Child Health
Call for Papers
Assesing Pediatric Practice Guidelines
and Quality Measures
Chair: Kevin Dombkowski, University of Michigan
Sunday, June 25 • 3:45 pm – 5:15 pm
●Indicators of Their Own: Pediatric Quality Indicators
Based on Administrative Data
Sheryl Davies, MA, Patrick Romano, M.D., M.P.H., Amy Ku,
MHSA, Corinna Haberland, M.D., Jeffrey Geppert, JD, Kathryn
McDonald, MM
Presented By: Sheryl Davies, MA, Research Manager,
Medicine, Stanford University, 117 Encina Commons,
Stanford, CA 94305; Tel: 650-723-0820; Fax: 650-723-1919;
Email: smdavies@stanford.edu
Research Objective: Proliferating quality measurement
systems have focused on adults rather than children.
Hospitalized children represent an important population, for
which most inpatient quality indicators are not applicable.
This study aims to assess quality of inpatient pediatric care
and access to high quality outpatient care using indicators
adapted to a pediatric population, the AHRQ Pediatric Quality
Indicators (PedQIs).
Study Design: Utilizing literature review, semi-structured
clinical panel review, and empirical exploration, we adapted
the current AHRQ Quality Indicators, widely used indicators
based on administrative data, for a pediatric population. We
systematically reviewed the literature for evidence regarding
coding and construct validity specific to the pediatric
population. In a unique partnership with hospitals currently
using the indicators, we also examined feedback from chart
reviews of cases flagged as a complication by the original
AHRQ QIs. Twenty-three revised indicators were then
reviewed by clinical panels of 8-13 physicians, using
methodology adapted from the RAND Appropriateness
Method. We empirically identified high risk populations for six
complications indicators, and developed stratification
schemes. We then applied these new pediatric indicators to a
nationally representative dataset. Downloadable software was
developed for application to administrative datasets.
Population Studied: We applied the PedQIs to the 2000
AHRQ Healthcare Cost and Utilization Project Kids’ Inpatient
Database (KID) to generate weighted estimates for pediatric
hospitalizations in nonfederal acute care facilities. We
examined rates for children’s hospitals in addition to overall
rates.
Principal Findings: Panelists recommended 18 indicators for
inclusion in the Pediatric Quality Indicator set based on overall
usefulness ratings for internal quality improvement. The
indicators included: 13 provider-level indicators, including 11
complications indicators (8 procedural), one mortality, and
one volume, and 5 area-level potentially preventable
hospitalization indicators. Panelists rated 10 provider-level
and two area-level indicators as suitable for inter-hospital
comparisons. Indicator rates for specific complications varied
from 0.007 to 21.6 per 1000 discharges at risk. Foreign Body
Left in During a Procedure and Transfusion Reaction were the
least common complications; Postoperative Respiratory
Failure and Postoperative Sepsis were the most common. Age
trends were heterogeneous for complications indicators, with
rates of Postoperative Sepsis and Postoperative Respiratory
Failure decreasing with age, and Decubitus Ulcer increasing
with age. For most indicators, children’s hospitals
demonstrated higher complications rates, even when patients
were stratified by clinical risk. Non-risk-adjusted mortality for
Pediatric Heart Surgery was similar for children’s and nonchildren’s hospitals. Potentially preventable hospitalization
rates varied from 19.6 (diabetes hospitalization) to 177.7
(gastroenteritis hospitalization) per 100,000 population in a
given area (e.g., county). With the exception of diabetes, all
potentially preventable hospitalizations decreased with age;
diabetes admissions increased in the adolescent age category.
Conclusions: Pediatric patients are at risk for developing
potentially preventable complications and admissions.
Tracking these events in children is an important aspect of
improving quality of care. While children’s hospitals generally
demonstrate higher rates even when stratified by risk, these
differences may be mitigated with risk adjustment.
Implications for Policy, Delivery, or Practice: The AHRQ
Pediatric Quality Indicators are a novel set, widely applicable
quality indicators. These indicators also incorporate clinical
stratification important to quality improvement efforts. The
indicators can be applied to readily available data.
Primary Funding Source: AHRQ
●Reassessing the Cost Effectiveness of Vaccines for Young
People
Daniel Eisenberg, Ph.D., Gary Freed, M.D., M.P.H.
Presented By: Daniel Eisenberg, Ph.D., Assistant Professor,
Health Management and Policy, University of Michigan,
M3517 SPH II, Ann Arbor, MI 48109-2029; Tel: (734) 615-7764;
Fax: (734) 764-4338; Email: daneis@umich.edu
Research Objective: The cost-effectiveness of some recently
developed vaccines targeting children and adolescents, such
as those for HPV or meningococcal disease, is controversial. If
we are to use cost effectiveness analysis (CEA) as a decisionmaking aid regarding coverage and use of these vaccines, it is
important that the method reflect society's preferences
accurately. We analyzed empirically the extent to which CEA
of vaccines as currently practiced may be biased against young
people. In related literature this possibility has been
supported by three arguments. First, net resource use,
whether or not related to the intervention being studied,
should be included in the analysis, as David Meltzer has
shown. Second, the discount rate should be adjusted
downwards to account for the fact that our society is steadily
become wealthier and the marginal utility of health is
consequently increasing. Third, several survey studies provide
direct evidence that most people, when asked to make
hypothetical trade-offs between a life-year for a young person
and that of an elderly person, will strongly favor the young
person. We synthesized these three strands of literature and
applied corresponding adjustments to recently conducted
CEAs of vaccines.
Study Design: We conducted comprehensive searches of
Medline and Harvard's CEA Registry for CEAs meeting the
following criteria: 1) the intervention primarily affected people
under age 25; 2) an incremental cost effectiveness ratio (ICER)
was calculated in terms of $/QALYs or $/LYs; 3) the ICER
result was between $50,000 and $500,000 (what we call
"dubious cost-effectiveness"); 4) the study was published
since 1995. For each CEA we then applied adjustments based
on the three arguments described above and recalculated the
ICERs. In sensitivity analyses we allowed for a range of
assumptions regarding these adjustments.
Population Studied: Based on the criteria above we selected
10 CEAs for re-analysis. These studies pertained to a range of
diseases, including HPV, meningococcal virus, and hepatitis
A, and to a range of age groups, including infants, toddlers,
young children, and adolescents.
Principal Findings: In our main analysis the proposed
adjustments reduced the cost effectiveness ratios by as much
as 50%, changing 8 of the 10 conclusions from dubious costeffectiveness to clear cost-effectiveness (well under
$50,000/QALY). Even under the most conservative sensitivity
analyses, the cost effectiveness of 6 of the 10 studies shifted
to under $50,000/QALY.
Conclusions: Reflecting societal preferences for prioritizing
the health of children more accurately reversed the basic
conclusion regarding whether an intervention is cost-effective
from no to yes in the case of several recently conducted CEAs
pertaining to vaccines.
Implications for Policy, Delivery, or Practice: CEA is being
used explicitly for rationing decisions in other countries, and
some signs suggest that its prominence is increasing in the
United States. Important policy decisions regarding child and
adolescent vaccines, particularly those which are effective but
expensive, will depend on assessments of cost effectiveness,
among other factors. In this context, refining and using CEA
methods to reflect societal preferences related to age as
accurately as possible should be a high priority.
Primary Funding Source: No Funding
●Risk Factors for RSV-Related Hospitalizations Among
Infants Born at 32 to 35 Weeks of Gestation
Norma Gavin, Ph.D.
Presented By: Norma Gavin, Ph.D., Senior Research
Economist, , RTI International, 3040 Cornwallis Road,
Research Triangle Park, NC 27709-2194; Tel: (919) 541-6432;
Fax: (919) 990-8454; Email: gavin@rti.org
Research Objective: Prophylaxis with palivizumab has been
demonstrated to be highly safe and effective in reducing
hospitalization caused by RSV. However, given the large
number of premature infants born at 32 to 35 weeks of
gestation and the cost of prophylaxis, the American Academy
of Pediatrics has recommended that use of the product in this
cohort of infants be restricted to those infants with additional
risk factors. This study examines the predictive utility of a
variety of risk factors for identifying infants born at 32 to 35
weeks of gestation who are most likely to be hospitalized for
severe respiratory syncytial virus (RSV) and therefore most
likely to benefit from prophylaxis.
Study Design: We used linked birth certificate and Medicaid
enrollment and claims data to identify RSV hospitalizations
and a variety of risk factors. We used two different definitions
of RSV hospitalizations, one including pathogen-specific
diagnoses only and the other including both pathogen-specific
diagnoses and diagnoses for bronchiolitis and pneumonia of
unspecified origin. The risk factors included the presence of
siblings, birth within 6 months of the RSV season, birth stays
of 7 or more days, neonatal intensive care unit stays at birth,
ventilator assistance at birth, teenaged mothers, unmarried
mothers, and mothers who smoked during pregnancy. We
estimated unadjusted and adjusted odds ratios for each of the
eight different risk factors and their sensitivity, specificity and
positive and negative predictive values for predicting RSV
hospitalizations in the first year of life as a single predictor and
in combination with other factors.
Population Studied: We included infants born 32 to 35 weeks
of gestation in Texas during 1997 who had continuous
Medicaid coverage from birth through the first 12 months of
life. We excluded infants with missing or incomplete
enrollment or claims records, infants enrolled in capitated
managed care during their first year of life, infants with
congenital anomalies, and infants who had any claims for RSV
immune globulin intravenous or palivizumab. The final
sample size was 2,098 infants.
Principal Findings: Most of the factors investigated had a
statistically significant, positive impact on the probability of
RSV-related hospital stays among infants born at 32 to 35
weeks of gestation. However, their predictive power was
limited; none of the factors, singly or in combination, was
both sensitive and specific.
Conclusions: Examined risk factors are not a compelling
guide for selecting which premature infants should receive
RSV prophylaxis.
Implications for Policy, Delivery, or Practice: Current
guidelines for decisions regarding which infants born at 32 to
35 weeks of gestation should receive prophylaxis for RSV
hospitalizations may not be identifying those infants who
would most benefit from the treatment.
Primary Funding Source: MedImmune
●Development of Measures of the Quality of Emergency
Department Care for Children
Astrid Guttmann, MDCM, MSc, Asma Razzaq, M.P.H., Patrice
Lindsay, Ph.D., Brandon Zagorski, MSc, Geoff Anderson,
M.D., Ph.D.
Presented By: Astrid Guttmann, M.D.CM, MSc, Scientist, ,
Institute for Clinical Evaluative Sciences, G Wing Sunnybrook
Hospital, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5; Tel:
416-480-4055 x 3783; Fax: 416-480-6048;
Email: astrid.guttmann@ices.on.ca
Research Objective: To use a systematic process to develop
measures of the quality of Emergency Department (ED) care
for children that are 1) based on research evidence and expert
opinion, 2) representative of a range of conditions treated in
most ED's, 3) based on a link between process and outcomes,
and 4) feasible to measure.
Study Design: We used a panel of providers and managers
from a number of ED settings with reference to populationbased data of ED utilization by children, to identify a series of
common conditions, across levels of patient acuity, which
could be targets for quality improvement efforts. We used a
structured panel process informed by a literature review to 1)
identify condition-specific links between processes of care and
defined outcomes, and 2) select and define measures to
assess these process-outcome links. We determined the
feasibility of calculating these measures using routinely
collected population-based data of all ED visits for Ontario,
Canada.
Population Studied: All ED visits for children 0-19 years
(1,226,849 visits) in Ontario, Canada for 2003/4.
Principal Findings: A panel identified 18 clinical conditions
for indicator development. The structured panel process
identified 61 condition-specific links between process and
outcomes for 14 of these conditions. After two rounds of
ratings the panel defined 76 specific clinical performance
measures for the following 12 conditions: ankle injury, asthma,
bronchiolitis, croup, adolescent depression/mood disorders,
diabetes, fever, gastroenteritis, minor head injury, neonatal
jaundice, seizures, and urinary tract infections. These
conditions covered a range of acuity and age groups, and
accounted for 38 % of all pediatric ED visits. Using routinely
collected data it was possible to calculate 19 measures,
covering 9 conditions, representing 21% of all visits. There
was significant variability in the measures across hospitals in
Ontario.
Conclusions: Performance measures are essential
components of public reporting and quality improvement.
Using a structured panel process, data on ED utilization and a
literature review, it was possible to identify common clinical
conditions for which processes in the ED have an impact on
outcomes, define and measure some indicators of care using
existing administrative data. Developing benchmarks for these
measures will require a number of strategies.
Implications for Policy, Delivery, or Practice: This is the first
set of comprehensive performance measures of pediatric ED
care relevant across all ED settings. Locally these measures
will be used in the Ontario Hospital Report which routinely
reports on the quality of care of all acute care hospitals in
Ontario. This list of measures could be used by other
jurisdictions interested in reporting ED performance either as
is, or as a starting point for similar panel processes with
relevant stakeholders. The list also provides ED managers
and clinicians with tools to focus quality improvement.
Primary Funding Source: Ontario Hospital Report Research
Collaborative
●Improving Severity Adjustment Measures for the Quality
of Care Provided to Premature Infants by Outpatient
Pediatric Practices
Scott Lorch, M.D., MSCE, Gabriel J. Escobar, M.D., Andrea
Millman, BA, Susan Bakewell-Sacks, RN, Ph.D., Barbara
Medoff-Cooper, RN, Ph.D., Jeffrey H. Silber, M.D., Ph.D.
Presented By: Scott Lorch, M.D., MSCE, Assistant Professor,
Neonatology and the Center for Outcomes Research, 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: With the growth of pay-for-performance
plans, severity adjustment for outcomes such as the
rehospitalization of premature infants has become an
important issue for outpatient pediatric care. Traditional
severity adjustment tools for these infants, such as gestational
age (GA) and the score for neonatal acute physiology (SNAP),
are measured at delivery and may not adjust for lateroccurring differences in neonatal practice. The objective of
this study, then, was to (1) evaluate the discrimination of
various severity adjustment tools for the risk of
rehospitalization of premature infants within 2 and 4 weeks of
discharge from the neonatal intensive care unit and (2)
determine how the addition of physiologic maturity at
discharge, a measure of later-occurring differences in the
condition of neonates, influences the rank ordering of 31
outpatient pediatric practices.
Study Design: As part of the Infant Functional Status Study,
we determined the number of days prior to discharge that an
infant was monitored without supplemental heat or oxygen,
apnea or bradycardia, methylxanthines, naso-gastric feedings,
or weight loss. Logistic regression models were constructed
to establish the ability of various sets of factors to predict
rehospitalizations within 2 and 4 weeks of discharge; these
sets of factors included (1) GA and race; (2) GA, race, and
SNAP; (3) GA, race, and complications of prematurity; and (4)
GA, race, complications of prematurity, SNAP, and
physiologic maturity at discharge. These models were then
used to rank order outpatient facilities on the basis of 2 and 4week rehospitalization rates.
Population Studied: Premature infants born at a GA <= 32
weeks at 5 Kaiser Permanente hospitals (N=780) between
1998 and 2001.
Principal Findings: Of the 780 infants, 280 had a GA <= 28
weeks. The median number of days from attainment of each
skill to discharge ranged from 7 days (IQR 5-11 days) for
feeding to 20 days (IQR 14-27 days) for methylxanthines.
Compared to GA and race (c-statistic 0.71), the addition of
complications of prematurity improved model discrimination
for 2-week rehospitalizations (c-statistic 0.79, p=0.002). The
addition of maturity variables resulted in the highest
discrimination for both the 2-week (c-statistic 0.84, p<0.02
versus all other models) and 4-week rehospitalization models
(c-statistic 0.78). The addition of the maturity variables to the
severity adjustment model with GA, SNAP, race, and
complications resulted in 26% of the outpatient facilities
changing rank order quintiles for 2-week rehospitalizations
and 19% of the facilities changing quintiles for 4-week
rehospitalizations. 11 of the 14 hospitals that changed
quintiles moved at least 2 ranks. 26% and 13% of the facilities
in the 2 and 4-week rehospitalization models, respectively,
moved at least 10% in the final rank order when the model
accounted for physiologic maturity.
