Child Health
Call for Papers Sessions
Preventive Services to End-of-Life Care: Challenges in the
Care of Vulnerable Children
Chair: Michelle Mayer, Ph.D., M.P.H., R.N.
Sunday, June 3 • 11:00 a.m.-12:30 p.m.
ƒ Effects of Pediatric Asthma Education on Emergency
Department Visits & Hospitalizations: A Meta-Analysis
Janet Coffman, Ph.D., Michael D. Cabana, M.D., M.P.H.,
Helen Ann Halpin, Ph.D., Edward H. Yelin, Ph.D.
Presented By: Janet Coffman, Ph.D., Senior Research Analyst,
Institute for Health Policy Studies, University of California, San
Francisco, 3333 California Street, Suite 265, San Francisco, CA
94118, Phone: (415) 476-2435, Fax: (415) 476-0705, Email:
Janet.Coffman@ucsf.edu
Research Objective: To improve the quality of asthma care,
NIH clinical practice guidelines strongly recommend that
health professionals educate children with asthma and their
caregivers about self-management. A wide variety of asthma
education programs for children have been implemented and
evaluated over the years. However, results have been mixed
and many studies did not enroll sufficient numbers of children
to detect differences in health care utilization. A meta-analysis
was conducted to synthesize findings from controlled trials of
the effects of pediatric asthma education on emergency
department (ED) visits and hospitalizations.
Study Design: The meta-analysis examined the effects of
pediatric asthma education on mean numbers of ED visits
and hospitalizations, and on the odds of having one or more
ED visits or hospitalizations. Pooled standardized mean
differences (SMDs) and pooled odds ratios (ORs) were
calculated using the inverse variance and Mantel-Hanzel
methods, respectively. Both fixed effects and random effects
methods were used to generate estimates for all outcomes.
Tests of statistical homogeneity were performed to determine
which estimate was most appropriate for each outcome.
Population Studied: Inclusion criteria included publication in
English and enrollment of children aged 2----17 years with a
clinical diagnosis of asthma. Studies conducted outside the
United States were excluded, because health care utilization
may vary across nations with different types of health care
systems.
Principle Findings: Of the 174 studies identified and
screened, 34 (20%) met the inclusion criteria. Twenty-six
compared asthma education to usual care and eight
compared different types of educational interventions. Among
studies that compared asthma education to usual care,
asthma education was associated with statistically significant
decreases in mean hospitalizations (SMD = -0.35, 95% CI = 0.43, -0.08), mean ED visits (SMD = -0.17, 95% CI = -0.31, 0.03), and odds of an ED visit (OR = 0.77, 95% CI = 0.63,
0.94). Asthma education did not affect odds of hospitalization
(OR = 0.87, 95% CI = 0.60, 1.27). Providing education in
clinical settings or to individual children or families (as
opposed to groups) was associated with fewer ED visits.
Findings from studies that compare different interventions
suggest that interventions that provide more sessions or
supplement sessions with telephone calls produce greater
reductions in ED visits and hospitalizations.
Conclusions: Providing pediatric asthma education reduces
mean hospitalizations and ED visits for asthma and odds of
an ED visit but not odds of hospitalization. Our findings also
suggest that educational interventions that are more
extensive, more individualized, and integrated with clinical
services are more effective. Additional research is needed to
determine the most important components of interventions
and to compare the cost-effectiveness of different
interventions.
Implications for Policy, Practice or Delivery: Health plans
should invest in pediatric asthma education or give health
professionals incentives to furnish such education. Employers
should promote asthma education by requiring the health
plans with which they contract to cover it. Policymakers can
mandate coverage or compel health plans to report ED visits
and other performance measures associated with asthma
education.
Funding Source: California Health Benefits Review Program
ƒ Waiting for Rehabilitation Services for Children with
Physical Disabilities: Effects on Child Function & Quality
of Life
Debbie Feldman, Ph.D., Bonnie Swaine, Ph.D., Julie Gosselin,
Ph.D., Garbis Meshefedjian, Ph.D., Lisa Grilli, M.Sc.
