, all but 11 of these
achieved >90% UTD coverage (range 87.1% to 98.2%, median
92.1%).
Conclusions: Achieving at least 90% coverage appears
attainable, regardless of race/ethnicity, with a single additional
provider visit for catch-up vaccinations among incompletely
vaccinated 24-month olds. Most such children would require
only one vaccination during this visit. Furthermore, providing
a catch-up visit has the potential to substantially reduce racial
disparities in vaccination coverage.
Implications for Policy, Delivery, or Practice: Strategies to
promote such a catch-up vaccination visit should be
developed.
Primary Funding Source: No Funding Source
●Injury prevalence among children and adolescents with
mental retardation
Elspeth M. Slayter, MSW, MA, Deborah W. Garnick, Sc.D.,
Joanna M. Kubisiak, MPH, Christine E. Bishop, Ph.D., Daniel
M. Gilden, MS, Rosemarie B. Hakim, Ph.D.
Presented By: Elspeth M. Slayter, MSW, MA, The Heller
School for Social Policy and Management, 415 South Street
MS 035, Waltham, MA 02454-9110; Tel: (617)686-6594; Email:
eslayter@brandeis.edu
Research Objective: Medicaid is a major source of health
insurance coverage for children and adolescents with mental
retardation and is estimated to pay almost a third of their
injury care costs. To better understand these basic statistics,
we examined the prevalence of specific types of injuries
among children and adolescents with mental retardation.
Study Design: Using eligibility and claims data collected by
the Centers for Medicare and Medicaid Services’ Medicaid
Statistical Information System for calendar year 1999, injury
prevalence for 8.4 million Medicaid-eligible children in 26
states was measured through the use of an episode algorithm
for the identification of injury using ICD-9-CM diagnosis and
CPT procedure codes. Data from inpatient, outpatient and
long-term care settings were examined in order to provide a
broader picture of injury prevalence than is allowed by single-
site-of-care studies. We calculated the odds ratio (OR) that
children and adolescents with mental retardation were treated
for injuries compared with a non-mental retardation
comparison group, controlling for age and gender.
Population Studied: This project studied Medicaid
beneficiaries aged one through twenty with a diagnosis of
mental retardation and a comparison group of Medicaid
beneficiaries without mental retardation.
Principal Findings: In total, 36.9 percent (N=18,344) of
children and adolescents with mental retardation had at least
one injury claim, compared with 23.5 percent (N=1,978,501)
among those without mental retardation. Overall, males were
more likely than females to experience injury in this
population, a finding that differed from previous research
results. Controlling for age and gender, children and
adolescents with mental retardation were more likely to be
treated for any injury (OR: 1.74), and were much more likely
than the comparison group to be treated for poisoning (OR:
3.72), foreign body injuries (OR: 3.45), dislocations (OR: 2.74)
and internal injuries (OR: 2.49).
Conclusions: Children and adolescents with mental
retardation in this sample, especially males, are at higher risk
for experiencing injury than are their counterparts in the
comparison group without mental retardation. Although
most types of injury were prevalent at a greater rate in this
population, four types of injuries may be especially important
to target for prevention intervention, poisoning, foreign body
injuries, dislocations and internal injuries.
Implications for Policy, Delivery, or Practice: The higher risk
of injury among this sample of youth with mental retardation
may result in increased disability and morbidity. This has
implications for community inclusion, a central policy goal for
this population. Childhood injuries in this population result in
significant costs for public insurance programs in the United
States. Because a majority of youth with mental retardation
are covered by the Medicaid health insurance program,
targeted prevention interventions should be formulated and
implemented to support this vulnerable population, an effort
that has the potential to reduce costs for state and federal
Medicaid programs. Using Medicaid data, an important new
resource for childhood injury surveillance for the population
with mental retardation, planning prevention interventions can
be explored further by focusing on the specific injury types for
which this population is at greatest risk.
Primary Funding Source: CMS, American Association of
University Women
●Using Linked State and Local Data to Understand a
State-Sponsored Home Visiting Program for Medicaid
Insured Families
Wm. Thomas Summerfelt, Ph.D., Leeanne Roman, MSN,
Ph.D., Lynette Biery, PAC, Denise Holmes, MS, Susan Moran,
BSN, MPH, Doug Paterson, MPH
Presented By: Wm. Thomas Summerfelt, Ph.D., Director of
Research & Innovation, Research & Innovation, Grand Rapids
Medical Education & Research Center, 1000 Monroe Avenue,
NW, Grand Rapids, MI 49503; Tel: (616) 732-6225; Fax: (616)
732-6255; Email: tom_summerfelt@grmerc.net
Research Objective: Infant mortality and children’s health are
of public concern and many states have responded by
sponsoring home visiting services aimed at those most at risk
for poor birth, parenting, and infant outcomes. The primary
research objective of this project was to determine if a state
sponsored home visiting program was reaching the highest
risk women (demographic, behavior, and health risks) with
greater intensity of services, and better participation in
maternal and child health services (prenatal care,
immunization, WIC, EPSDT). A second objective was to
develop an outcomes monitoring system using linked state
and local data to inform policy and program development and
to evaluate these services continually.