Conclusions: The type of severity adjustment can significantly
alter the ranked quality of care provided to premature infants
by outpatient pediatric practices. Models that include
information near discharge may improve the severity
adjustment of outpatient pediatric facilities.
Implications for Policy, Delivery, or Practice: Administrative
data that includes information about the physiologic maturity
of premature infants at the time of discharge could improve
the assessment of the quality of care delivered by outpatient
pediatricians.
Primary Funding Source: Maternal and Child Health Bureau
Call for Papers
Children in the Context of School, Community & Family
Chair: Michael Cabana, University of California,
San Francisco
Monday, June 26 • 3:45 pm – 5:15 pm
●The Effectiveness of the Olweus Bullying Prevention
Program in Public Middle Schools: A Controlled Trial
Nerissa Bauer, M.D., Paula Lozano, M.D., M.P.H., Frederick P.
Rivara, M.D., M.P.H.
Presented By: Nerissa Bauer, M.D., Pediatric NRSA Senior
Fellow, General Pediatrics, University of Washington/Child
Health Institute, 6200 NE 74th Street, Suite 210, Seattle, WA
98115-8160; Tel: 206-616-2898; Fax: 206-616-4623;
Email: nerissa@u.washington.edu
Research Objective: The Olweus Bullying Prevention
Program, OBPP, is a widely-disseminated school-based
intervention designed to reduce student bullying and promote
healthy peer relationships. However, only 1 study has tested
its effectiveness in US schools. Therefore, our objective was
to determine the effectiveness of the OBPP in decreasing
student reports of victimization and increasing students’
willingness to intervene if another student is being bullied.
Study Design: A controlled trial with 10 middle schools was
conducted between 2003 and 2005. We assessed studentreports of relational (spreading rumors, social exclusion) and
physical victimization, pre- and post-implementation.
Students were asked how they felt when they witnessed
bullying and whether other students and teachers intervened.
Poisson regression was performed, controlling for baseline
prevalence and school characteristics such as size, percent
free lunch eligible and reading test pass rate.
Population Studied: Seattle public middle school students in
6th through 8th grade.
Principal Findings: Seven middle schools implemented the
OBPP (intervention group) and 3 did not (comparison group).
The OBPP was not associated with significantly different
overall rates of relational and physical victimization. Yet when
stratified by ethnicity, reports of relational and physical
victimization decreased by 28% (RR=0.72, 95% CI 0.53-0.98)
and 37% (RR=0.63, 95% CI 0.42-0.97) respectively among
white students in intervention schools relative to white
students in comparison schools. No similar effect was found
for students of other races/ethnicities; there were no
differences by gender or by grade. Students in intervention
school were more likely to perceive other students as actively
intervening in bullying incidents (RR=1.21, 95% CI 1.05-1.40)
and 6th graders were more likely to feel sorry and want to help
victims (RR=1.21, 95% CI 1.05-1.39).
Conclusions: The OBPP had some positive effects varying by
race/ethnicity and grade on victimization and feelings towards
bullying, but did not show an overall effect. The intervention
was associated with greater perception of students actively
intervening in bullying incidents.
Implications for Policy, Delivery, or Practice: Schools
should tailor anti-bullying measures to students of all
ethnicities and cultures. Future studies of large-scale violence
prevention programs in the community must be rigorously
evaluated.
Primary Funding Source: HRSA
●Acculturation, Generational Status, Place of Birth,
Primary Language at Home, and Overweight: A Case of
“When in Rome, Do As The Romans Do?”
Jane M. Brotanek, M.D., M.P.H., Hong Ji, MS, Emmanuel
Ngui, DrPH, MS, Glenn Flores, M.D.
Presented By: Jane M. Brotanek, M.D., M.P.H., Assistant
Professor, Pediatrics, Medical College of Wisconsin, 8701
Watertown Plank Road, MS 756, , WI 53226; Tel: (414) 4565778; Fax: (414) 456-6385; Email: jbrotane@mcw.edu
Research Objective: Along with the overweight epidemic in
US adolescents, there is a dramatic surge in the immigrant
population. Little is known about whether acculturation,
generational status, birthplace, or primary language are
associated with overweight in US adolescents. The study
objective was to examine whether acculturation, generational
status, place of birth, or primary language are associated with
overweight in US adolescents.
Study Design: Analyses were performed of the National
Health and Nutrition Examination Survey (NHANES: 19992002) for a nationally representative sample of US
adolescents 12-18 years old. Measures included acculturation
(using the Short Acculturation Scale), generational status,
birthplace, primary language spoken at home, and
overweight/at risk of overweight (OWARO: BMI greater than
or equal to the 85th percentile). Multivariate analyses were
done to adjust for gender, poverty, and race/ethnicity.
Population Studied: A nationally representative sample of US
adolescents 12-18 years old
Principal Findings: 92% of the 4,339 adolescents were USborn and 8% were foreign-born; 90% had English as their
primary language (EPL) and 10%, a non-English primary
language (NEPL). Among Latino adolescents, 73% had high
acculturation and 27%, low acculturation. 21% of foreign-born
adolescents and 33% of US-born adolescents were OWARO
(p=.001). 32% of EPL adolescents and 29% of NEPL
adolescents were OWARO (p=0.5). 30% of 1st-generation
Latino adolescents, 41% of 2nd-generation Latino adolescents,
and 38% of 3rd-generation Latino adolescents were OWARO
(p=.4). 35% of Latino adolescents with low acculturation and
39% of those with high acculturation were OWARO (p=.2). In
multivariate analyses, US-born (OR, 1.8; 95% CI, 1.1-3.0) and
EPL (OR, 1.6; 95% CI, 1.1-2.2) adolescents had higher odds of
OWARO; among Latino adolescents, being 2nd-generation
was associated with OWARO (OR, 2.0; 95% CI, 1.2-3.2).
Conclusions: US-born and EPL adolescents are at
significantly higher risk of overweight. Among Latino
adolescents, generational status, but not acculturation, is
associated with OWARO. Further research is needed to
identify how generational status, place of birth, and primary
language spoken at home might be protective against
adolescent overweight.
Primary Funding Source: The Center for the Advancement of
Underserved Children and the Department of Pediatrics,
Medical College of Wisconsin
●The Relationship of Parental Psychopathology and PainRelated Medical Problems to Child Medical Management
and Avoidable Emergency Pediatric Services
Joseph Logan, MAE, M.H.S., Ph.D. candidate
Presented By: Joseph Logan, MAE, M.H.S., Ph.D. candidate,
Doctoral Student, Health Policy and Management, The Johns
Hopkins Bloomberg School of Public Health, 695 Americana
Drive, #46, Annapolis, MD 21403; Tel: 443-722-2194;
Email: jlogan@jhsph.edu
Research Objective: Studies in health services research have
shown that many children do not receive well-child visits or
timely care when they are in need of services. Also, a large
percentage of emergency department (ED) visits and
hospitalizations among children occur for medical problems
that could have been avoided had they received timely nonemergency based outpatient care. These avoidable ED visits
and hospitalizations are often referred to as Ambulatory Care
Sensitive or ACS-ED visits and ACS hospitalizations. Children
of parents with mental health or pain-related conditions may
be at greater risk for having medical mismanagement,
especially if the parent’s symptoms impair their ability to
monitor health, communicate, seek care, provide
transportation, and/or navigate the health system. This study
investigated which types of parental psychiatric and painrelated conditions are associated with poor use of outpatient
pediatric services and increased occurrences of child ACS-ED
visits and child ACS hospitalizations.
Study Design: This investigation was a secondary data
analysis of the 1997-1998 Thomson/Medstat® MarketScan
claims and administrative dataset. Three logistic regression
models using generalized estimating equations (GEE) to
control for children being in the same family were analyzed to
assess the odds of a child having at least two well-child visits,
at least one ACS-ED visit or one ACS hospitalization during
the 2-year study period in relation to parental diagnoses of the
various mental health conditions and pain-related conditions
including back pain, migraine headaches, and arthritis. This
analysis controlled for child and parental health status,
personal demographics, family characteristics, and health plan
characteristics.
Population Studied: A study population of 258,332 children
and 262,799 caregivers enrolled in private health insurance
plans was included for this analysis.
Principal Findings: Maternal depression was inversely
associated with a child having two well-child visits (OR: 0.87,
p<0.05), and positively associated with a child having at least
one ACS-ED visit (OR: 1.24, p<0.001) and a child having at
least one ACS hospitalization (OR: 1.24, p<0.10). Maternal
depression with back pain was strongly associated with a child
having an ACS-ED visit (OR: 1.78, p<0.001) and a child having
an ACS hospitalization (OR: 2.5, p<0.001). These results were
similar to those of mothers with four or more medical
conditions. Paternal schizophrenia was significantly and
inversely associated with a child having two well-child visits
(OR: 0.25, p<0.10). Paternal depression was also significantly
and positively associated with a child having at least one ACSED visit (OR: 1.15, p<0.10) and a child having at least one ACS
hospitalization (OR: 1.35, p< 0.10). Both parents diagnosed
with depression or each having three or more medical
conditions was significantly and positively associated with a
child having at least one ACS-ED visit (OR: 1.4-1.88, p<0.05),
and a child having at least one ACS hospitalization (OR:2.13.00, p<0.05).
Conclusions: Parental depression and schizophrenia and
multiple medical conditions are both independently and
strongly associated with inadequate well-child care and
avoidable emergency pediatric services, especially if cooccurring with pain-related health conditions.
Implications for Policy, Delivery, or Practice: Mental health
providers, pediatricians, policy makers, and insurers need to
consider parental mental health as an influencing factor when
seeking to improve medical management of potentially
serious conditions in children.
Primary Funding Source: NIMH
●Are Non-Citizen Parents More Likely than Citizen Parents
to Choose Emergency Departments for Their Children’s
Non-Urgent Care?
Emmanuel Ngui, Dr.P.H., Glenn Flores, M.D.
Presented By: Emmanuel Ngui, Dr.P.H., Assistant Professor
of Pediatrics, Epidemiology, and Health Policy, Department of
Pediatrics, Medical College of Wisconsin, 8701 Watertown
Plank Rd, Milwaukee, WI 53226; Tel: 414 456-4302; Fax: 414
456-6385; Email: engui@mcw.edu
Research Objective: Emergency department (ED) use for
non-urgent care (NUC) is a significant public health problem.
Not enough is known about parental use of EDs for children's
NUC, particularly among immigrant parents. The study
objectives were to 1) compare parental choice of EDs for
children’s NUC among citizen parents (CPs) and non-citizen
parents (NCPs); 2) examine whether the choice of EDs for
children’s NUC differ across the different NCPs subgroups
(legal permanent resident parents [LPRPs], undocumented
immigrant parents [UIPs], and temporary resident parents
[TRPs]); and 3) identify factors associated with disparities in
parental choice of using ED for NUC among CPs and NCPs.
Study Design: Cross-sectional survey of parents in
predominantly Latino inner-city Boston communities,
including supermarkets, hair salons, and Laundromats.
Participants were asked 76 questions on topics such as
insurance coverage, barriers to care, and choices regarding
NUC. Multivariate analyses adjusted for age, insurance,
education, poverty status, usual source of care, Limited
English Proficiency (LEP), and barriers to care.
Population Studied: Inner-city citizen and non-citizen
parents.
Principal Findings: 1100 parents were interviewed; 40% were
CPs; 29%, LPRPs; 24%, UIPs; and 7%, TRPs. Parental choice
of the ED for NUC differed significantly by parental citizenship
status, with only 20% of CPs choosing EDs for children's NUC
vs. 48% of NCPs. Among NCPs, the ED was chosen for
children's NUC by 35% of LPRPs, 58% of UIPs, and 60% of
TRPs. In multivariate analyses, NCPs were significantly more
likely than CPs to choose EDs for children's NUC (OR=1.6 [1.12.3]). Among NCPs, a significant gradient was found with
LPRPs the least likely to choose ED for children’s NUC
(OR=1.3 [0.8-1.9]), followed by UIPs (OR=2.0 [1.3-3.3]), and
TRPs (OR=2.9 [1.6-5.4) at greatest risk. For CPs, the number of
siblings (OR=1.6 [1.3-1.9]), uninsurance (OR=6.7 [1.8-25.2]),
unemployment (OR=4.6 [2.1-9.9]), and LEP (OR=7.4 [3.7-14.8])
were all associated with greater likelihood of choosing ED for
children’s NUC. Among NCPs, uninsurance (OR=1.9 [1.1-3.4],
lower educational attainment (OR=1.7 [1.2-2.5]) and poverty
(OR=2.7 [1.7-4.3]) were associated with choosing the ED for
NUC. Parental unemployment (OR=0.5 [0.3-0.8]) and long
waits to see a doctor (OR=0.6 [0.4-0.9]) were associated with
a lower likelihood of choosing EDs for NUC among NCPs.
Conclusions: NCPs are significantly more likely than CPs to
choose EDs for children's NUC, with UIPs and TRPs at
highest risk. Poverty, uninsurance, and lower parental
educational attainment significantly increase the likelihood of
NCPs, particularly UIPs and TRPs, choosing EDs for their
children’s NUC. In contrast, unemployment, LEP, and the
number of siblings in the household increase the likelihood of
choosing EDs for children’s NUC among CPs.
Implications for Policy, Delivery, or Practice: Educational
programs that increase NCP’s (particularly UIPs and TRPs)
awareness, knowledge, and skills in responding to children’s
NUC needs and the appropriate use of EDs also are needed.
Our findings that suggest efforts to reduce poverty, and
increase insurance coverage and education attainment among
NCPs are likely to reduce the use of EDs for children’s NUC.
Primary Funding Source: No Funding
●School Mental Health Services in the United States,
2002-2003
Judith Teich, MSW, Susan Foster, MSSW, M.P.H., Gail
Robinson, Ph.D., Mary Rollefson, Ph.D., Theresa Doksum,
Ph.D., M.P.H., Denise Noonan, Ph.D.
Presented By: Judith Teich, MSW, social Science Analyst,
Center for Mental Health Services, SAMHSA, 1 Choke Cherry
Road, Rockville, MD 20852; Tel: (240)276-1967; Fax: (240)2761340; Email: judith.teich@samhsa.hhs.gov
Research Objective: This study, “School Mental Health
Services in the United States, 2002-2003,” provides the first
national survey of mental health services in a representative
sample of the approximately 83,000 public elementary,
middle, and high schools and their associated school districts
in the United States. It provides new information about the
role of schools in providing mental health services, and how
these services are organized, staffed, funded, and coordinated.
Study Design: The survey methodology included two mail
questionnaires that were developed for this project with the
guidance of an expert panel. Questions concerned services
and supports delivered to students who have been referred
and identified as having psychosocial or mental health
problems. The school questionnaire collected data on the
types of MH problems encountered in schools, the MH
services provided, the types and qualifications of staff
providing services, the type and degree of care coordination,
and the arrangements for delivering MH services. The district
questionnaire collected data on funding sources for MH
services and issues related to funding. The survey also
solicited impressions from school administrators and MH
personnel concerning issues affecting school MH services.
Population Studied: School Mental Health Services in the
United States, 2002–2003 is a nationally representative
sample of public K–12 schools and their associated school
districts. A random sample of 2,125 schools and the 1,595
districts associated with them was drawn from the U.S.
Department of Education’s public school data file, the
Common Core of Data for 2000–2001. The size of the sample
was designed to provide reliable estimates of the universe of
regular public schools by level (elementary, middle, and high
school) and by size, as measured by student enrollment: small
(from 1 to 250 students); medium (251–500 students); large
(501–1,000 students); and very large (1,001 and more
students). The sampling strategy was also designed to yield
estimates by each region (Northeast, Midwest, South, West)
and locale (urban/central city, suburban/large town, small
town/rural) and to populate the standard table shell used in
this report. Ultimately,1,147 schools in 1,064 districts across
the country responded to the survey. “Critical items”
information was collected from an additional 150 schools.