Presented By: Debbie Feldman, Ph.D., Associate Professor,
School of Rehabilitation, Universite de Montreal, C.P. 6128,
Centre-ville, Montreal, H3C3J7, Canada, Phone: (514) 3436111,1,1252, Fax: (514) 343-2105,
Email: debbie.feldman@umontreal.ca
Research Objective: It is estimated that there are 5.5 million
children under 14 years in Canada who have physical
disabilities. For many of these children, their main treatment
is rehabilitation which aims to maximize their function and
enhance activity and participation. Limited accessibility to
these services could potentially have a significant impact on a
child’s functional and health status. Lengthy waiting times for
rehabilitation services for children with developmental
disabilities have, in fact, been reported. The objective of this
study was to explore whether longer waiting times for
rehabilitation were associated with deterioration in child
functional status and/or the parental perception of child’s
quality of life.
Study Design: The study design was a prospective cohort
study of children with physical disabilities. Data on date of
referral, age, gender, and diagnosis were obtained from the
hospital databases. Data on date of first PT or OT
appointments at the rehabilitation center, family sociodemographics, use of private supplementary services,
disability severity (WeeFIM) and child quality of life (PedsQL)
were obtained during parental interviews. Parents were
interviewed at time of referral and at three month intervals
until either admission to the rehabilitation program or end of
the period of follow-up of the study. ANALYSIS: Multiple
linear regression models were used to describe change in
WeeFIM scores and PedsQL scores as a function of waiting
time, adjusted for baseline score and receipt of any private
services while waiting.
Population Studied: 124 children with physical disabilities,
aged 25.7-116.7 months, referred in 2002-2004 from two
tertiary care pediatric hospitals to pediatric rehabilitation
centers.
Principle Findings: The mean age of our sample was 45.2
months (SD 13.3 months). In terms of level of disability, 6.5%
were classified as severely disabled, 41.9% as moderately
disabled, and 51.6% as mildly disabled. Half of the sample
waited more than 9.1 months for admission to a
rehabilitation program. Longer waiting time was significantly
associated with declining total quality of life score (p<0.03)
and psychosocial summary score (p<0.04), although it was
not related to change in functional score.
Conclusions: Waiting for rehabilitation services among
preschool aged children is negatively associated with the
child's quality of life, particularly the psychocsocial aspect.
Implications for Policy, Practice or Delivery: Rehabilitation
specialists should pay particular attention to psychosocial
aspects of functioning and participation among children with
physical problems, as these may become more problematic
over time. Reducing waiting times for rehabilitation services
will allow rehabilitation specialists to address psychosocial
problems and eventually improve outcomes for children with
physical disabilities.
Funding Source: Canadian Institutes of Health Research and
Fonds de la recherche en sante du Quebec
ƒ EPSDT Preventive Services among Children in Arkansas’
Medicaid Program
Pamela Hull, Ph.D., M.A., Robert Levine, M.D., Dustin Brown,
M.A., Van Cain, M.A., Marie Griffin, M.D., Baqar Husaini,
Ph.D.
Presented By: Pamela Hull, Ph.D., M.A., Associate Director,
Center for Health Research, Tennessee State University, 3500
John A. Merritt Bouldevard, Box 9580, Nashville, TN 37209,
Phone: (615) 320-3005, Fax: (615) 320-3071, Email:
pamhull@tnstate.edu
Research Objective: State-administered Medicaid programs
are federally mandated to cover free clinical preventive
services for Medicaid-eligible enrollees from birth to age 21,
under the umbrella of the Early and Periodic Screening,
Diagnosis and Treatment (EPSDT) program. While the
national target EPSDT participation rate (at least one wellchild visit per year) is 80% of eligible children, Arkansas’
official EPSDT participation rate has been the lowest in the
U.S. for several years (around 25%). The objective of this
paper was to use Medicaid enrollment and claims data to
describe patterns in the utilization of EPSDT services in
Arkansas in 2001 by age, gender, race/ethnicity, and
geographic region.