Study Design: The study cohort was comprised of 46, 617
women who gave birth to 47,300 infants in Michigan during
2001. Individual mother and child data were linked across
state and county agencies. Data sources included Medicaid,
vital records, WIC, lead screening records, and local data from
one county’s home visiting programs.
Population Studied: Pregnant women and children who were
Medicaid insured
Principal Findings: The state sponsored home visiting
program did not consistently engage high-risk women and
their infants (e.g., of the 46,617 women in the sample, 31%
smoked during pregnancy and only 28% of those smokers
were enrolled). Further, even for those that were enrolled,
service intensity did not vary by risk. However, enrolled
families did achieve better participation in child health services
(i.e., well child visits, immunization rates, lead screening, and
breastfeeding initiation).
Conclusions: Comprehensive risk screening of the population
with clear linkages to targeted interventions around those risks
is critical in developing and maintaining effective programs.
Linked data becomes crucial in identifying the most efficient
(i.e., families had home visits by various state and local
programs that may have duplicated services) and the most
effective interventions.
Implications for Policy, Delivery, or Practice: Linked state
and local community data can be used to inform practioners
and policymakers regarding efficient and effective
programming. A population management approach that
includes uniform risk screening, assessment, early
identification, and stratification into appropriate services is
presented. Such an approach is indicated to improve
outcomes in Medicaid insured women and infants and help to
reduce costs.
Primary Funding Source: CMS
●Addressing Early Childhood Behavior Problems
Carole Upshur, EdD, Carole Upshur, EdD, Melodie WenzGross, Ph.D.,
Presented By: Carole Upshur, EdD, Professor, Family
Medicine and Community Health, University of
Massachusetts Medical School, 55 Lake Ave North, Worcester,
MA 01655; Tel: (508)334-7267; Fax: (508)856-1212; Email:
carole.upshur@umassmed.edu
Research Objective: To pilot an early childhood mental health
intervention with children identified in child care programs
with behavior problems.
Study Design: Teachers were taught how to screen children
using a standardized behavioral checklist. Families whose
children scored above clinical cutoffs were referred to
individualized short term intervention services and
reassessed. A mean of 21 hours of services was delivered,
including individual child sessions, and parent and teacher
guidance on managing the child’s behavior. Waiting list
controls were also reassessed in a quasi-experimental
repeated measures design.
Population Studied: Preschool children, ages 3-5 in 5 low to
moderate income urban and suburban community child care
centers serving 440 children
Principal Findings: The screening methodology identified 119
children, representing approximately 27% of all children, as
meeting criteria for clinically significant behavioral issues (81
externalizing and 38 internalizing; 63% boys). Intervention
outcome data are available on 40 target children and families
enrolled in brief services, with 79 children serving as waitlist
controls. The ethnic backgrounds of target children were
diverse, 30% Latino, 40% White, 17.5% Black, and 12.5%
other. Family education and income also varied, with 70% of
caregivers completing high school and 40% having at least
some college. Target family incomes ranged from under
$5,000 to over $60,000; median incomes were under
$25,000. Assessment of outcomes revealed significant
improvements in child behavior from baseline to follow-up,
including pre- to post- decreases in aggressive F(1,54)=23.80,
p<.001 and maladaptive behaviors F(1,82)=43.84, p<001, and
increases in adaptive behavior F(1,83)=26.65, p<.001. Further,
there was a significant interaction effect for both aggressive F
(1,54)=11.28, p=.001, and maladaptive behavior F (1,16)=7.7,
p<.013, showing that the target children improved significantly
more than the control children in these areas. In addition for
the target children, there was a trend toward improvement in
the areas of social development t=-1.865, df=28, p=.07; and
communication t=-1.80, df=28, p=.08. However, we found no
significant change in either parenting stress or parenting
skills. Nevertheless, most parents (84%) reported being
satisfied or very satisfied with the intervention.
Conclusions: Significant improvement in child behavioral
outcomes was found after brief individualized mental health
interventions targeted to children identified has having
clinically important behavioral problems in child care settings.
Unfortunately, little change was found in parenting stress or
discipline skills. The potential for longitudinal change in the
intervention children needs to be assessed.