The quantifiable data were weighted to create national
estimates for numbers of schools and districts by region and
by size. This was done so that the total numbers and the
distributions would match those of all schools and districts in
the nation in the 2002–2003 school year. The final weighted
response rates were 60.5 percent for schools and 59.85
percent for school districts.
Principal Findings: • Nearly three-quarters (73%) of the
schools reported that “social, interpersonal, or family
problems” were the most frequent MH problems for both
male and female students. • For males, aggression or
disruptive behavior and behavior problems associated with
neurological disorders were the second and third most
frequent problems, while anxiety and adjustment issues were
the next most frequent problems for females. • All students,
not just those in special education, were eligible to receive
MH services in the vast majority of schools (87%). • On
average, one-fifth of students received some type of schoolsupported mental health services in the school year prior to
the study. • Virtually all schools reported having at least one
staff member whose responsibilities included providing
mental health services to students. • The most common types
of school mental health providers were school counselors,
followed by nurses, school psychologists (non-Ph.D.), and
social workers. School nurses spend approximately a third of
their time providing mental health services. • More than 80
percent of schools provided assessment for mental health
problems, behavior management consultation, and crisis
intervention, as well as referrals to specialized programs. A
majority also provided individual and group counseling, and
case management. • Financial constraints of families and
inadequate school mental health resources were the most
frequently cited barriers to providing mental health services.
• Almost half of school districts (49%) used contracts or other
formal agreements with community-based individuals and/or
organizations to provide mental health services to students.
The most frequently reported community-based provider type
was county mental health agencies. • Districts reported that
the most common funding sources for mental health services
or interventions were the Individuals with Disabilities
Education Act (IDEA); State special education funds, and local
funds. In 28 percent of districts, Medicaid was among the top
five funding sources for mental health services. • One third of
districts reported that funding for mental health services had
decreased since the beginning of the 2000-2001 school year,
while over two-thirds of districts reported that the need for
mental health services increased. • Sixty percent of districts
reported increased referrals to community-based providers;
one third reported that the availability of outside providers to
deliver services to students had decreased.
Conclusions: This study, School Mental Health Services in
the United States, 2002–2003, provides the first source of
comprehensive information on the mental health services
provided in the approximately 83,000 public elementary,
middle, and high schools and their associated school districts
in the United States. The study's findings confirm that mental
health services currently play an integral role in the school
setting. The findings also suggest that needs for mental health
services are increasing, and that adequate funding and
availability of community resources are essential if schools are
to meet the challenge of addressing these needs.
Implications for Policy, Delivery, or Practice: This survey is
the first comprehensive, nationally representative survey of
mental health services in U.S. public schools. Obtaining an
unbiased sample of schools and districts was a timeconsuming, labor-intensive process. While the survey provides
important baseline information, it also leaves many questions
unanswered and raises additional questions. It provides
measures of the mental health problems encountered in
school settings, but it does not address how many students
present with each type of problem and how these problems
differ by demographic background characteristics of students.
While the survey found widespread eligibility for mental health
services and a surprisingly wide array of services provided, the
measures of service eligibility and provision are fairly broad.
The survey revealed the percentage of schools offering various
types of services, but it did not ask about the intensity or
duration of different services, which services were provided for
which mental health problems, the adequacy or
appropriateness of the services to the needs of the students,
or the degree to which the need for various services was met.
Further, the survey gathered only limited information about
prevention. Future research should be conducted to guide
school officials regarding the most effective combinations of
prevention and intervention services for their schools. The
individuals who provide mental health services in schools
include specialists with graduate degrees and licensure in their
fields as well as nurses and paraprofessionals, but this survey
does not address whether these staff have specific
qualifications to treat the major presenting problems at each
school level. Several open-ended comments also pointed to
the inadequacy of staff-to-student ratios. Future research
should measure specific staff and service assignments, the
qualifications of staff to provide those services, and the
professional development needs and experiences of staff. It
would be important to learn more about the amount of
funding allocated to different types of prevention, assessment,
and treatment services according to the number of children
served and their presenting problems. Such an analysis would
shed light on equity of funding, disparities between wellresourced and under-resourced schools, and would guide
policymakers in their decisions about funding allocation for
mental health services. The survey identified the top sources
of funding for mental health services and which sources were
used for prevention versus intervention services. However,
additional information is needed about the specific services
that various funding streams support. Further, more research
is needed to determine the distribution of funding and other
resources for mental health services by region, urbanicity,
minority enrollment, and other school characteristics.
Primary Funding Source: Other
Related Posters
Child Health
Poster Session A
Sunday, June 25 • 2:00 pm – 3:30 pm
●Why Do Parents Bring Children to the Emergency
Department (ED) For Nonurgent Conditions?
Anne Berry, BA, David C. Brousseau, M.D., Jane Brotanek,
M.D., Sandra C. Tomany-Korman, MS, Glenn Flores, M.D.
Presented By: Anne Berry, BA, Medical Student, Penn State
College of Medicine, 321 University Manor West, Hershey, PA
17033; Tel: 717-531-7880; Email: aberry@psu.edu
Research Objective: Emergency department (ED) use
increased 20% from 1992 - 2001, with children comprising 1/4
of all ED visits, or 22 million visits per year. 58-82% of
pediatric ED visits are for nonurgent conditions.
Demographic characteristics of families using the ED for
pediatric nonurgent conditions are well described, but the
reasons parents seek this care in the ED have not been
identified, and no published qualitative research has examined
this issue. The objective of this study was to determine why
families use the ED for nonurgent pediatric care by identifying
parents’ reasons for choosing the ED over primary care.
Study Design: Ethnographic interviews of parents of children
presenting for nonurgent care. Parents were asked 20
questions using a semi-structured interview guide. Interview
transcripts were analyzed using grounded theory.
Population Studied: Parents of children presenting for
nonurgent care on weekdays from 8 am - 4 pm at a children’s
hospital ED over a 4-week period
Principal Findings: For the 31 families (37 parents)
interviewed, the mean parental age was 29 years, and the
mean child age was 3 years. English was the primary language
for 30 parents and Spanish for 7. All patients were insured
(68% publicly insured), and only one child did not have a
primary care physician (PCP). Reasons identified by
caregivers for choosing the ED over their child’s PCP were:
healthcare provider referral (“If my doctor recommended it,
that was the only reason I went”), long appointment wait (“He
wasn’t able to get him in… today or tomorrow, he has so
many patients.”), efficiency (“you can’t beat it for speed”), ED
resources (“They can perform a test right there”),
convenience, quality of care (“I feel that the doctors [in the ED]
are more skilled.”), dissatisfaction with the PCP (“They have
bad attitudes there”), communication problems (accents and
unhelpful staff at PCP), and ED expertise with children. Some
parents said they would like education on the urgency of
pediatric problems. When asked if her child’s PCP provided
such teaching, one mother replied, “It would be helpful, but
no.”
Conclusions: Parents bring their children to the ED for
nonurgent care because of PCP referral, efficiency,
dissatisfaction with PCPs, higher quality of care, long waits to
see PCPs, and PCP communication problems.
Implications for Policy, Delivery, or Practice: Although
parents report that education on the urgency of pediatric
conditions would be helpful, substantial reduction of pediatric
nonurgent ED use may require improvements in families’ PCP
office access, efficiency, experiences, and appointment
scheduling. In particular, the study findings indicate that the
most useful measures might include enhanced patientprovider communication, extended office hours, access to a
"fast-track" option in practices for urgent care, and periodic
quality assurance review of reasons for ED referrals.
Primary Funding Source: APS/SPR Student Research
Program
●The Use of Hospital Discharge Data in the Study of
Births and Deliveries: Results from the 2003 Nationwide
Inpatient Sample.
Thomas M. Brady, Ph.D., Claudia A. Steiner, M.D., M.P.H.,
Chaya T. Merrill, M.P.H.
Presented By: Thomas M. Brady, Ph.D., Lead Health Services
Researcher, Thomson Medstat, 4301 Connecticut Ave., Suite
330, Washington, DC 20008; Tel: (202) 719-7871; Fax: (202)
719-7801; Email: thomas.brady@thomson.com
Research Objective: The National Center for Health Statistics
birth certificate data (BCD) are widely considered the gold
standard for information regarding births in the United States.
In addition to BCD, hospital discharge data are also useful in
the analysis of births and deliveries. This paper compares a
national sample of BCD with a national data set of hospital
discharge data, the Nationwide Inpatient Sample (NIS) of the
Healthcare Cost and Utilization Project (HCUP). The aim of
the paper is to evaluate the HCUP NIS and provide a valuable
resource for researchers who wish to use national discharge
data to study births and deliveries.
Study Design: The number of hospital-based births and
deliveries presented in the NCHS’ report Births: Final Report
for 2003 are compared to the counts of live births sampled in
the 2003 NIS. Births, deliveries and associated conditions are
identified using the International Classification of Diseases,
9th Revision, Clinical Modification (ICD-9-CM) codes in the
analysis of NIS data. Rates of low birth weight and prematurity
from both national datasets are compared. Comparisons of
obstetrical procedures, labor and/or delivery complications,
newborn abnormal conditions and congenital anomalies are
also presented. Rates are calculated using 2003 NCHS data as
the population denominator.
Population Studied: All hospital-based U.S. births and
deliveries reported in 2003.
Principal Findings: Findings from a preliminary analysis of
2002 data are available. In that year, national birth certificate
data systems reported 4,021,726 live births compared to
4,154,343 in the NIS. National estimates from the NIS revealed
a greater prevalence of abnormal conditions and congenital
anomalies of the newborn compared to birth certificate data in
2002. Rates of anencephalus (0.1/1,000 births in both the
BCD and NIS) and spina bifida (0.2/1,000 births in the BCD
and 0.3/1,000 births in the NIS) were similar between the two
data systems. Reports of birth injuries, however, were more
than ten times more prevalent in the NIS than the NCHS data
set. The rate of birth injuries in the BCD was 2.7/1,000 births
and the rate in the NIS was 30.4/1,000 births. In addition,
among newborn congenital anomalies, there were much
higher estimates of heart malformations and malformed
genitalia in the NIS compared to the NCHS data. Findings
using 2003 data, including a comparison of frequencies of
obstetrical procedures and labor and delivery complications,
will be presented.
Conclusions: In comparing the two data systems, the total
number of annual births is similar. The preliminary findings
suggest that there are significant differences in some
estimates of abnormal conditions and congenital anomalies of
the newborn between the NIS data as compared to birth
certificate data. The paper will discuss these findings and
potential explanations for the observed differences. The
project will also explore the relative strengths and weaknesses
of utilizing hospital discharge data in the study of births and
deliveries.
Implications for Policy, Delivery, or Practice: Our
preliminary findings support the use of hospital discharge
data as a powerful and reliable alternative data source to the
BCD to monitor and study conditions of the newborn as well
as track the utilization of perinatal health care services.
Primary Funding Source: AHRQ
●Impact of Family Structure on Children's Ambulatory
Care
Alex Chen, M.D., MS, Jose Escarce, M.D., Ph.D.
Presented By: Alex Chen, M.D., MS, Assistant Professor,
Pediatrics, Childrens Hospital Los Angeles, 4650 Sunset Blvd.
MS # 30, Los Angeles, CA 90027; Tel: 323-671-7620; Fax: ;
Email: achen@chla.usc.edu
Research Objective: To examine how family structure impact
children's use of ambulatory care services including office
visits, emergency room visits, and prescription medications.
Study Design: This is a secondary data analysis of the 19962001 Medical Expenditure Panel Survey (MEPS). We used
negative binomial regression to model office visits and
emergency room visits and logistic regression to model the
likelihood of prescription medication use. Our analyses
adjusted for demographic and socioeconomic characteristics
as well as measures of children’s health and parental
education and child-rearing experience.
Population Studied: The study consisted of a nationally
representative sample of children 0-17 years of age living in
single-mother or two-parent families.
Principal Findings: Living in single-mother family was
strongly associated with decreased ambulatory care services
use compared to living in two-parent family; however, the
effect exerted by single-mother vs. two-parent status was
completely explained away after adjustments for race,
insurance coverage, family income, and maternal education.
In addition, we found that children living in families with many
other children had fewer total and physician office visits and a
lower likelihood of using a prescription medication than
children living in families with no other children. Children
who lived with other adults in addition to their parent (such as
cohabitation) also had fewer office visits and a lower likelihood
of using a prescription medication.
Conclusions: Children living in families with many other
children or with other adults use less ambulatory care and
prescription medications than their peers.
Implications for Policy, Delivery, or Practice: Our study
findings suggest that children can be vulnerable to decreased
ambulatory care and possibly unmet need as a result of their
family structure. It would be helpful to raise awareness
among health care providers so that they can monitor children
in cohabiting households or children with many siblings more
closely for follow-up appointments. In addition, policies that
provide support for working parents with many children, such
as family leave days, may enable them to take their children for
care while alleviating some of the stress and demand on their
time
Primary Funding Source: AHRQ
●Effectiveness of Kentucky's Mandated Preschool Vision
Specialist Exam
Julia Costich, J.D., Ph.D., William Reynolds, O.D., Svetla
Slavova, M.S.
Presented By: Julia Costich, J.D., Ph.D., Chair, Dept. of Health
Services Management, College of Public Health, 121
Washington Ave., Lexington, KY 40536; Tel: 859-257-6712; Fax:
859-257-3909; Email: julia.costich@uky.edu
Research Objective: To determine whether the
comprehensive cycloplegic vision examination mandated by
Kentucky law prior to school entry is effective in detecting
vision problems that are missed on primary care provider
vision screenings.
Study Design: A survey was fielded with 46 optometrists and
ophthalmologists who agreed to participate, resulting in 1,391
complete responses. Data were encoded and analyzed using
SAS to determine correlations among findings. An algorithm
was developed to identify children whose vision problems
were not identified by screening in preschool physicals.
Significance and confidence levels were calculated. Vision
problems were identified using widely accepted professional
guidelines.
Population Studied: Kentucky children ages 3-6 years.
Children eligible for publicly funded health coverage were
disproportionately represented (56% v. 37% statewide).
Principal Findings: Some 300 children were identified as
having vision problems, 72 of whom had been screened in the
context of preschool exams and had not previously seen an
eye care specialist. Only 9 identified vision problems had
been found in the preschool physicals (95% confidence
interval: .76-.93). Supplementary funding sources for children
without coverage for the exams were underutilized. Nearly
half of parents reported no vision screening in preschool
examinations.
Conclusions: Kentucky's mandated preschool vision
examination identified a significant number of children with
previously undetected vision problems, even among those
children whose vision was screened in their preschool
physicals.
Implications for Policy, Delivery, or Practice: While
comprehensive vision examinations were significantly superior
to screenings in detecting vision problems, the contribution of
early detection to school performance or remediation has not
been clearly demonstrated. Nevertheless, these findings
indicate that broader adoption of and coverage for preschool
examinations by a vision care specialist would help children
overcome vision-related barriers to success in school.
Primary Funding Source: Vision Council of America
●An Examination of Specialization and Outcomes of Care
at Children's Hospitals: Are Children's Hospitals Better
Qualified to Care for Children?
Jami DelliFraine, Ph.D.
Presented By: Jami DelliFraine, Ph.D., Assistant Professor,
Health Policy and Administration, The Pennsylvania State
University, 116 Henderson, University Park, PA 16802; Tel:
(814) 863-2861; Email: jld40@psu.edu
Research Objective: Objective. To test the hypotheses that 1)
children’s hospitals provide more specialized care than
general hospitals, 2) specialization is associated with better
outcomes of care for children, and 3) some organizational
factors are associated with better outcomes for children.
Study Design: Study Design. A structural equation model
with latent variable analysis assessed the risk-adjusted
outcomes differences for children admitted to children’s
hospitals and general hospitals. Key variables in the analysis
included children’s hospital status, a latent variable
representing organizational specialization, and overall riskadjusted mortality rates for children.