Study Design: This study employed a longitudinal
observational design. Children enrolled in Medicaid in
Arkansas were observed across the 12 months of calendar year
2001, through Medicaid enrollment and claims data files.
Individual-level data were used to calculate aggregate EPSDT
screening rates for the overall population, for demographic
subgroups, and for geographic regions to examine patterns in
utilization.
Population Studied: This study used the 2001 Medicaid
Analytic eXtract (MAX) files for Arkansas obtained from
Centers for Medicare and Medicaid Services (CMS), including
enrollment data and claims data for all enrollees under age 21.
Medicaid-eligible children enrolled in the ARKids A program
were observed during 2001. EPSDT procedure billing codes
were used to measure the utilization of well-child visits.
EPSDT ratios were calculated based on the CMS formula
(which adjusts for age and the recommended periodicity
schedule) overall and by gender, race/ethnicity, and
geographic region.
Principle Findings: EPSDT rates varied greatly across age
groups, as expected, being highest for 1-2 year-olds, less than 1
year old, and 3-5 year-olds, with very low rates for teenagers.
There was very little difference in screening rates by gender,
both overall and within age groups. The total screening rate
was virtually the same for all racial/ethnic groups except for
Asian/Pacific Islanders, who had a higher rate. However, agespecific rates varied somewhat by race/ethnicity. Hispanic
children under age 3 and Native American children under 1
year old had relatively lower screening rates. Geographic
variation in EPSDT rates by county and region are presented
graphically in maps.
Conclusions: Arkansas represents a valuable case study for
examining factors related to EPSDT utilization, since Arkansas
has the greatest need for improvement. In spite of this need,
very little research has been published about EPSDT utilization
patterns or general well-child care in Arkansas. By tracing
patterns in EPSDT utilization, this study helps to identify areas
where increased outreach efforts to families and health care
providers are needed.
Implications for Policy, Practice or Delivery: The findings of
this project provide useful information that Arkansas and
other states can use to target strategies for increasing EPSDT
rates. This study also contributes to health disparities
research by identifying gaps in EPSDT service utilization
across racial/ethnic groups, which can then be targeted in
Medicaid EPSDT outreach efforts to facilitate access to and
utilization of available services.
Funding Source: AHRQ
ƒ Expenditure Patterns for Medicaid Eligible Children in
the Last Year of Life
Caprice Knapp, Ph.D., Lindsay Thompson, M.D., M.S.,
Elizabeth Shenkman, Ph.D.
Presented By: Caprice Knapp, Ph.D., Assistant Research
Scientist, Epidemiology and Health Policy, University of
Florida, 1329 SW 16th Street Room 5130, Gainesville, FL
32608, Phone: (352) 265-7220 x 86087, Fax: (352) 265-7221,
Email: cak@ichp.ufl.edu
Research Objective: About 500,000 children cope with lifelimiting conditions annually, yet little is known about their
health care use patterns, particularly at the end of life. Our
objective was to examine the relationship between
predisposing (age, race/ethnicity) and need (diagnostic)
factors and health care spending patterns for inpatient,
outpatient, emergency department (ED) and support services
(i.e., home nursing, counseling, various therapies) among
Medicaid eligible children with life-limiting conditions during
the last 12 months of life. Examining health care use patterns
provides valuable information about the types of services used
by different groups of children that can be used to identify
potential gaps or disparities in care.
Study Design: This is a retrospective study. Florida’s
Medicaid program provided individual-level enrollment and
claims/encounter data for all children in the program from
July 2002 to July 2005. Children were eligible for inclusion in
the analyses if they had a diagnosis that was life-limiting and
died during the observation period. Life-limiting conditions
were defined as those conditions where death was expected in
young adulthood. The list of conditions was developed using
two strategies. First, two general pediatricians specializing in
the care of children with chronic conditions at an academic
health center reviewed the diagnoses of children who died.