Implications for Policy, Delivery, or Practice: A significant
proportion of children in child care in typical moderate to low
income communities exhibit behavioral and social skills issues
that put them at risk of early stigmatization, expulsion from
child care, lack of school readiness, and longer term
behavioral problems. Child care centers are important
community settings were these children can be identified and
primary and secondary intervention can be initiated. Our
model tested an approach where child care centers engaged
parents in initiating child and family services before more
major interventions may be necessary. Modest levels of
service and cost produced impression child outcomes.
Systems for connecting child care centers to mental health
and developmental services need to be developed to address
this growing need.
Primary Funding Source: Health Foundation of Central
Massachusetts
●Cost Effectiveness of Comprehensive Eye Exams for PreSchool Children
Alan White, Ph.D.
Presented By: Alan White, Ph.D., Senior Associate, Abt
Associates, 55 Wheeler Street, Cambridge, MA 02138; Tel:
(617) 349-2489; Fax: (617) 349-2675; Email:
alan_white@abtassoc.com
Research Objective: Comprehensive eye exams and vision
screening assessments are two methods for detecting
amblyopia and other visual disorders in children. The purpose
of this study is to estimate the cost effectiveness of
comprehensive exams. Comprehensive exams cost more
than screenings, but have higher rates of detection and
treatment. Their cost effectiveness depends on whether the
benefits resulting from the higher rates of detection and
treatment of amblyopia offset the higher costs.
Study Design: We assessed cost effectiveness using costutility analysis, comparing the marginal benefits of
comprehensive exams (based on quality-adjusted life years
(QALYs)) to marginal costs, including both exam and
treatment costs. The model focuses on amblyopia, the only
vision disorder typically identified during exams/screenings for
which there was sufficient information for determining model
parameter estimates. The model considers the relative
performance of exams and screenings, the probability of
successful treatment, costs, utility values associated with
impaired vision, and patterns of treatment under usual care.
Model parameters were based on an extensive literature
review and input from a panel of experts.
While the literature is extensive, there are significant gaps in
the literature and differences across studies in their estimates
of model parameters. We developed a set of base values, but
these are subject to uncertainty given the range found in the
literature. Sensitivity analyses were used to examine how
results change using different values of model parameters.
Population Studied: The model tracks individuals from age 3
(the earliest age at which children could receive a preschool
exam) through their lifetime.
Principal Findings: Using base case parameters, the
incremental cost effectiveness (in terms of cost per QALY) of
comprehensive exams was $12,796 relative to preschool vision
screening. This is well below the conventional thresholds
used to determine whether a particular intervention is a
reasonable expenditure, indicating that investment in
comprehensive eye exams for preschool children produces a
greater return than other interventions. This basic conclusion
was robust across changes in the values of most model
parameters, although results were particularly sensitive to
assumptions made about the quality of life associated with
untreated amblyopia, prevalence, and the probability of
successful treatment. The study’s conclusions are largely
driven by the cost effectiveness of treatment for amblyopia.
While data are limited, we estimate that treating amblyopia
(not including detection) costs about $1,800 per QALY. As a
result, spending additional dollars on interventions that detect
and treat large numbers of children with amblyopia are highly
cost effective.
Conclusions: Comprehensive exams almost certainly detect
more cases of amblyopia than do vision screenings, and,
under a wide range of scenarios, comprehensive eye exams
appear to be highly cost effective relative to vision screening
programs, given existing standards of cost effectiveness.
Implications for Policy, Delivery, or Practice: Policymakers
should give consideration to programs that would increase
the number of preschool children who receive a
comprehensive eye exam. There are, however, important gaps
in our knowledge, and a need for further research to make
possible more precise estimates of the costs and benefits of
comprehensive exams.
●Do Early Intervention Programs Alleviate Behavioral
Problems In Children With Learning Disabilities?
Jennifer Yu, Sc.D., Stephen Buka, Sc.D., Marie McCormick,
M.D., Sc.D., Garrett Fitzmaurice, Sc.D., Alka Indurkhya, Ph.D.
Presented By: Jennifer Yu, Sc.D., Research Fellow, Institute
for Health Policy Studies, University of California, San
Francisco, 3333 California Street, Suite. 265, San Francisco, CA
94143-0936; Tel: (415)514-0244; Fax: (415)476-0705; Email:
jyu1@itsa.ucsf.edu
Research Objective: Although early interventions such as
Early Head Start programs demonstrate positive behavioral
findings in children typically at risk for psychosocial
maladjustment, it is unclear if such programs would produce
similar results in other high-risk populations. This paper aims
to fill this gap in the literature by examining the influence of an
early intervention program received at ages 0-3 on the
behavioral development of 8-year-old children with verbal
(VLD) and nonverbal (NVLD) learning disabilities.