Population Studied: Population Studied. This study used the
2000 Healthcare Cost and Utilization Project KID database
and the 2000 American Hospital Association database. The
study examined 464 hospitals that provide children’s care in
nineteen metropolitan areas. Data were extracted from the
secondary data sources using SPSS 13.0 and AMOS 5.0
statistical software.
Principal Findings: Principal Findings: The results of this
study indicate that children’s hospitals are more specialized in
children’s care than most general acute care hospitals.
However, no significant overall mortality differences were
found between children treated at children’s hospitals and
children treated at general acute care hospitals.
Conclusions: Conclusions: Findings support the premise that
children’s hospitals offer the most specialized care for
children and treat the sickest children. The results suggest that
organizational factors influence specialization in children’s
care. However, more research is needed examining outcomes
and quality differences between hospitals that treat children.
Implications for Policy, Delivery, or Practice: Implications:
For policymakers, this study demonstrates that children's
hospitals offer the most specialized services and that these
institutions are magnets for very ill children. Funding cuts that
decrease Medicaid payments, decrease Disproportionate
Share Hospital payments, and cut Graduate Medical
Education funding are likely to cut into the revenue of these
facilities, threatening the ability of these institutions to offer
specialized services.
Primary Funding Source: No Funding
●Impact of Managed Care on Perinatal Regionalization
Deborah Dobrez, Ph.D., Peter Budetti, Ph.D., M.D., Susan
Gerber, M.D., M.P.H.
Presented By: Deborah Dobrez, Ph.D., Assistant Professor,
Health Policy and Administration, University of Illinois at
Chicago, 1603 West Taylor Street, Chicago, IL 60618; Tel: 312413-8854; Email: ddobrez@uic.edu
Research Objective: The goal of this study was to describe
trends in regionalization of perinatal care, to identify factors
that predict the extent of regionalization, and to test the effect
of managed care penetration on regionalization.
Study Design: Secondary analysis of birth certificate,
managed care enrollment, and American Hospital Association
databases was conducted. Bivariate tests compared birth rates
within weight categories by state and hospital level over time.
Panel data models estimated the impact of managed care
enrollment on site of delivery for low, very low, and extremely
low birthweight neonates.
Population Studied: All deliveries at non-military hospitals
with obstetrical services and greater than 50 deliveries
annually in California, Washington, North Carolina, and
Illinois were included in the study. To capture changes over
time in the degree of regionalized perinatal care, data were
drawn over a ten year time period, from 1989 to 1998.
Principal Findings: Strong evidence for enhanced perinatal
regionalization over time was observed for North Carolina and
Illinois, with little change in site of delivery in Washington,
which was highly regionalized at the beginning of the study
period. A shift from level III to level II hospitals, which we
consider evidence of de-regionalization, was observed for low
and very low birthweight neonates in California. Although
managed care enrollment increased substantially in all four
states, no relationship between enrollment and site of delivery
was detected.
Conclusions: Perinatal studies provide strong evidence of the
benefits from the delivery of high-risk neonates at tertiary care
centers, yet the percentages of very low birthweight neonates
delivered at level III hospitals were substantially lower than the
goal of 90% set by Healthy People 2010. Nevertheless,
increased managed care penetration cannot be cited as the
reason for the failure to meet this national goal.
Implications for Policy, Delivery, or Practice: Our study
demonstrates significant failures in meeting Healthy People
2010 goals for site of delivery of high risk infants that require
explanations other than the financial pressures introduced by
managed care. Further studies of market and institutional
barriers to regionalization are needed to identify steps to
improve performance toward meeting the Healthy People
2010 goals.
Primary Funding Source: National Institute for Child Health
and Human Development
●Can Education and a Preemptive Prescription Prevent ER
Visits for Ear Pain?
Dawn Finnie, M.P.A., Deborah McWilliams, M.D., James
Naessens, M.P.H., Holly Van Houten, BA
Presented By: Dawn Finnie, MPA, Health Services Analyst,
Health Care Policy & Research, Mayo Clinic, Pavilion 3,
Rochester, MN 55905; Tel: (507)538-3346; Fax: (507)284-1731;
Email: finnie.dawn@mayo.edu
Research Objective: To determine whether providing parent
education and a prophylactic prescription of an ear-numbing
agent (antipyrine/benzocaine) at a well child visit at 15 months
of age affects the utilization of ear pain-related emergency
room (ER) visits over the next 12 months.
Study Design: A “differences in differences” assessment was
performed on a controlled cohort study where parents of
patients visiting a pediatric clinic for a 15 month well-child visit
March 2003 to June 2003 were given a prescription for earanalgesic drops along with RN-provided education on
managing ear pain (N=191). All patients with 15 month well
child visits during the same timeframe at other sites caring for
children at our institution were identified as controls (N=133).
Additionally, cohorts of patients with 15 month well child visits
in the same 3 months in the year prior to intervention were
used as baseline values (N=168 for intervention clinic and 126
for other clinics). Dependent variables included the percent of
patients with ear pain – related visits,ER visits and the ER visit
rate per eligible.
Population Studied: Primary data (patient satisfaction and
medical care knowledge) and secondary data (ER and office
visit utilization) were collected from 03/2002 to 06/2004
among patients on primary care panels at our institution. All
children with 15 month well child visits to primary care sites in
the study and baseline timeframes were identified through
administrative data. Those children making visits to the
intervention site were considered as receiving the intervention.
Visits with a principal or secondary diagnosis of ear pain were
identified through administrative data.
Principal Findings: After the intervention, significant
decreases were observed in the intervention clinic in visit
utilization for ear pain to the ER (down 80%. p=0.01), Urgent
Care Center (40%, p=0.02) and also primary care (28%,
p=0.04), with no significant change in the controls over this
time. When using a regression model to compare the change
in rates between sites, the decline in ER use in the intervention
site remained significant (p=0.04). When surveyed, parents
receiving education and the prescription strongly endorsed the
practice change at the 15 month visit and remained
supportive at the 2 year visit. On the 2 year survey, over 80%
of those with ear pain since their 15 month visit felt the
intervention helped them to avoid an ER/UCC visit. No safety
concerns were identified.
Conclusions: RN-provided education at a well child visit (with
prophylactic analgesic prescriptions) reduced ER, Urgent Care
and primary care visits for ear pain in toddlers and was well
appreciated by parents.
Implications for Policy, Delivery, or Practice: Pediatric
health care utilization is influenced by parents' knowledge and
their ability to manage common pediatric symptoms.
Providing parents with management tools for typically minor
illnesses can result in fewer medically-unnecessary after-hours
visits.
Primary Funding Source: No Funding
●A Method for Risk Adjustment for the AHRQ Pediatric
Quality Indicators
Corinna Haberland, M.D., MS, Jeffrey Geppert, J.D., Patrick
Romano, M.D., Sheryl Davies, MA, Amy Ku, M.H.S.A., Kathryn
McDonald, MM
Presented By: Corinna Haberland, M.D., MS, Researcher,
Center for Health Policy / Primary Care Outcomes Research,
Stanford University, 117 Encina Commons, Stanford, CA
94305; Tel: 650-723-1935; Fax: 650-723-1919; Email:
corinnah@stanford.edu
Research Objective: When using quality indicators for
comparative purposes, adjusting for underlying health status
of the patient is crucial. Several tools exist for use with adult
administrative data sources; however no comparable
approach is available for pediatrics. We analyze the feasibility
of using the Clinical Classification Software (CCS) from the
Agency for Healthcare Research and Quality (AHRQ) in
conjunction with the 2002 State Inpatient Data (SID) to
develop risk adjustment measures based on clinical
importance and empirical validity.
Study Design: We augmented standard methods of
developing a risk adjustment system with use of newly
available data from two states (NY and CA) that specify
whether a condition is present on admission (POA). We
identified codiagnoses present in pediatric inpatients with
diagnoses flagged as complications of care by the AHRQ
Quality Indicators (QIs). Using the NY and CA SID data, we
identified those cases where the codiagnoses were POA, i.e.
likely comorbidities, and those not POA, i.e. likely
complications associated with that hospital stay. We also
calculated the relative risks (RR) to compare the rates for
patients developing the QI diagnosis when the CCS diagnosis
was likely either a complication or comorbidity, versus the
overall rate. Finally we developed a measure of estimator bias
(EB), a function of the QI rate when the CCS is POA, adjusted
for the rate calculated if POA status were unknown (as is the
case for most states in the SID 2002), with possible values
ranging from 0 (no bias) to 1 (maximum bias). After a clinical
review of the CCS codiagnoses list, we assessed the
consistency of the clinical expectation with these empiricallygenerated values to determine which CCS categories were
candidates for risk adjustment, given a dataset where POA
status is unknown.
Population Studied: Pediatric inpatients in the SID 2002
database.
Principal Findings: Clinically, we expected some CCS
categories to have higher risks of a QI complication.
Empirical results were confirmatory. For example, Fluid and
Electrolyte Disorders had a RR of 2.7 in patients with the CCS
POA for the Post-Operative Hemorrhage and Hematoma
indicator, and a RR of 3.6 in patients where the CCS was not
POA. CCS categories that would not be clinically useful risk
adjusters showed RR closer to 1 (e.g. Genitourinary Symptoms
in the Post-Operative Respiratory Failure indicator).
Comparing clinical and empirical results was most helpful
when the CCS category could be associated with either an
elevated risk of developing the indicator diagnosis, or
occurrence along with the indicator diagnosis.
Using the EB, which for the Iatrogenic Pneumothorax
indicator ranged from 0 to 0.9 in Intestinal Obstruction and
Other Upper Respiratory Infections, respectively, we selected
CCS categories that were clinically important, and minimized
the potential of misclassifying complications as comorbidities.
For example, in the Post-Operative Respiratory Failure
indicator the CCS group with Urinary Tract Infections has an
overall RR of 2.6, a potentially important risk-adjuster.
However, when the RR for POA and not POA are compared
(less than 2 and 6.5, respectively) its risks as a comorbidity are
much less than as a complication, consistent with the
relatively high EB value of 0.6. These numbers comport
clinically, given that such an infection is unlikely to increase a
patient’s risk of respiratory failure if identified on admission
(assuming appropriate treatment during hospital stay).
Conclusions: Using enriched data and these metrics along
with clinical judgment provides insight about potential
usefulness of codiagnoses as risk-adjusters (i.e. avoiding
adjusting for a comorbidity that is likely to be a complication
arising during a hospitalization).
Implications for Policy, Delivery, or Practice: Risk
adjustment techniques for pediatrics have become
increasingly necessary in quality assessment work. This
approach provides a parsimonious method of generating a
risk adjustment tool based on administrative data for the
forthcoming AHRQ pediatric quality indicators.
Primary Funding Source: AHRQ
●Access to Safe Parks Helps Increase Physical Activity
Among Teenagers
Theresa Hastert, M.P.P., Susan Babey, Ph.D., E. Richard
Brown, Ph.D.
Presented By: Theresa Hastert, MPP, Research Associate, ,
UCLA Center for Health Policy Research, 10911 Weyburn Ave.,
Suite 300, Los Angeles, CA 90024; Tel: (310) 794-2827; Fax:
(310) 794-2686; Email: thastert@ucla.edu
Research Objective: To examine the relationship between
neighborhood characteristics and physical activity among
adolescents in California.
Study Design: We used data from the 2003 California Health
Interview Survey (CHIS), a random-digit dial (RDD) telephone
survey of 42,000 households drawn from every county in
California. Bivariate and multivariate analyses were used to
examine the relationship between family and neighborhood
characteristics and level of physical activity.
Population Studied: Responses of 4,010 adolescents
interviewed for CHIS 2003.
Principal Findings: Nearly 30% of California adolescents do
not meet physical activity recommendations. Teens with
access to a safe park have higher rates of regular physical
activity (71.8% vs. 67.3%) and lower rates of inactivity (6.4%
vs. 10.3%) than those without access, but more than one in
four teens does not have access to a safe park, playground or
open space. Access to safe parks is particularly important for
teens living in urban areas, those from low-income families,
those living in apartments, and those living in neighborhoods
perceived as unsafe. Twice as many teens living in urban
areas are inactive (9.4% vs. 4.5%) and fewer get regular
activity (66.8% vs. 76.1%) compared to those living in rural
areas, but fewer urban teens with access to a safe park are
inactive (7.8% vs. 14.1%) and more get regular activity (68.6%
vs. 61.3%) than urban teens without access. More teens living
in multi-unit apartment buildings are inactive (10.2% vs.
6.5%) and fewer get regular activity (63.1% vs. 72.9%)
compared to those living in single family homes, but among
teens living in apartments, half as many with access to a safe
park are inactive (8.0% vs. 16.3%) and more get regular
activity (65.6% vs. 56.1%) than teens in apartment buildings
without access to a safe park. Fewer teens from lower-income
families with access to a safe park are inactive (7.6% vs.
12.0%) and more get regular activity (68.7% vs. 63.1%) than
those without access to a safe park. In neighborhoods
perceived as unsafe, fewer teens with access to a safe park are
inactive than those without access to a safe park (9.0% vs.
16.3%). After adjusting for other factors, adolescents living in
apartments are less likely to get regular physical activity than
those living in houses and those with no access to a safe park
are more likely to get NO physical activity than those with
access.
Conclusions: These findings suggest that access to safe parks
has a positive effect on physical activity behaviors in
teenagers, especially those from urban areas, those living in
apartment buildings, those from low-income families and
those living in neighborhoods their parents perceive as
unsafe.
Implications for Policy, Delivery, or Practice: Expanding
park access and safety for adolescents living in urban areas
and less advantaged adolescents promises to have the
greatest and most positive impact on adolescent physical
activity behaviors.
Primary Funding Source: RWJF
●On the Front Line in Children’s Health Care: Caseloads,
Scope of Practice, and Satisfaction with Care among Rural
and Urban School Nurses in Pennsylvania
Marianne Hillemeier, Ph.D., M.P.H., Lisa A. Davis, M.H.A.
Presented By: Marianne Hillemeier, Ph.D., M.P.H., Assistant
Professor, Health Policy and Administration, The Pennsylvania
State University, 116 Henderson, University Park, PA 16802;
Tel: 814-863-0873; Fax: 814-863-2905; Email: mmh18@psu.edu
Research Objective: To evaluate the scope of nursing
services provided in rural and urban public schools in
Pennsylvania, and nurses’ perceived satisfaction with the level
of care provided.
Study Design: Survey of school nurses representing each of
Pennsylvania’s 500 active school districts (n=615 out of a total
sample of 996; response rate=61.7%). Topics assessed
included number and proportion of students with specific
health care needs; types of nursing services and procedures
provided in the school setting; percent of students screened
annually for various health conditions; provision of instruction
and counseling related to specific health topics; perceived
satisfaction with the current level of nursing services provided;
and the school nurse to student ratio.
Population Studied: School nurses practicing in rural and
urban public elementary and secondary schools in
Pennsylvania.
Principal Findings: School nurse caseloads contained a
sizable proportion of students with special health care needs;
the most prevalent health problems included asthma (9.4%),
weight disorder (6.0%), severe allergies (5.5%), and ADHD
(4.9%). Specialized procedures were often provided including
blood sugar testing (75.8%), nebulizer treatments (68.9%),
insulin pump management (41.0%), and catheterization
(15.3%). Similar types and numbers of medical procedures
were provided by both rural and urban school nurses. Over
70% of all secondary school nurses provided education and
counseling on pregnancy prevention, STD prevention, and
substance use, however education and counseling on other
important issues such as nutrition and mental health were
less often provided. Among secondary school nurses, those
in rural settings were more likely to report being very satisfied
or satisfied with the health care provided to students in their
schools; no differences in satisfaction with care was found
among rural and urban elementary school nurses. There were
fewer nurses per school district in rural areas relative to urban,
however because rural districts generally have fewer enrolled
students their school nurse to student ratios tended to be
more favorable (1:936 on average in rural districts vs. 1:1084 in
urban districts). Overall, lower school nurse to student ratios
were positively and significantly associated with greater
perceived satisfaction with the level of health care provided to
students (p=0.05).