Conditions that were the cause of death but were not likely the
underlying life-limiting condition were discarded, (for example,
children that have sickle cell disease and later experienced a
lethal stroke.) Second, these same physicians reviewed a
diagnostic list of chronic conditions that has been used in
other studies reported in the peer-review literature and
identified those conditions that were likely to lead to death in
young adulthood. A total of 825 diagnoses were identified and
used to select the children along with the indicator of death
found in the enrollment files. Next, the life-limiting diagnoses
were grouped into one of 10 categories: Cardiovascular,
Genetic, Gastrointestinal, Gestational, Injury, Immunologic,
Metabolic, Neuromuscular, Neoplasm, and Other. Ordinary
least squares regression was used to examine the relationship
between diagnostic category, child characteristics and
expenditures by type of service (inpatient, outpatient, ED, and
support services). Expenditures were adjusted and logtransformed. Finally, regression adjusted mean expenditures
were compared for White and non-White children to identify
differential spending in the last year of life.
Population Studied: A census of infants (0 to 1 year) and
children (1 to 21 years) enrolled in the Florida Medicaid
program who subsequently died between July 2002 and July
2005 and had an identified life-limiting illness (N=891).
Principle Findings: Variations in health care expenditure
patterns were observed based on diagnostic categories, age,
and race/ethnicity. Infants and children had similar mean
annual total expenditures ($75,000). Ninety-six percent of total
expenditures for infants were inpatient; they represented only
63% for children. We also found that expenditures decreased
in the last six months of life for children overall: -4.8%
decrease for inpatient, -14.5% for emergency department, 15.3% for support services, and -8.3% for total costs; (p =0.00
for each category). However, racial/ethnic variations were
found. Inpatient expenditures decreased for White and
Hispanic children in the last 6 months of life; whereas Black
non-Hispanic children had a 32% increase in inpatient
expenditures. While Hispanic children experienced declines in
inpatient expenditures in the last six months of life, their
inpatient expenditures during the last 12 months of life were
double those of White non-Hispanic children. Unexpectedly,
Hispanic children’s expenditures for support services were ten
times higher than White non-Hispanics while Black nonHispanic children had support service expenditures that were
about 80% relative to White non-Hispanic children.
Implications for Policy, Practice or Delivery: There is an
increasing emphasis on implementing comprehensive
palliative care programs for children with life-limiting
conditions that would provide supportive therapies from the
time of diagnosis to the time of death with an emphasis on
care in the home and community. Children with life-limiting
conditions would likely benefit from placement in these
programs, which are designed to improve children’s quality of
life through pain and symptom management, therapy,
counseling, and general support for the families. Our
analyses indicate that children are receiving a substantial
portion of their care in inpatient settings during the last year
of life. Further investigation is needed to better understand the
racial/ethnic differences in end of life expenditures, especially
the variations in spending patterns among Hispanic and Black
non-Hispanic children.
Funding Source: State of Florida, Children's Medical Services
Division
ƒ Losing Insurance & Using the Emergency Dept; Critical
Effect of Transition to Adulthood for Youth with Chronic
Conditions
Peter Scal, M.D., M.P.H., Robert Town, Ph.D.
Presented By: Peter Scal, M.D., M.P.H., Assistant Professor,
Pediatrics, University of Minnesota, 200 Oak Street SE, Suite
260, Minneapolis, MN 55455, Phone: (612) 624-7141, Fax:
(612) 626-2134, Email: scal0005@umn.eduy
Research Objective: To evaluate the impact of losing health
insurance on health care utilization, expenditures and health
for young adults with chronic conditions during the transition
to adulthood.
Study Design: Using longitudinal data from the Medical
Expenditures Panel Survey (MEPS) we study changes in
utilization and expenditures between the 1st and 2nd years of
the 2 year period of observation. Simple and regression
based difference-in-differences (DD) evaluate the impact of
losing insurance between the 1st and 2nd years on #
emergency department visits (EDV), physician visits(DRV)
and total health care expenditures, comparing those who lose
insurance with those retaining continuous coverage. The
focus on this age group has particularly policy relevance since
many young adults ‘‘age out’’ of insurance coverage at this
time.