Study Design: Secondary data analysis was conducted on a
longitudinal study of a randomized clinical trial to examine the
effects of early intervention on elementary-school aged
children with learning disabilities. Logistic regression models
were employed in which learning disability status predicted
externalizing and internalizing behavior problems. Children
were identified at age 8 as VLD or NVLD based on their
discrepancy between cognitive performance and academic
achievement in reading and arithmetic, respectively. Clinicallydefined externalizing and internalizing behavior problems
were identified using the Achenbach Child Behavior Checklist.
Population Studied: The study sample was derived from the
Infant Health and Development Program, a multi-site,
randomized clinical trial examining the effects of an early
intervention on the cognitive, social, and emotional
development of low birthweight infants. Among the 713
children included in these analyses, 11% were identified with
VLD and 10% were identified with NVLD.
Principal Findings: There was a significant interaction
between VLD and the intervention when predicting
internalizing behavior. Specifically, VLD children who received
the early intervention were three times more likely to exhibit
internalizing behavior problems when compared to VLD
children who did not receive the intervention (p=0.01). This
interaction was not significant for externalizing behavior
problems in VLD children. In addition, the intervention did
not significantly modify the relationships between NVLD and
externalizing or internalizing behavior.
Conclusions: The findings suggest that the early intervention
had little impact on most clinical behavior problems in
learning disabled children. The findings also suggest that
early intervention programs may have iatrogenic effects on the
behavioral outcomes of VLD children. Before drawing such
conclusions, there are a number of factors to consider, such
as methodological issues or the potential consequence of
early intervention services without subsequent educational
support.
Implications for Policy, Delivery, or Practice: A number of
implications are associated with these findings. For instance,
most evaluations of early interventions recommend additional
“booster” resources, such as counseling and family support
programs, in order to extend the positive effects of the
intervention into later life. This paper discusses how
incorporating similar services into special education programs
may benefit learning disabled children by reducing the risk of
future behavioral problems.
Primary Funding Source: RWJF
●Social Capital and Self-reported Negative Parenting
Behaviors
Adam Zolotor, M.D., MPH, Desmond K. Runyan, M.D., DrPH
Presented By: Adam Zolotor, M.D., MPH, NRSA Primary
Care Research Fellow, Family Medicine, University of North
Carolina, CB# 7595, Chapel Hill, NC 27599-7595; Tel: (919)
843-4817; Fax: (919) 966-6125; Email: ajzolo@med.unc.edu
Research Objective: The World Bank defines social capital as
the glue that holds a society together. Social capital includes
collective efficacy, psychological sense of community,
neighborhood cohesion and parental investment in the child.
In this study we develop a scale to assess social capital from a
population-based survey of parents. We then evaluate social
capital as a protective factor from harsh physical punishment,
failure to meet a child’s basic needs, and psychologically harsh
parenting.
Study Design: This study is a secondary analysis of crosssectional telephone survey data. The survey assessed a range
of parenting behaviors, demographic factors, and
neighborhood characteristics. We factor-analyzed 22
questions designed to assess social capital. We then
assessed the relationship of social capital to indices of
parenting behavior representing harsh physical punishment,
failure to meet a child’s basic needs, and psychologically harsh
parenting.
Population Studied: North and South Carolina Households
were selected by random digit dial including only households
with children under 18. A complementary sample of
households known to have children was also surveyed. 1435
households participated in the survey for an adjusted
response rate of 52%. The data is weighted to reflect the
socioeconomic, racial, and ethnic composition of the
Carolinas.
Principal Findings: Three social capital variables were created
from the factor analysis. These variables represent different
aspects of social capital: neighborhood characteristics,
willingness to take personal action to intervene on the behalf
of neighbors, and recent history of helping a neighbor. We
found that a willingness to take personal action was the
strongest protective factor for harsh physical punishment
(p=0.05). Neighborhood characteristics (p=0.04) and
willingness to take personal action (p=0.02) were both
protective from psychological harsh punishment (p=0.04 and
0.02 respectively). The variable for neighborhood
characteristics was most protective against failure to meet a
child’s basic needs (p=0.02). There was no significant
relationship between a recent history of helping a neighbor
and the three indices of parenting behavior examined.
Conclusions: In this factor reduction of questions related to
social capital, we are able to identify three factors most
reflective of social capital. Both neighborhood characteristics
and willingness to take personal action are protective factors
against the use of harsh physical punishment, failure to meet
a child’s basic needs, and psychologically harsh parenting.
Implications for Policy, Delivery, or Practice: There is
increasing interest among government and private agencies
on the impact of social capital on health and well-being. In
this study, we demonstrate an effective method of measuring
three dimensions of social capital. We also show that
neighborhood characteristics and a willingness to take
personal action to intervene on the behalf neighbors are
protective factors against negative parenting behaviors. These
findings support the development of social capital as a
resource in communities. Proposed methods for augmenting
social capital include programs such as neighborhood centers,
clean neighborhoods, social organizations, and community
empowerment.
Primary Funding Source: National Research Service
Association