Conclusions: The health care needs of children in elementary
and secondary schools are diverse and complex, and many
school nurses are called upon to provide skill-intensive
procedures. Education and counseling about important
health-related issues are provided in some, but not all, school
settings. Nurses practicing in schools where school nurse to
student ratios are lower are more likely to express satisfaction
with the level of health care provided to students.
Implications for Policy, Delivery, or Practice: School nurses
are the health professionals most consistently involved in
dealing with the complex health needs in the school-age
population. Professional nursing organizations and public
health initiatives such as Healthy People 2010 recommend
that school nurse to student ratios not exceed 1:750, and study
findings suggest that lowering current ratios will result in
more optimal health services for children in public school
settings.
Primary Funding Source: The Center for Rural Pennsylvania
●Developing and Evaluating Networks to Enhance
Population Health
Timothy Huerta, Ph.D., Ann Casebeer, Ph.D., Janice Popp
Presented By: Timothy Huerta, Ph.D., Research Scientist,
PHSA Research and Networks, Child and Family Research
Institute, 601 West Broadway, Vancouver, V5Z4C2; Tel:
604.707.6398; Fax: 604.707.6399; Email: tim.huerta@ttu.edu
Research Objective: This paper presents the lessons that five
years of networked experience has produced for CYHNC
network members collectively, and puts forward a plan for
improving network capacity in support of population health
goals.
Study Design: Action Research involving academics and
practitioners to define the implementation challenges faced by
interorganization networks.
Population Studied: The Child and Youth Health Networks of
Canada (CYHNC) is an inter-organizational network
connecting child and youth health services networks across
Canada.
Principal Findings: Increasingly, health services
organizations are being called to take on more proactive roles
in promotion and prevention rather than focusing on services
alone. Several factors are moving them toward collaboration
as a strategy for managing the complexity of the problems
they encounter: There is growing consensus that solutions
require broader responses than health service agencies can
marshal alone; Many organizations find themselves offering
services to populations served by others in similar ways;
creating duplication and inequity; Clients must self-manage
the burden of navigation among inter-organizational partners,
often at times when they are least able to cope; Organizations
are seeking opportunities increasing their awareness of better
practices among agencies sharing similar problems and goals.
Conclusions: In response, some agencies have self-organized
to create inter-organizational networks. This ‘network of
networks’ has developed for a number of reasons and in a
variety of ways. Individually and collectively, they have
struggled to conceptualize, implement and evaluate ways to
organize and develop themselves.
Implications for Policy, Delivery, or Practice: It identifies key
challenges and opportunities for improving networked
capacity to promote organizational and social change and
improve health.
Primary Funding Source: No Funding
Hispanic counterparts. Differences in socioeconomic status
and insurance coverage accounted for only a small portion of
the overall differences in health care utilization between
Hispanic and non-Hispanic children with asthma.
Primary Funding Source: Flinn Foundation
●Patterns of Health Care Utilization for Hispanic and
Non-Hispanic Children with Asthma
Tricia Johnson, Ph.D., Mary Rimza, M.D., William G. Johnson,
Ph.D.
●Prescription for Success: How School-Based Health
Centers Affect Health Status, Healthcare Use and Cost
Kathryn Keller, M.P.A., Terrance Wade, Ph.D., Jeff Guo, Ph.D.,
Ann McCracken, Ph.D.
Presented By: Tricia Johnson, Ph.D., Assistant Professor,
Health Systems Management, Rush University, 1700 West
Van Buren Street, TOB Suite 126B, Chicago, IL 60612; Tel:
(312) 942-7107; Fax: (312) 942-4957; Email:
tricia_j_johnson@rush.edu
Research Objective: A substantial and increasing share of
expenditures for hospitalizations and emergency medical
services for children in the U.S. are for asthma-related
illnesses. This paper examines the effect of ethnicity and
insurance coverage on health care utilization patterns for
children who have asthma.
Study Design: Data come from the Arizona HealthQuery, a
state-wide multi-year community health data system, for Yuma
County, Arizona. Yuma County is a low-income, semi-rural
agricultural community that borders Mexico. More than 70%
of Yuma children were Latino. The study included children
with an asthma diagnosis (ICD-9-CM diagnosis code of 493)
in 2002 and received medical care in each of the years, 2002,
2003 and 2004. Multivariate regression equations were used
to estimate the number of emergency department (ED)
services, inpatient hospitalizations and ambulatory physician
services for asthma care during this time period for Hispanic
and non-Hispanic children separately. Differences in
utilization were decomposed into differences due to
race/ethnicity and other observed characteristics (age, sex,
insurance coverage and geographic region of residence).
Population Studied: Children with asthma Yuma County,
Arizona.
Principal Findings: Both Hispanic and non-Hispanic children
with one or more gaps in health insurance used more ED
visits, and fewer ambulatory physician visits than Medicaidinsured children, while uninsured Hispanic children used
fewer hospitalizations than their Medicaid-insured
counterparts. Similarly, children who switched between public
and private insurance coverage had more hospitalizations and
fewer ambulatory physician visits than children consistently
covered by Medicaid. Decomposition results showed that
non-Hispanic children experienced more ED visits and
hospitalizations, but fewer ambulatory physician visits.
Conclusions: Differences in health care utilization for
Hispanic and non-Hispanic children were primarily due to
unobserved differences associated with race/ethnicity than
age, sex, insurance coverage or geographic region of origin.
Implications for Policy, Delivery, or Practice: Gaps in
insurance coverage markedly increased the utilization of ED
and inpatient services. Providing public (e.g., Medicaid)
insurance to uninsured children who have asthma could
decrease utilization of expensive emergency and inpatient
services. In this low income, rural community, Hispanic
children were more likely to use outpatient physician care and
used fewer ED visits and hospitalizations than their non-
Presented By: Kathryn Keller, MPA, Program Officer, The
Health Foundation of Greater Cincinnati, 3805 Edwards Road,
Suite 500, Cincinnati, OH 45209; Tel: 513-458-6616; Email:
kkeller@healthfoundation.org
Research Objective: To determine how SBHCs influence
student health, healthcare access and costs.
Study Design: As part of the SBHC Initiative, the Foundation
funded two multi-year studies to evaluate the effectiveness of
the model. For the first study, the SBHC Health Outcomes
Study, we conducted a 3-year longitudinal process and
outcome evaluation of eight SBHCs. Four comparison schools
were matched on student characteristics and proportion of
students receiving free and reduced lunch. Multiple, linked
sources of data included a 3-year panel survey of randomly
selected parent-child dyads, yearly student absence records,
and SBHC records and health encounters. A yearly survey
among SBHC school personnel was also collected. The
objective of the second study, the SBHC Cost Study, was to
evaluate health care utilization and costs of students in SBHC
programs. Using a retrospective quasi-experimental timeseries analysis, four SBHCs and two comparison school
districts were studied from 1997 to 2003. Repeated-measure
analyses were conducted to assess the changes of student’s
health care utilization and costs in hospitalizations,
emergency departments, physician encounters, mental health
services, dental, prescriptions, well child check-ups, and other
outpatient care.
Population Studied: The population for SBHC Health
Outcomes Study consisted of eight SBHCs and the schools
using the centers, the Schools’ students in grades K-8, parents
and school personnel. Four of these SBHCS were in Ohio and
four were in Kentucky. Four SBHCS were rural and four were
urban. This study also included matched schools without
SBHCS and their students and parents. The SBHC Cost Study
consisted of the students who were in the Ohio Medicaid
database and who were enrolled in one of the six Ohio
schools in the SBHC Health Outcomes study, four with
SBHCs and two without.
Principal Findings: Among other findings, our primary
findings from the studies showed that SBHCs improved the
health-related quality of life of students who used the SBHC,
did not change the overall Medicaid costs, decreased primary
care costs, increased mental and dental health
costs,decreased prescription drug costs,decreased
hospitalization and emergency room costs for children with
asthma, closed the healthcare utilization gap for African
American students, and reduced Medicaid costs for children
in the rural
Conclusions: SBHCs improve the health of students, help
keep kids in the classroom, support working parents and do
so at no additional cost to the Medicaid system.
Implications for Policy, Delivery, or Practice: SBHCs are a
model for providing quality healthcare services for children
that eliminates most barriers children face when trying to
access healthcare. SBHCs can address problems of
transportation, lack of nearby providers, lack of providers
accepting public insurance, and parental difficulties getting
time away from work to take a child to the doctor. While
SBHCs provide access to healthcare for children, funding
these centers can be challenging for a variety of reasons.
Addressing these reasons at a state level can help create an
environment in which SBHCs become an integral part of the
healthcare system. At the same time, because SBHCs
improve children’s health status, they support strategies that
seek to improve the lives of children.
Primary Funding Source: The Health Foundation of Greater
Cincinnati
●Persistence of High Health Care Expenditures Among
Children in Medicaid
Caprice Knapp, Ph.D., Elizabeth Shenkman, Ph.D., David
Sappington, Ph.D., Bruce Vogel, Ph.D., Des Schatz, M.D.
Presented By: Caprice Knapp, Ph.D., Post Doctoral Fellow,
Institute for Child Health Policy, University of Florida, 1329 SW
16th St, Room 5130, Gainesville, FL 32608; Tel: (352) 265-7220;
Fax: (352) 265-7221; Email: cak@ichp.ufl.edu
Research Objective: Our objective was to examine the
association between children’s health and sociodemographic
characteristics and the persistence of high health care
expenditures among Medicaid Health Maintenance
Organization (HMO) and Primary Case Management PCCM)
Program enrollees over a 3 year period. Because children
disenroll from and/or move between the HMO and PCCM
Programs, we also examined the relationships between the
children’s health and sociodemographic characteristics and
their odds of disenrollment and their odds of transferring
between programs.
Study Design: The Texas Medicaid HMO and PCCM
Programs provided child-level enrollment and
claims/encounter data for 2002 through 2005. The children’s
health status was categorized, using the Clinical Risk Groups
(CRGS), into one of five categories: healthy, significant acute,
minor chronic, moderate chronic, and major chronic
conditions. The sociodemographic characteristics included
age, gender, race/ethnicity, and months enrolled in the
program. Logistic regressions were used to examine the
relationship between the children’s CRG health status
category and their sociodemographic characteristics and the
odds that they would remain in the top 10% of health care
spenders in their program (i.e., HMO or PCCM). Other
spending cut-points were examined (i.e., 5%, 20%, 30%, and
40% of spenders). The patterns of results were the same
regardless of the cut-point used. The 10% cut-point is
presented here.
Population Studied: A census of children ages 0 to 18
enrolled in the Texas Medicaid program from 2003 (N=
1,202,294) through 2005 (N=1,509,806).
Principal Findings: Mean annual expenditures between the
top 10% of spenders varied significantly between eligibility
category (e.g., PCCM/SSI - $60,680 and PCCM/TANF $5,842) and program (e.g., HMO/TANF - $4,345 and
PCCM/TANF - $5,842). Among TANF HMO enrollees, 17% of
those in the top 10% of expenditures in 2003 remained at that
level in 2004 and 13% remained at that level in 2005. Similar
patterns were seen for HMO SSI enrollees and for PCCM
TANF and SSI enrollees. The children’s health status was
significantly associated with the odds of remaining enrolled in
Medicaid, the odds of transferring from HMOs to PCCM, and
the odds of remaining in the top 10% of spenders. For
example, children with moderate chronic conditions, like
diabetes, were 3.42 times more likely than those classified as
healthy to remain in the top 10% of health care spenders from
2002 through 2005; whereas those with major chronic
conditions like cystic fibrosis were 13 times more likely to do
so. Race/ethnicity also was significant with black nonHispanic and Hispanic children about 50% as likely as white
non-Hispanic children to remain in the top 10% of spenders
from year to year. The same pattern was observed regardless
of program and eligibility status.
Implications for Policy, Delivery, or Practice: Children at
high risk for persistent high health care expenditures can be
identified and proactively placed in care coordination
programs designed to facilitate access to care and to
minimize or prevent morbidity. Further investigation is
needed to better understand the racial/ethnic disparities in the
persistence of high health care spending to ensure that
minority children are receiving needed care.
Primary Funding Source: HRSA
●Evaluating Appropriateness of Antibiotic Use for Children
with Otitis Media in Rhode Island
Sylvia Kuo, Ph.D., Susan Miller, Ph.D., M.B.A., James Burrill,
M.D.
Presented By: Sylvia Kuo, Ph.D., Investigator, Center for
Gerontology & Healthcare Research, Brown University, Box GST210, Providence, RI 02912; Tel: (401) 863-2060; Fax: (401)
862-9219; Email: Sylvia_Kuo@brown.edu
Research Objective: To assess whether antibiotic use among
children with otitis media (OM) insured by Blue Cross & Blue
Shield of Rhode Island (BCBSRI), the dominant insurer in the
state of Rhode Island, is consistent with established evidencebased guidelines, and whether this use varied by visit or
demographic characteristics. Evidence-based guidelines
recommend that antibiotic therapy (i.e. high-dose amoxicillin)
should be the default treatment only for children under age 6
months, with use in more limited circumstances in older
children. Little is known of variations in antibiotic practices
within a health care market despite the local nature of practice
patterns and disease spread.
Study Design: Using BCBSRI administrative encounter and
pharmacy claims in 2004, the visit-based analysis used logistic
regressions on the probability of receipt of any antibiotic, and
the probability that the child received amoxicillin given that an
antibiotic was received. Covariates included visit location
(physician office, urgent care center or hospital emergency
room), insurance coverage type (PPO, HMO and Medicaid
managed care), age (<6 months, 6 months – 2 years, over 2
years), an indicator for whether the visit occurred on the
weekend, and interaction terms.
Population Studied: The study used a cohort of children age
13 or under as of January 1, 2004 who had a diagnosis of OM
at any time during 2004 and were continuously enrolled with
BCBSRI with both medical and drug coverage. Antibiotic
prescriptions filled within 2 days of an otitis-related encounter
were matched to encounter data. The sample included 12,436
children, who were associated with 26,090 otitis-related
encounters and 9,318 matched antibiotic prescriptions.
Principal Findings: Results suggest that the use of antibiotics
by age is consistent with evidence-based practices; children
under age 6 months are more likely to receive an antibiotic,
with most children receiving the recommended antibiotic of
amoxicillin. Interestingly, no differences were found by
insurance coverage type. However, children who visit urgent
care centers are over twice as likely to receive an antibiotic,
while the antibiotic received is only half as likely to be
amoxicillin compared to similar children who visit physician
offices. Additionally, children are significantly more likely to
receive antibiotics during weekend versus weekday visits for all
visit locations.
Conclusions: The patterns of antibiotic use in Rhode Island
appear consistent with evidence-based guidelines. In
particular, antibiotic use appears reasonable at physician
offices, where most cases of pediatric OM are seen in Rhode
Island. However, antibiotics may be used less judiciously for
children with OM when care is sought on the weekend and/or
at urgent care centers -- visit characteristics not typically
available in other studies.
Implications for Policy, Delivery, or Practice: The results
suggest that maintaining continuity of care through a regular
provider may reduce inappropriate use of antibiotics, and
provide justification for health plan incentives for offices to
provide extended hours (as is BCBSRI’s policy). Although
urgent care centers may play an important role in reducing
costly emergency room visits for acute situation, these sites
may have practice patterns that deviate from recommended
pediatric practices because of less familiarity with both the
patients themselves, and pediatric patients in general.
Primary Funding Source: Blue Cross & Blue Shield of Rhode
Island
●ADHD Medications in US and OECD Countries:
Determinates of Quantity and Price
Hui-Chu Lang, Ph.D., Richard M. Scheffler, Ph.D., Teh-wei
Hu, Ph.D.