Population Studied: Data from panels beginning in 19972002 were combined to achieve a sample size of 705 young
adults with chronic conditions ages 18-19 at the end of the first
year of observation. Chronic condition status is identified via
an ICD-9 coding system.
Principle Findings: 11.1% of the young adults with chronic
conditions who were insured in Year-1 were uninsured for the
full second year of observation, with differences evident by
type of insurance in Year-1 (16.9 who had public and 9.0%
who had private insurance lost coverage, Chi-Sq. 8.5, 1 df, p <
0.01). Among those who lose insurance, the mean EDV
increased by 96% (0.26 to 0.51) while DRV decreased 55%
(1.72 to 0.94). For those who retained coverage the EDV and
DRV remained nearly stable (0.27 to 0.24, and 2.99 to 2.94,
respectively). Expenditures did not change significantly for
either group. In regression DD analyses adjusting for
confounders and the non-normal distribution of the count
data, losing insurance results in a 153% (p<0.01) increase in
ED visits and a 44% decrease in DR visits (p<0.01) without
significant change in expenditures. Findings are robust to
multiple model specifications.
Conclusions: Loss of health insurance results in decreased
use of office-based physician services and a dramatic increase
in ED visits. This shift in the locus of care is in stark contrast
with best practices to assure high quality management of
chronic conditions and likely represents a response on the
part of young adults with chronic conditions to diminished
access to coordinated care. While overall expenditures do not
change with the loss of insurance there is a clear shift of the
burden of expenditures from insurance provider to young
adults with chronic conditions.
Implications for Policy, Practice or Delivery: Policy and
clinical practice changes are needed to address the ability of
young adults with chronic conditions receive optimal care into
adulthood
Funding Source: AHRQ
Children’s Healthcare Quality: Measures, Medications &
Drivers
Chair: Lisa Simpson, Ph.D., M.B.
Sunday, June 3 • 5:00 p.m.-6:30 p.m.
ƒ The AHRQ Neonatal Quality Measures - Development
and Ratings
Corinna Haberland, M.D., M.S., Sheryl Davies, M.S., Patrick
Romano, M.D., M.P.H., Jeff Geppert, J.D., Olga Saynina, M.A.,
M.B.A., Kathryn McDonald, M.M.
Presented By: Corinna Haberland, M.D., M.S., Researcher,
Primary Care & Outcomes Research/Center for Health Policy,
Stanford University, 117 Encina Commons, Stanford, CA
94305, Phone: (650) 723-1935, Fax: (650) 723-1919, Email:
corinnah@stanford.edu
Research Objective: Critically ill neonates represent an
important group within the pediatric inpatient population. We
sought to develop a group of neonatal quality indicators based
on administrative hospital data, and adapted from existing
measures, to add to the publicly available Agency for Health
Research and Quality, AHRQ, Pediatric Quality Indicator set.
Study Design: We identified previously developed quality
measures, e.g., from California Perinatal Quality Care
Collaborative, the Joint Commission on Accreditation of
Healthcare Organizations, JCAHO, the Child Health
Corporation of America, and the National Perinatal
Information Center, grade III and IV intraventricular
hemorrhage, IVH, retinopathy of prematurity, ROP,
necrotizing enterocolitis, NEC, meconium aspiration
syndrome, MAS, neonatal mortality, and nosocomial
bloodstream infections, BSI. We revised definitions to
facilitate use with ICD 9 CM coded administrative data and
defined specific patient populations for purposes of
stratification or exclusion. Measure rates were generated
using the 2003 Kids Inpatient Sample. The measures were
then presented to an expert panel, composed of clinicians
nominated by national organizations, and were evaluated
using a two stage modified Delphi process. Panelists were
aided by thorough reviews of the relevant medical literature
and data analyses. In the case of Neonatal Mortality, the
panel was presented with two versions of the measure, one
closely approximating the JCAHO measure and another with
stricter inclusion and exclusion criteria.