Presented By: Hui-Chu Lang, Ph.D., Postdoctoral Fellow,
School of Public Health, UC Berkeley, 140 Warren Hall,
Berkeley, CA 7360; Tel: (510)643-3366; Fax: 510-643-1853;
Email: hclang@berkeley.edu
Research Objective: Attention Deficit Hyperactivity Disorder
(ADHD) is the most commonly diagnosed behavioral/mental
health disorder in children. Despite public attention and
controversy on the increased use of ADHD medications, we
have seen no published report comparing expenditures,
pricing, and usage internationally. Hence, the purpose of this
study is to investigate trends in ADHD medication
expenditures among U.S. and OECD countries over a 10-year
period. An analysis of changes in expenditures over time will
shed light on whether and to what extent they reflect provider
price increases or decreases, variations in quantity, or other
factors.
Study Design: We used data from the IMS Health MIDAS
worldwide database from 1993 to 2003. The three-digit
Anatomical Therapeutic Chemical Classification (ATC) system
for drugs was adopted to extract study drugs. ADHD
medications include those in the ATC=N6B psychostimulants
category, along with the non-amphetamine-like stimulants
Modafinil (Provigil) and Atomoxetine HCL (Strattera). Both
branded and generic drugs within those categories were
included. The quantity measure was a standard unit (SU),
defined as the smallest common dose unit included by the
IMS. Price was defined as the standard unit average price at
the ex-manufacturer level. To analyze the global and country
trends in expenditures over the time period 1994-2003, we
disaggregated the expenditures into three components:
change in quantity; change in price; and the residual product
of the change in quantity and change in price.
Principal Findings: The global ADHD medication
expenditures were $332 million, $720 million, and $2.26 billion
in 1994, 1999, and 2003, respectively. In the U.S. market, the
real ADHD medication expenditures were $304 million, $658
million, and $2.11 billion in 1994, 1999, and 2003, respectively.
For OECD countries, the real ADHD medication expenditure
was $17 million, $50 million, and $121 million in 1994, 1999,
and 2003, respectively. During the study decade, the U.S.
market had higher rates of expenditure and price increase than
OECD nations. U.S. expenditures increased 221% in real
dollars; sales volume increased 2%; and price increased 214%.
For OECD countries during this period, expenditures
increased 141% in real dollars; sales volume rose 63%; and
price increased 48%. The rate of price increase in the U.S.
market was far higher during the later years of the study
(1999-2003) than in the earlier years (1994-1999); the increase
rate was 214% in the latter period compared to 23% in the
prior period. The OECD countries saw lower rates of price
increase: 48% in 1999-2003 compared to 15% in 1994-1999.
Conclusions: During the study decade, ADHD medication
expenditures have dramatically increased in the United States
and the OECD countries. The U.S. increase is primarily a
reflection of rising prices, while the OECD countries’ increase
reflects mainly higher quantities.
Primary Funding Source: UC Berkeley
●Can Real-Time Decision Support Increase Appropriate
Influenza Immunization at two Urban Children's
Hospitals?
James Levin, M.D., Ph.D., Sivakumaran Raman, MBBS, MS,
Patsy Stinchfield, MSN, CPNP
Presented By: James Levin, M.D., Ph.D., Medical Director,
Informatics, Infectious Disease and Information Technology
Services, Children's Hospitals and Clinics, 345 Smith Ave N,
MS 70-504, Saint Paul, MN 55102; Tel: (651) 220-6444; Email:
jim.levin@childrensmn.org
Research Objective: Young infants and children with chronic
diseases are at as high a risk of death from influenza as any
population group. We evaluated whether a combination of
family and provider targeted interventions could to increase
appropriate immunization rates for these groups at two urban
Children’s hospitals.
Study Design: Analysis of diagnosis and demographic
information in a clinical data warehouse was used to identify
high priority patients. Patients were flagged in the health
system's electronic medical record online problem list.
Reminder/recall postcards were mailed to families.
Automated real-time alerts were delivered to clinicians each
time unvaccinated patients presented for care. The primary
outcome measure was the immunization rate for targeted
patients as compared to the two previous yearly seasons.
Additional measures included the timeliness of the
immunization and the number of immunized patients with
missed opportunities (prior encounters during the season
without vaccine administration). Multivariate logistic
regression was used to evaluate the association with
immunization uptake of insurance type (government-funded
versus others), language spoken in the home, patient gender,
patient home nearest census-tract poverty level, and whether
the mailed postcard was undeliverable.
Population Studied: Patients with outpatient clinic
encounters at Children’s Hospitals and Clinics of Minnesota
(CHC) in the 12 months prior to the beginning of the 2004-5
influenza season. CHC is a not-for-profit pediatric care
system with inpatient, Emergency Department, primary and
subspecialty care clinics in Minneapolis and Saint Paul,
Minnesota.
Principal Findings: During the 2004-5 vaccine season 11,336
postcards were sent to high priority patients. 7.4% of the
postcards were undeliverable. 2,178 patients with chronic
conditions were vaccinated, a 28% increase over the previous
season. Of the 6-23 month olds, 1,191 were vaccinated, a
yearly increase of 135%. High priority patients were vaccinated
a median of 3 weeks earlier. There was a decrease of 26%
(chronic disease patients) and 45% (6-23 month olds) in
immunized patients with missed opportunities. For patients
with chronic diseases the following were associated with
increased immunization: Previous year immunization (Odds
Ratio (OR) 4.2, 95% CI [3.5, 4.9]), Spanish speaking (OR 2.4,
[1.8, 3.3]), government insurance payer (OR 1.6, [1.3, 1.8]), and
census tract poverty (OR 1.1, [1.1, 1.2]). For this group, African
language speaking was associated with decreased
immunization (OR 0.6, [0.4, 0.9]). In contrast, for 6-23 month
olds, significant decrease was associated with government
insurance payer (OR 0.8, [0.7, 1.5]) and undeliverable postcard
(OR 0.4, [0.3, 0.5].
Conclusions: Using a data warehouse to identify high priority
patients and communicating directly to their families
(postcards) and their providers (automated real-time alerts)
was associated with improved immunization performance
during the first year of the intervention. Demographic and
socioeconomic factors associated with immunization uptake
differed between two targeted groups.
Implications for Policy, Delivery, or Practice: New
recommendations for universal vaccination of 6-23 month
olds were initiated during the 2004-5 season, a year of
unprecedented vaccine shortage. Media attention on the
shortage created confusing and sometimes contradictory
messages to families and health care workers. Even in this
fluid environment, our results suggest a role for the use of
advanced information technology to identify and promote
accurate immunization at two urban pediatric hospitals. The
barriers to immunization may be different for the two high
priority groups studied.
Primary Funding Source: No Funding
●Family Involvement and Children with Disabilities: Myth
or Reality
Ana Lopez - De fede, Ph.D., Karen Kirtland, Ph.D., George
Johnson, Ph.D.
Presented By: Ana Lopez - De fede, Ph.D., Research Associate
Professor, Institute for Families in Society, Universty of South
Carolina, 1600 Hampton Street - 5th Floor, Columbia, SC
29208; Tel: 803-777-5294; Fax: 803-777-1120; Email:
adefede@sc.edu
Research Objective: The research literature has documented
the extent of minority student disproportionality in special
education, citing broad inadequacies across a variety of
educational fronts. This study addressed two primary
questions. First, are there significant differences in family
involvement for children disproportionaly represented in
special education? Second, do these factors differ for children
in special education based on their disability classification?
Study Design: Data were collected through telephone surveys
of randomly-selected households in South Carolina with
children in special education placements. For the purpose of
this survey, special education services were defined as extra
reading or math instructions in a resource room, speech or
therapies, or special education. Response categories were
collapsed and stratified by race (whites and African
Americans). Chi square tests were used to detect significant
differences in demographics between whites and African
Americans as well as to determine significant differences in
survey responses between whites and African Americans.
Odds ratios were calculated to determine if significant
associations existed between having a disability and
demographic (individual) characteristics, special education
scores, school characteristics scores, or family involvement
scores.
Population Studied: Households were randomly selected
from a representative state sample of 30,670 children in
special education in 9 counties. 453 interviews were
completed for a response rate of 44.8% with a margin of error
of ± 4.61% at the 95% confidence level.
Principal Findings: Race, health status, and school
characteristics were significantly associated with children
having both a learning disability and a serious emotional
disability. These children were 1.9 times more likely to be
African American than white, and were 8.9 times more likely to
be in fair or poor health versus excellent health. School
characteristics were negatively associated with children having
both a learning disability and a serious emotional disability.
For each point increase in the school characteristics score, a
caregiver was 0.70 times less likely to have a child with both
disabilities.
Conclusions: The findings illustrate that there are significant
differences in family involvement for African American
children disproportionaly represented in special education.
They were more likely to be over represented among children
with LD, SED or both classifications. Among students in
special education, African American students were more likely
to report poorer health compared to White students.
Implications for Policy, Delivery, or Practice: The
disproportionate representation of racial and ethnic minorities
in special education and the inequities in educational
opportunities are among the most critical issues faced by the
U.S. public school system. This study illustrates the
continued need place the involvement of families of children
with special education in the education system.
Primary Funding Source: No Funding
●Medicaid’s Role in Treating Children in Military Families
D. Richard Mauery, M.P.H., Peter Shin, Ph.D., M.P.H., Sara
Rosenbaum, J.D.
Presented By: D. Richard Mauery, M.P.H., Senior Research
Scientist, Department of Health Policy, GWU School of Public
Health and Health Services, 2021 K Street NW, Suite 800,
Washington, DC 20006; Tel: (202) 530-2376; Fax: (202) 2960025; Email: rmauery@gwu.edu
Research Objective: To measure and describe Medicaid’s
role in meeting the needs of children with special health care
needs (CSHCN) in military families covered by TRICARE, the
Department of Defense health insurance program for military
service members and their families.
Study Design: 1) Quantitative analysis of survey data to
identify the size of this population and its characteristics and
needs. The data derived from CDC’s 2000-2002 State and
Local Area Integrated Telephone Survey National Survey of
Children with Special Health Care Needs. Quantitative
comparisons of military CSHCN with and without Medicaid
were performed. 2) By purposive sampling of four large U.S.
military bases, telephone interviews with TRICARE Beneficiary
Counseling and Assistance Coordinators to assess individual
base experiences with CSHCN. Qualitative analysis
completed by cross-referencing responses to identify
similarities and differences across bases.
Population Studied: 1) CSHCN in military families covered by
TRICARE and/or Medicaid; 2) TRICARE Beneficiary
Counseling and Assistance Coordinators at four U.S. military
bases.
Principal Findings: Medicaid covers one in 12 military
children and one in 9 military CSHCN. Military children with
Medicaid are more likely than those without Medicaid to be
nonwhite and twice as likely to have low family incomes,
consistent with Medicaid’s financial eligibility rules. Among
the 14% of all military CSHCN, 11% have both TRICARE and
Medicaid coverage. Military CSHCN are more likely than
privately insured civilian CSHCN to have Medicaid (one in 9
vs. one in 11). Military CSHCN with Medicaid are almost five
times more likely than those without Medicaid to have
fluctuating needs, and ten times more likely to receive SSI.
The average disease severity rank of military CSHCN with
Medicaid is greater than military CSHCN without Medicaid.
Interviews suggested that the military health system views
Medicaid as an important supplement to TRICARE. However,
military CSHCN likely face the same barriers that commonly
confront other Medicaid-enrolled children, particularly in the
case of behavioral health provider shortages. TRICARE’s new
“Extended Care Health Option” (ECHO) program for persons
with disabilities may reduce reliance on Medicaid among
military CSHCN. However, ECHO contains limitations that
would not apply to children covered by Medicaid.
Conclusions: Although Medicaid coverage is critical to
military CSHCN, military CSHCN with Medicaid are less likely
than those without Medicaid to receive the care they need,
particularly mental health services, possibly due to greater
severity of their conditions. Its capacity to mitigate needs of
military CSHCN may also be lessened by state-to-state
mobility, interstate coverage and health resource variations,
and residential isolation on non-metropolitan military bases.
Implications for Policy, Delivery, or Practice: This analysis
underscores a less analyzed aspect of Medicaid: its capacity to
supplement basic coverage for CSHCN. Medicaid plays an
important role for children with significant health risks in both
civilian and military sectors. This hidden side of the program
merits attention as an element of longer term Medicaid
reform. It also suggests the importance of reconsidering
existing Federal SCHIP policy, which prevents under-insured
children from qualifying for SCHIP in order to fund
supplemental benefits.
Primary Funding Source: RWJF
●Laws and Policies for Children Deprived of Parental Care
in Least Developed and Middle Income Countries: An
International Comparative Analysis
Emily Nicklett, M.S.
Presented By: Emily Nicklett, M.S., Doctoral Student, Health
Services Organization and Policy, University of Michigan
School of Public Health, 1781 Cram Circle #7, Ann Arbor, MI
48105; Tel: 917-399-4092; Email: enicklet@umich.edu
Research Objective: The objective is to document and
analyze the current progress of countries in developing laws
and policies to uphold the Convention for the Rights of the
Child’s (CRC) standards specific to children without parental
care.
Study Design: A four-page survey instrument was sent to 131
UNICEF country offices in April-May 2005 to analyze laws and
policies addressing: forms of family and child assistance to
promote preservation; maintenance of family ties; familybased care; and types, standards, and child participation in
family-based and institutional care placement settings.
Population Studied: 68 questionnaires were analyzed, 25 of
which are Least Developed Countries (LDCs) and 43 of which
are Middle Income Countries (MICs). The overall response
rate was 52%, with 58% from LDCs and 49% from MICs.
Principal Findings: A baseline of existing laws and policies
was established for the countries studied in the areas of (a)
family assistance and preservation, (b) maintenance of family
ties, (c) family-based care, and (d) child participation. While
the results indicated that numerous LDCs and MICs espoused
CRC standards in laws and policies, improvement is
particularly necessary in the following areas: (a) Further
development of programs for family assistance (such as
school feeding programs, free daycare, and parental
education) and improvement of preservation efforts (child
abuse prevention, home visits, and parental education) (b)
Legislative development articulating grounds for removal,
requiring a judicial decision and the approval of a designated
authority prior to separation (c) Prioritization of family-based
care over institutionalization, with regular monitoring of
placements and budgetary assistance allocated to providers
(d) Participation of children in placement decisions for
institutional and family-based care
Conclusions: The analysis provides a mechanism by which
legislation on children without parental care can be tracked
internationally. Future periodic analyses will track the progress
of legislative development internationally. These studies
should include existing legislation in industrialized countries
as well as the extent to which existing laws and policies are
upheld in practice.
Implications for Policy, Delivery, or Practice: Further
development of laws and policies is necessary in some of the
countries studied, particularly those lacking comprehensive
legislation for child protection. Cooperation is necessary from
NGOs, international organizations, and industrialized
countries to assist in the attainment of these goals.
Primary Funding Source: UNICEF
●Increasing Asthma Awareness by Integrating Asthma
Education into The Public School Literacy and Science
Curriculums
Betty Perez-Rivera, MS, EdD, CHES, Natalie Langston-Davis,
M.D., M.P.H.
Presented By: Betty Perez-Rivera, MS, EdD, CHES, Program
Director, Childhood Asthma Initiative, Children's Health Fund,
317 East 64 Street, New York, NY 10021; Tel: 212 535-9779; Fax:
212 812-5272; Email: bperez@chfund.org
Research Objective: The educational programs focus on
creating awareness about the impact of asthma in medicallyunderserved communities of the South Bronx as well as
empowering families to take control of their asthma through
active management of their environmental triggers.