Population Studied: Neonatal inpatients in the 2003 Kids
Inpatient Sample.
Principle Findings: For those measures focusing on infants
weighing 500 to 1499 grams, IVH, ROP and NEC, the rates
per 1,000 eligible admissions were 50.3, 126.3, and 47.6
respectively. The rate of MAS among infants weighing 1500
grams or more was 5.02 per 1,000 eligible admissions.
Neonatal Mortality, which included infants weighing 500
grams or more, had a rate of 2.72. Finally, Nosocomial BSI,
which included all infants weighing 500 to 1499 grams and
those weighing more under certain conditions, i.e. death,
mechanical ventilation, major surgery, or acute transfer, had a
rate of 311.91. Of the six presented measures, only the
modified version of Neonatal Mortality and Nosocomial BSI
were endorsed by the expert panel, receiving a median score
of 7 or above on a 9 point scale, without significant
disagreement, on one of two questions asking whether the
measure would be useful for quality improvement or
comparative reporting. The most common concern raised for
nonendorsed measures was the uncertainty of preventability
of the outcome. Another major concern was that existing ICD
9 CM codes are not specific enough to identify the events of
interest, e.g., NEC with pneumatosis, high grade ROP.
Conclusions: The AHRQ versions of the measures for
neonatal mortality and nosocomial BSI will allow for national
surveillance and comparisons among hospitals of serious
outcomes. Several widely used measures of neonatal quality,
including the current JCAHO measure of mortality, were not
endorsed by a multidisciplinary expert panel, largely because
existing ICD 9 CM codes are not specific enough to identify
the events of interest.
Implications for Policy, Practice or Delivery: These
measures have the potential to help prioritize quality
improvement efforts for neonates at both local and national
levels. While measures that were not endorsed by the panel
would not be recommended for comparative reporting, they
have potential as research tools, for identifying hospitals or
areas with lower than expected rates to investigate best
practices. Coding changes are needed to improve the
acceptability and usefulness of other potential measures.
Funding Source: AHRQ
ƒ Specialty Difference in Appropriate Antidepressant
Dosing for Children
Michael Ong, M.D., Ph.D., Bo Liu, M.S., Eric Hamilton, M.S.,
Edward Jones, Ph.D., Jeb Brown, Ph.D., Susan Ettner, Ph.D.
Presented By: Michael Ong, M.D., Ph.D., Assistant Professor,
Medicine, University of California, Los Angeles, 911 Broxton
Avenue, 1st Floor, Los Angeles, CA 90024, Phone: (310) 7940154, Fax: (310) 794-0766, Email: michael.ong@ucla.edu
Research Objective: Many mentally ill children, even those
with access to the mental health specialty sector, receive
antidepressant drug treatment from non-specialty providers.
We tested the hypothesis that children whose antidepressant
drug prescriptions were obtained from a mental health
specialist were more likely to receive appropriate treatment.
Study Design: Prescription episodes were generated by
linking antidepressant drug prescriptions less than 30 days
apart. We examined differences among episodes in which
prescriptions were provided by psychiatrists only, primary care
providers (PCPs) only, all other types of specialists only, and
by more than one type of provider. Appropriateness was
measured by dosing within recommended limits derived from
Micromedex age-specific minimum and maximum
recommended dose ranges, and by duration of episode of
treatment. Multinomial probit models were used for dosing
analyses and proportional hazards models for duration of
episode analyses, with controls for age and gender. Episodes
were considered inappropriate if any prescription claim in the
episode had a dosage outside recommended dose ranges;
tapered prescriptions were not considered inappropriate. An
episode that contained any prescription of a drug without
recommended dose ranges was considered ‘‘off-label’’.