Study Design: Nationwide, the prevalence rates for asthma
have risen dramatically in the past 2 decades. New York City
has the 3rd highest level of asthma (17% citywide). Poor urban
minority children in medically underserved communities are
disproportionately affected (20-30%). Asthma impacts child
and family productivity, physical activity, self-esteem, & overall
quality of life. Lack of health education, quality continuity of
care and poor living conditions add to the problem. Using
National Heart, Lung and Blood Institute (NHLBI) guidelines,
the Children’s Health Fund’s Childhood Asthma Initiative
(CAI) uses a comprehensive medical model with clinical,
psychosocial, and educational components to address family
needs. CAI has made substantial progress in creating an
asthma friendly community by offering new and innovative
comprehensive programs in public schools, after-school
programs and community centers. The CAI has created a
number of curricula that are suitable for a variety of audiences
based on their time constraints. Families are encouraged to
speak with their medical providers about asthma and to follow
instructions related to asthma medications. An asthma
curriculum for public schools was added to teach children
about asthma, incorporating asthma education into the
literacy and science curriculum of elementary through high
school students. The students worked in groups to answer
questions about asthma using self-expression, inquiry,
research, and writing to present what they learned. These
activities were completed while engaging in normal literacy or
science activities with their teachers. The students had two
weeks to work on presentations which included posters,
poetry, short stories, role-play, interviews, and personal
experiences about asthma. Letters were sent home to
encourage parents to help their children do the research on
asthma. They were invited to attend the student presentations
in the classroom. Parent and provider workshops were then
invited to attend adult workshops, given at a later date. A
“Family Asthma Guide” was used as a teaching tool.
Population Studied: Grade school students grades 3,4,9, and
10.
Principal Findings: In the past 2 years (2004 and 2005) the
curriculum has been incorporated into the literacy curriculum
for 3rd grade (n=110) and 4th grade (n= 466) students and the
science curriculum for 9th and 10th grade students (n=84
combined). Students successfully presented accurate asthma
facts. Pre- and post-tests showed that student knowledge had
increased by 59%. In addition, 27 workshops reached 226
parents/providers. CAI plans to market this innovative
concept for public schools citywide. This program will be
implemented in Washington DC by Spring 2006. More than
4000 children and families participated in CAI’s educational
programs.
Conclusions: Students can learn about health issues while
engaging in daily academic activities.
Implications for Policy, Delivery, or Practice: This
curriculum increases the number of people with formal
asthma education. Teachers, under pressure to improve test
scores, can use this new approach without reducing valuable
classroom instruction time. It can be used to teach about
other health concerns. A health educator, associated with
primary care, can help the community by providing the
connection to clinical care
Primary Funding Source: Picower Foundation
●Interactive Programming to Teach Students About
Asthma Through Music
Betty Perez-Rivera, MS, EdD, CHES, Natalie Langston-Davis,
M.D., M.P.H.
Presented By: Betty Perez-Rivera, MS, EdD, CHES, Program
Director, Childhood Asthma Initiative, Children's Health Fund,
317 East 64 Street, New York, NY 10021; Tel: 212 535-9779; Fax:
212 812-5272; Email: bperez@chfund.org
Research Objective: Focus groups and discussions with
parents in adult asthma workshops have revealed parent
discomfort with having their children participate in physical
activities for fear that it will exacerbate their asthma. This fear
together with a lack of understanding about asthma limits
children from fully participating in their school activities. The
Children’s Health Funds, Childhood Asthma Initiative (CAI)
has created new and innovative programs to help dispel
myths about asthma and empower families by teaching better
control of their asthma through management of
environmental triggers. As it is also important for students to
have knowledge about asthma, an asthma and music
workshop for children was created to help students learn
about breathing and the impact of asthma in their lives and
the community.
Study Design: Asthma and music workshops were created to
help increase awareness about asthma characteristics and
symptoms while encouraging students to participate in music
and recreational activities in a fun and creative way. The
interactive workshops had two different components. The
asthma component provided information and education
about asthma management (approximately 10-15 minutes)
while the musical component helped to familiarize the
students with different types of musical interpretations and
the use of an instrument of choice (approximately 70-75
minutes) to expand their airways. Each workshop consisted of
four sessions, lasting about 90 minutes each. CAI health
educators taught about asthma and coordinated all sessions
within the school setting. The Central Park Jazz, a
professional quartet, collaborated by teaching the musical
component and integrating the breathing exercises into their
musical routines to reaffirm the relevance to benefits for
asthma.
Population Studied: Elementary school students
Principal Findings: One hundred and one elementary school
students within three New York City Public Schools completed
the 4-session Asthma and Music Workshop that allowed them
to learn about asthma characteristics, symptoms, triggers, and
medications while also spending time learning how to help
expand their lungs for better control through breathing
exercises and playing a musical instrument.
Students had a jam session with the musicians in a concert
held during the fourth session of the workshop. Parents,
asthmatic students and teachers in the school were invited.
The participants used posters to teach others about asthma.
They also reinforced the ability of asthmatics to participate in
sports and other recreational activities. All participants were
encouraged to participate in community service activities and
to continue to teach others about asthma. One Hundred and
Fifty “Family Asthma Guides” and other educational materials
were distributed.
Conclusions: Teachers, parents, and school administrators
learn how to engage students to learn about asthma and other
health topics, reinforcing the need for parent/provider/teacher
communication for better health management.
Implications for Policy, Delivery, or Practice: A good
understanding of the child’s physical capacity can decrease
loss of productivity from lack of participation in physical
activities, school absenteeism and parent work days missed.
In a time when the budget for music and gym classes has
been eliminated from the public schools, this asthma and
music program is essential to help provide students with
avenues to show their creativity, participate in music, and
learn new things.
Primary Funding Source: Goodman Memorial Foundation
●Does Treating Maternal Depression Improve Child
Health Management? The Case of Pediatric Asthma
Cynthia Perry, Ph.D.
Presented By: Cynthia Perry, Ph.D., Robert Wood Johnson
Scholar in Health Policy Research, Harvard University, 1730
Cambridge Street, S-412, Cambridge, MA 02138; Tel: 617-3593828; Fax: 617-496-6085; Email: cdperry@rwj.harvard.edu
Research Objective: Past studies have demonstrated an
association between maternal depression and poor
management of pediatric asthma, but have not answered the
causal question of whether maternal depression causes a
mother to manage her child’s asthma poorly. This project
uses an instrumental variables strategy to assess whether
treating maternal depression causes an improvement in
pediatric asthma management as measured by child's health
care utilization.
Study Design: I use differences in physician propensity to
diagnose depression as an instrument for whether a woman’s
depression is identified and she is therefore offered treatment
through the Florida Medicaid system. This is the variable of
interest in a set of equations that estimate various types of
health care utilization by the asthmatic child in the six months
following the offer of depression treatment for the mother,
relative to the six months prior.
Population Studied: I use Florida Medicaid claims data for
mothers and children who qualify for Medicaid because of
their cash welfare status. The data cover the time period of
July 1996 through June 1999.
Principal Findings: I find that emergency department visits
for asthma care are significantly reduced following the offer of
treatment for maternal depression. I also estimate a
reduction in total asthma costs in the six month period
following diagnosis of $347 per asthmatic child whose mother
is diagnosed with, and offered treatment for, depression.
Conclusions: There is a significant improvement in the
management of pediatric asthma, manifested in reduced
emergency room visits, when maternal depression is
diagnosed and treatment is offered. Cost savings from
reduced asthma costs for children can offset the cost of
screening for maternal depression in this population.
Implications for Policy, Delivery, or Practice: The findings
suggest that there could be gains in the efficiency of health
care delivery with increased screening for maternal
depression, especially for mothers of children with chronic
diseases such as asthma.
Primary Funding Source: RWJF
●Utilizing Logic Models to Create Community Ownership
of School Health Programs
MaryAnn Phillips, BS, M.P.H., Bernette Sherman, BA, M.P.A.,
James G. Emshoff, Ph.D.
Presented By: MaryAnn Phillips, BS, M.P.H., Senior Research
Associate, Georgia Health Policy Center, Georgia State
University, 14 Marietta Street, Atlanta, GA 30308; Tel: (404)
651-1643; Fax: (404) 651-3147; Email: mphillips2@gsu.edu
Research Objective: To determine whether logic models can
be utilized to facilitate ownership of community school health
programs and measure program success.
Study Design: A public-private partnership created a
mechanism to enhance the capacity of select school health
programs in Georgia. Researchers and individuals
representing six community grantees collaborated to design
and implement a participatory evaluation by using logic
models as the conceptual framework for the evaluation and as
a method for engaging the communities in understanding and
buying into the evaluation process. Each model addressed the
identified need and target group, specified outcomes and
relevant activities, and depicted the relationship between
activities and objectives. Activities, outputs, and outcomes
identified through the logic model created the framework
through which success of the programs would be measured.
In addition to the site-specific logic model, a meta-logic model
was developed to tie together similarities in values and
outcomes among the six sites. Common measures were
identified at the meta-level which drove the development of
evaluation tools used across the six sites.
Population Studied: Six community collaboratives in Georgia
funded to enhance capacity, measure impact, and sustain
their school health programs.
Principal Findings: Outside researchers and local community
representatives can work together to evaluate school health
programs. Through a participatory evaluation process, the
researchers and the local community developed logic models
which identified evaluation questions, determined appropriate
data collection methods, documented interventions, and
analyzed results. Although logic models can be utilized to
document best practices and measure prior and post levels of
success, these models cannot guarantee that the
programmatic activities are completed by each program. For
some of the programs, time, resources, and political
constraints limited the completion of certain activities.
Conclusions: Partnership throughout the process was critical
for the successful ownership of the logic models and their
successful implementation by the grantees. The logic model is
a tool to facilitate ownership of community programs,
maximize their sustainability and get results. Created by the
community partners– not by the research team -- the
individual and meta-logic models are representative of the
value and worth that community partners place on specific
aspects of their programs. Through this public/private
partnership, grantees were able to be very hands on in
developing the measures needed to evaluate their programs.
Their work, individually and collectively, yielded several tools
for measuring success, one of which was a student survey,
used by all six grantees to gather data at two points in time for
student health behaviors.
Implications for Policy, Delivery, or Practice: Community
ownership of any local program is essential to its long-term
sustainability. A tool used to secure this ownership of school
health programs is the logic model. A well thought out,
logical, theory-based program design decreases the risk of
flaws in the program design. The logic models, interviews,
site visits, and survey results will help link what is learned to
theory, outcomes, and indicators. The evaluation will provide
information on questions/issues that cut across all sites and
highlights the strengths, differences, challenges, and best
practices found at both the individual and meta levels of
school health programs.
Primary Funding Source: Other Foundation
●The Effect of Medicaid/SCHIP Disenrollment on
Pediatric Health Care Utilization in an Urban County
Mary Rimsza, M.D., Megan Jehn, Ph.D., Richard Butler, Ph.D.,
William G Johnson, Ph.D.
Presented By: Mary Rimsza, M.D., Professor and Co-Director,
WP Carey School of Business, Arizona State University Center
for Health Information & Research, 9885 N 131 Place,
Scottsdale, AZ 85259; Tel: 480 9651622; Fax: 480 657 0635;
Email: mrimsza@asu.edu
Research Objective: To predict changes in health care
utilization if children insured by Medicaid/SCHIP are
disenrolled in response to changes in enrollment processes,
eligibility and/or cost sharing.
Study Design: A model has been developed to determine the
anticipated changes in community health care utilization
using a community wide administrative health database
Arizona Health query (AZHQ) which includes healthcare
transactions on over 5 million Arizona residents including all
Medicaid participants. AZHQ links patients and claims across
health care systems over multiple years. The model combines
the estimated coefficients of a multivariate model of health
care utilization by currently uninsured children with children
who are currently enrolled in Arizona’s Medicaid and SCHIP
programs if 10% of these children become uninsured. A
system of logistic regression equations is used to estimate the
probability of emergency department (ED) transactions for
ambulatory care sensitive (ACS) conditions, inpatient
transactions and ambulatory care transactions, and a system
of three nonlinear regression equations is used to estimate
the quantity of services for each of the three types of services if
10% of the children became uninsured. We use the Oaxaca
decomposition, modified to fit health care comparisons, to
separate differences in utilization between Medicaid and
SCHIP-insured children and uninsured children into
differences due to the characteristics of the children and
differences due to insurance.
Population Studied: Children living in Maricopa County,
Arizona (the greater Phoenix area who are included in the
AZHQ database are either uninsured (n = 38,380) or insured
by Medicaid/SCHIP (n = 118,244) in 2004.
Principal Findings: In 2004, the uninsured children had
83,654 ED transactions for ACS conditions, 70,731 inpatient
ransactions, and 110,802 ambulatory transactions.
Approximately 37% of all health care transactions for
uninsured children were for ACS ED services compared to
21% of ACS ED services for Medicaid/SCHIP children. Using
the model, if 10% of the children insured by Medicaid/SCHIP
became uninsured, there would be 17,521 more ED visits for
ACS conditions in Maricopa County annually. Using MEPS
median cost estimates and AZHQ data, the cost to the
community of this increase in utilization will be discussed.
Decomposing the difference in the probability of use between
Medicaid/SCHIP-insured and uninsured children revealed that
100% of the difference in ED utilization was due to the
differences in insurance.
Conclusions: Disenrollment of children from
Medicaid/SCHIP can be expected to increase pediatric care at
expensive sites including EDs for conditions which could be
managed in physician offices and also increase
hospitalizations. These differences in utilization can be
attributed almost entirely to changes in insurance status.
Implications for Policy, Delivery, or Practice: Policy changes
which result in disenrollment of children from
Medicaid/SCHIP will not only increase health care costs but
will also aggravate current community problems of ED
overcrowding and inpatient bed shortages
Primary Funding Source: St Lukes Health Initiatives
●Health Care Expenses and Out-of Pocket Costs for
Children with Special Health Care Needs (CSHCN) and
the Role of Health Insurance Coverage
Parag Shah, M.D.
Presented By: Parag Shah, M.D., Postdoctoral Fellow,
Institute for Healthcare Studies, Northwestern University, 339
E. Chicago Avenue Rm 712, Chicago, IL 60601; Tel: 312-5030448; Fax: ; Email: p-shah7@northwestern.edu
Research Objective: Between 6-30% of children in the US
have a disability. These children utilize more health care than
the rest of the population, and therefore have increased health
care costs. Various health insurance characteristics provide
different levels of cost sharing for these families. The purpose
of this study is to explore the relationship between health
insurance status and out-of-pocket costs for various health
care services among families with children with special health
care needs (CSHCN).
Study Design: Secondary data analysis was conducted using
the MEPS from 2000-2002. CSHCN were categorized into
one of three insurance categories: public all year, private all
year, and uninsured all year. Total and out of pocket
expenditures for various health care services were computed
by insurance category and weighted to represent a national
sample. A ratio of out of pocket expenses to total
expenditures, representing the level of protection from costs
was estimated. Linear regression analyses were used with the
percent out of pocket as the dependent variable and insurance
status as the independent variable, while controlling for
perceived health status, gender, age, and poverty level. The
analyses were repeated stratifying by poverty level to examine
the effects of insurance for families with varying incomes.
Population Studied: All children under age 18 were selected
from the MEPS database between the years 2000-2002. A
total of 27,256 children were identified and of these 4787 met
the Maternal and Child Health Bureau definition of CSHCN.
Principal Findings: Overall, 18.5% of U.S. children were
classified as CSHCN. Most CSHCN were privately insured
(59.3%); with fewer uninsured CSHCN (4.6%) compared to
uninsured, non-CSHCN (8.2%). Publicly insured CSHCN paid
a significantly lower proportion of total expenditures out of
pocket compared to privately insured CSHCN (10% versus
32.5%, p<0.01). Uninsured CSHCN paid the highest
percentage out of pocket expense ratio at 73.2%. This trend
held true for all CSHCN regardless of family income. All
insurances protected CSHCN well from Emergency
Department and inpatient costs but not as well against
prescription drug costs and miscellaneous other medical
expenditures.
Conclusions: Publicly insured CSHCN pay a smaller
percentage of total health care costs out of pocket compared
to privately insured CSHCN, while having an increased
amount of total health care costs. When these families were
stratified by income, families with public insurance continued
to pay smaller percentages of total costs out of pocket
compared to their privately insured counterparts. Insurance
protects well against certain types of health care costs but not
prescription drugs, which represent the fastest rising category
of health care expenditures.
Implications for Policy, Delivery, or Practice: With states
struggling to keep up with rising Medicaid costs, new policies
are allowing for more cost-sharing on Medicaid recipients,
including children. Increased cost sharing for publicly insured
CSHCN will increase the amount these families will pay out of
pocket. However, this policy may be justified given that
privately insured families at the same income levels currently
pay a much higher percent of total health care costs out of
pocket.
Primary Funding Source: National Institute on Disability and
Rehabilitation Research
●Health Care for Children and Youth: Patterns of
Coverage, Utilization, Expenditures and Quality by
Geographic Area
Lisa Simpson, MB, BCh, M.P.H., FAAP, Frances Chevarley,
Ph.D., Pamela Owens, Ph.D, Marc Zodet, MS, Marie C.
McCormick, M.D., ScD, Denise Dougherty, Ph.D.
Presented By: Lisa Simpson, MB, BCh, M.P.H., FAAP, ACH
Guild Endowed Chair in Child Health Policy, Pediatrics,
University of South Florida, 601 4th St South, CRI 1008, St.
Petersburg, FL 33712; Tel: (727) 553-3672; Fax: (727) 553-3666;
Email: lsimpso1@hsc.usf.edu
Research Objective: Health care availability and other
conditions are know to vary between urban and rural areas.
Most analyses of geographic differences in children's health
care have distinguished between metropolitan (aka urban)
and non-metropolitan (aka rural) areas. We aimed to examine
differences in child and hospital demographics and children's
health care coverage, use, expenditures, and quality using the
2003 Urban Influence Codes. A collapsed version of these
codes enable us to make finer distinctions: for metropolitan
areas, we could distinguish between the set of counties
labeled large or small; for non-metropolitan areas, the UIC
enabled us to distinguish between the newly labelled
"micropolitan" counties and so-called "non-core" counties,
which are typically lower in population density and often
remote from large and sophisticated health care settings.
Study Design: The 2002 Medical Expenditure Panel Survey
and the 2002 Healthcare Cost and Utilization Project
Nationwide Inpatient Sample and State Inpatient Databases
were used to distinguish sociodemographic patterns, health
status, and patterns of insurance coverage, health care
utilization, health care expenditures, and health care quality by
collapsed versions of the 2003 Urban Influence Codes. In
addition, we were able to compare child residence to location
of hospitalization by UIC code.
Population Studied: U.S. children ages 0-17; U.S. hospitals
with discharges for children ages 0-17.
Principal Findings: In large metro counties, greater
percentages of the child population are Hispanic or black nonHispanic than in small metro, micropolitan and noncore
counties; in micropolitan and noncore counties, higher
proportions of children live in families with incomes below
200% of the federal poverty level than in large metro and
small metro counties. Noncore areas have a greater
percentage of children in fair or poor health compared to
small metro and micropolitan counties, but not large metro
counties. In general, there were no overall differences by child
residence in the proportions uninsured, having private health
insurance, or public insurance, although differences emerged
in subpopulations within UIC types. Noncore low-income
children in the South were most likely to be covered by public
insurance. The proportion of children with at least one dental
visit was generally higher in small metro counties compared
to large metro and noncore counties. Children in noncore
areas were more likely to have a hospital inpatient stay and
any emergency department use compared with children in
large metro areas. Fewer medicines were prescribed in large
metro areas than all other areas. Over half of hospitalizations
for noncore children occurred in county types other than
noncore; rates of nonconcordant hospitalizations were higher
for conditions require subspecialty care such as mental and
emotional disorders and high risk newborn care. Children
from noncore counties tended to be hospitalized at greater
rates for ambulatory sensitive conditions. Pregnant and
postpartum adolescents in noncore areas suffered more
complications of pregnancy than their cohorts in other areas.
Children from large metro counties were 1.2 times as likely to
experience selected nosocomial infections as children from
micropolitan areas.
Conclusions: Application of the UIC codes allowed us to
identify differences not previously seen in grosser
comparisons of metropolitan to non-metropolitan areas. In
addition, we observed differences within UIC county types by
subpopulation. Further exploration of the codes and
requirements for adequate sample sizes are needed.
Implications for Policy, Delivery, or Practice: In examining
children's health care by geography, it seems worthwhile to
move beyond the dichotomous notion of urban or
metropolitan and rural or non-metropolitan.
Primary Funding Source: AHRQ
●Health Beliefs and Health Behaviors of Adolescents with
Type 2 Diabetes and their Parents.
Asheley Skinner, BS, Shelagh Mulvaney, Ph.D., David
Schlundt, Ph.D., Russell Rothman, M.D.
Presented By: Asheley Skinner, BS, Health Policy and
Administration, University of North Carolina at Chapel Hill, CB
7411, Chapel Hill, NC 27599-7411; Tel: 336-392-5021; Email:
asheley@unc.edu
Research Objective: The emerging “epidemic” of children
and adolescents with type 2 diabetes, which is attributed to
increases in childhood overweight, has led to substantial
concerns about its impact on young lives. It is likely that both
parents’ and children’s perceptions of weight and health
beliefs influence adolescents’ self-care behaviors and health
care utilization. We hypothesize that: (1) parents and
adolescents will underestimate the severity of the adolescent’s
overweight and (2) parents and adolescents who perceive
greater barriers to, and fewer benefits of, care will engage in
fewer self-care behaviors and be more likely to miss clinic
appointments.
Study Design: Cross-sectional interviews and chart
abstraction. Telephone interviews were conducted separately
with parents and adolescents in which respondents reported:
the adolescents’ estimated weight; their own beliefs regarding
diet, exercise, and clinic visits; and perceptions of severity of
the adolescents’ overweight (e.g., a little overweight, about
right). Adolescents’ actual clinic weights (categorized as
normal, at-risk for overweight, or overweight based on bodymass index), clinical parameters, and missed appointments
were extracted from chart audits. Both self-reported
adherence to recommended regimens and beliefs (e.g.,
barriers) were assessed separately for diet and exercise using
multiple item scales. Multivariate analyses use standardized
ordinary least squares regression.
Population Studied: Adolescents aged 10-20 years with type
2 diabetes who receive care from an academic health center
and their parents (103 pairs)
Principal Findings: The adolescents were 85% overweight,
47% white, 69% female, and 42% privately insured. Both
parents and adolescents underestimated the adolescent’s
weight (mean=7 pounds) and showed poor agreement with
actual clinic weights (kappa=0.12 and kappa=0.09). In
multivariate analyses, adolescents perceiving more barriers to
diet and exercise regimens had poorer adherence to both (b =
–0.28; b = –0.48), while parents’ perceptions of greater weight
severity are related to better adherence (b = 0.27; b = 0.54).
When excluding adolescents’ beliefs, parent self-efficacy is
related to poorer adherence to diet (b = –0.38), contrary to
expectations. When parents perceived their adolescent’s
overweight as more severe, the adolescent had fewer missed
appointments (b = –0.36); the opposite was observed for
adolescents’ perceptions (b = 0.36).
Conclusions: Despite being engaged in the health system and
having a serious chronic condition related to their weight,
adolescents and their parents underestimated the severity of
the adolescent’s overweight. Parents and adolescents’
perceptions regarding the severity of overweight appeared to
have competing effects on health behaviors and missed
appointments.
Implications for Policy, Delivery, or Practice: While virtually
all patients would be classified as overweight, these
adolescents with type 2 diabetes and their parents both
underestimated the actual weight and its severity. Our
findings indicate the need to address inconsistencies in
parents’ and adolescents’ perceptions of overweight severity.
Interventions to enhance self-care must target both
adolescents and parents, and must be tailored to their own
perceptions of adolescents’ overweight.
Primary Funding Source: Vanderbilt Physician Scientist
Development Award
●The Impact of State Medicaid Policy on Pediatric Patient
Safety in Hospitals
Richard Smith, Ph.D., Lisa Simpson, MB, BCh, M.P.H., FAAP,
Robyn Cheung, Ph.D., Pamela Owens, Ph.D., Aileen Sedman,
M.D., R. Mark Wilson, Ph.D.
Presented By: Richard Smith, Ph.D., Assistant Professor,
College of Business, University of South Florida St.
Petersburg, 140 Seventh Avenue South, St. Petersburg, FL
33701; Tel: (727) 553-4943; Fax: (727) 553-4192; Email:
smithrb@stpt.usf.edu
Research Objective: Evidence is growing that pediatric
patient safety events do not affect all populations similarly,
and in particular, that publicly insured patients may be at
greater risk of adverse events. Moreover, while Medicaid pays
for approximately 17 percent of adult inpatient
hospitalizations, it is primary payer for approximately 40
percent of pediatric hospitalizations. The purpose of this
study is to examine the relationship of Medicaid
characteristics at the patient, hospital, and market level, to
adverse medical events for hospitalized children.
Study Design: Three of the Agency for Healthcare Research
and Quality (AHRQ) patient safety indicators (decubitis ulcer,
infection due to medical care, and laceration) are selected for
analysis based on their high probability of preventability.
Hospital discharge data from 1999-2001 State Inpatient
Database from the AHRQ HCUP is combined with hospitallevel data (e.g. nurse staffing, technology) through linkage to
the American Hospital Association database. Case-mix
variables at the individual level (co-morbidities) as well as at
the hospital level (using APR-DRG severity indices) are also
included, along with Medicaid variables (% discharges
Medicaid and total DSH payments) and measures of both
hospital and Medicaid managed care competition using
Herfindahl indices. These latter variables are obtained from
CMS and state Medicaid offices, as well as derived from the
HCUP. For each of the three patient safety indicators, a
logistic regression is used to estimate the probability of an
individual patient experiencing an adverse event.
Population Studied: All pediatric hospital discharges between
1999 and 2001 for patients of Medicaid-eligible age in Florida,
New York, and Wisconsin, and for which any of the three
patient safety indicator (PSI) events could occur.
Principal Findings: Medicaid recipients have significantly
higher rate of decubitis ulcers (OR=1.30) and infections due to
medical care (OR=1.19), but significantly lower rates of
laceration (OR=0.76) than non-Medicaid recipients. In
addition, relative to markets that are competitive for both
hospitals and payers, concentrated hospital markets
(Herfindahl>1800) significantly reduce PSI rates in 2 of 3
cases (Infection, OR=0.76; Laceration, OR=0.71), while an
inconsistent patttern emerges in concentrated payer markets
(Infection, OR=0.45; Laceration, OR=1.62).
Conclusions: While we find significant associations at all
three levels of Medicaid characteristics, the more significant
and largest effects generally appear at the market level.
Markets with only high hospital concentration tend to be
associated with the lowest incidence of adverse events. The
most compelling explanation, given our results, is that
hospital markets with high concentration produce high profits
that are then invested in quality-control mechanisms. This
explanation is consistent with other recent findings on the
relationship between hospital profitability and patient safety
(Encinosa and Bernard, 2005).
Implications for Policy, Delivery, or Practice: Recent trends
are for greater concentration in both hospital and payer
markets. From that perspective, and from our results,
markets with high payer concentration have a relatively greater
likelihood of adverse medical events for pediatric patients.
Thus, while states have yet to begun playing a significant role
in hospital patient safety, one important role they can play is
by ensuring sufficient competition of commercial Medicaid
managed care payers in local hospital markets.
Primary Funding Source: HRSA, Pediatric Clinical Research
Center of All Children's Hospital and the University of South
Florida
●Comparing the Experiences of CHIP and Medicaid
Children
Jeffery Talbert, Ph.D., Kristine Lykens, Ph.D.
Presented By: Jeffery Talbert, Ph.D., Professor and Chair,
Health Management and Policy, University of North Texas
Health Science Center, 3500 Camp Bowie Boulevard, Fort
Worth, TX 76107; Tel: 817-735-5027; Email:
jtalbert@hsc.unt.edu
Research Objective: This study compares the experiences of
children and their families in the Kentucky Medicaid and CHIP
programs from 1999-2005.
Study Design: The study uses a retrospective analysis of
CAHPS surveys administered annually from 1999 to 2005.
The sample is a statewide proportional sample stratified by
program type and county for 5000 children each year.
Multivariate analysis is conducted to compare outcomes
between children enrolled in CHIP and Medicaid, focusing on
quality, access, and health outcomes. Controlls include age,
gender, year, rural location, eligibility type, and managed care
type.
Population Studied: The population is an annual grouping of
all children enrolled in the Kentucky Medicaid program and
the Kentucky Children Health Insurance Program for at least
11 months during each year.
Principal Findings: The professional literature and much
legislative discussion has debated the impact of allowing
states to run CHIP programs through Medicaid. Many
analysts predicted that Medicaid run programs would provide
lower levels of care due to stigma and provider disinterest in
supporting a Medicaid based system.
Conclusions: Our findings indicate few differences in the
experiencces of children enrolled in CHIP and Medicaid.
Using measures of satisfaction, wait times for appointments,
and health outcomes there are no robust differences between
services provided to CHIP children and Medicaid children.
Implications for Policy, Delivery, or Practice: The SCHIP
and Medicaid programs are up for reauthorization in 2007,
where questions about the most appropriate design will be
explored. This study provides evidence of the impact of
program design for policy makers at the state and federal level
who may be considering redesigning or continuing current
programs. Efficiencies gained through using current Medicaid
infrastructure do not appear to impact quality and health
outcomes for children.
Primary Funding Source: No Funding
●Options for Introducing a Hospital-Based Newborn
Hearing Screening Programme in New Zealand: A Cost
Effectiveness Analysis
Laura Wilkinson-Meyers, MSc Health Policy, Planning &
Financing, Paul Brown, Ph.D.
Presented By: Laura Wilkinson-Meyers, MSc Health Policy,
Planning & Financing, Research Fellow, Centre for Health
Services Research + Policy, University of Auckland, School of
Population Health, Tamaki Campus, Auckland, 1009; Tel: +64
9 373 7599 x87659; Email: l.wilkinson-meyers@auckland.ac.nz
Research Objective: The National Screening Unit (NSU)
commissioned the Centre for Health Services Research and
Policy to examine the cost effectiveness of implementing a
national newborn hearing screening programme in New
Zealand to detect cases of permanent congenital hearing
impairment. This paper presents the results of the analysis for
a number of hospital-based screening programme options.
Study Design: A decision analytic model was constructed for
various screening scenarios, including: the current high risk
referral programme of detection, introducing hospital-based
screening for neonatal intenstive care unit (NICU) infants
only, and three different screening technologies to be used for
well infants. Technologies considered included combinations
of otoacoustic emissions testing (OAE), and automated ABR
testing, followed by a diagnostic exam. The main outcome
measure for the analysis was the number of infants diagnosed
by the age of 6 months. Probabilities for decision nodes in
the model were obtained from New Zealand data sources
where possible, and international evidence where no
information was found. Three categories of cost were used:
cost of screening, cost of diagnostic assessment, and the cost
of monitoring and administering the programme. Given that a
societal perspective was taken for the analysis, the lifetime
cost savings that would result from early detection of hearing
loss were also included.
Population Studied: All infants born in New Zealand.
Principal Findings: Using an OAE+aABR screening protocol
for all well infants screened in a hospital setting is is the most
cost effective screening option when compared to the current
high risk referral programme of detection.
Conclusions: The incremental cost effectiveness analysis
suggests that implementing a hospital-based screening
programme results in a greater number of early detections of
hearing impairment. The cost of implementing the
programme is greater than the current costs associated with
high risk referral detection, but the cost savings that can be
expected to result over the lifetime of the infant far outweigh
the costs of implementing and monitoring a screening
programme.
Implications for Policy, Delivery, or Practice: Introducing a
newborn hearing screening programme in New Zealand
would be cost effective and these findings are consistent with
previous international studies. However, this research is
unique in that it is tailored to the New Zealand health care
system, and it includes national monitoring and oversight
costs.
Primary Funding Source: New Zealand National Screening
Unit