Population Studied: We examined all antidepressant (n =
109,046) prescription drug claims made by children (n =
14,807) to a pharmaceutical benefit carve-out vendor
associated with a large national managed behavioral health
organization between 2000-2004. Study individuals were
restricted to those who had ever used specialty mental health
care during the time period to exclude confounding effects
from specialty mental health care inaccessibility, and claims
were restricted to 2001-2004 to minimize truncation error.
Principle Findings: Predicted probabilities that prescription
episodes by psychiatrists had all doses within recommended
limits was 27%, had overdoses was 2%, and had off-label use
was 70%; the average episode duration was 128 days. PCPs,
other specialists, and multiple provider types had significantly
higher (p < 0.05) levels of dosing within recommended limits
(predicted probability differences 3% to 16%) than
psychiatrists, and significantly lower (p < 0.05) levels of
overdoses (predicted probability differences 0.3% to 0.8%)
and off-label use (predicted probability differences 14% to
32%) than psychiatrists. PCPs had the largest amount of
differences. Duration of prescription episodes provided by
multiple provider types was significantly longer (p < 0.05) than
those provided by psychiatrists (hazard ratios 0.44). Duration
of prescription episodes provided by PCPs and other
specialists was significantly shorter (p < 0.05) than those
provided by psychiatrists (hazard ratios 1.12 for PCPs, 1.06 for
other specialists).
Conclusions: Psychiatrists are more likely to prescribe offlabel and use antidepressant doses larger than recommended
limits than any other group. PCPs and other specialists are
more likely than psychiatrists to prescribe antidepressants for
shorter duration, while antidepressant prescriptions by
multiple provider types are more likely to have longer duration
than those by psychiatrists.
Implications for Policy, Practice or Delivery: Psychiatrist
higher use of non-recommended antidepressant medications
and dosing raises concern, but further examination with
clinical outcomes would determine whether these behaviors
are truly inappropriate. Additional studies correlating duration
and clinical differences are needed.
Funding Source: NIMH
ƒ 2001-2004 National Trends in Prescription Medication
Use for Children and Adolescents: Assessment of National
Disparities and Quality-Related Practice Patterns
Christina Bethell, Ph.D., M.B.A., M.P.H., Debra Read, M.P.H.,
Tamela Stuchiner, M.A.
Presented By: Christina Bethell, Ph.D., M.B.A., M.P.H.,
Associate Professor, Director, Pediatrics, OHSU, The Child
and Adolescent Health Measurement Initiative, 707 SW
Gaines Street, Mailcode CDRC-P, Portland, OR 97239, Phone:
503-494-1892, Fax: 503-494-2475,
Email: bethellc@ohsu.edu
Research Objective: To assess 2001-2004 national trends in
disparities and quality-related patterns of care in new
prescriptions and refills for children and adolescents.
Study Design: Child rates of one or more new prescriptions
or refills overall and by therapeutic subclasses of medications
were calculated using 2001 to 2004 Medical Expenditures
Panel Survey (MEPS) data. Rates were compared and
adjusted odds ratios (AOR) calculated for children and youth
with special health care needs (CYSHCN), by race/ethnicity,
insurance status and type, age, gender, language and other
variables. Therapeutic subclass trends were evaluated for
evidence of practice patterns indicative of impact by the recent
quality improvement focus on medications for children with
asthma, reductions in antibiotic use for children and
modulation in use of psycho-therapeutic medications.
Population Studied: 41,908 children age 0 to 17 weighted to
represent children nationally included in the MEPS
Consolidated Household Component File in years 2001, 2002,
2003 and 2004.
Principle Findings: The proportion of children with one or
more new prescriptions or refills dropped 3.4 points between
2001 and 2004 (52.6% to 49.2%), with 0 to 5 age rates
increasing 4.5 points (84.3% to 88.8%). The 0 to 5 age
increase was driven by a 7.6 point increase in
hormones/corticosteroids (12.8% to 20.4%), a 5.7 point
increase in gastrointestinal agents (5.7% to 11.4%), a 3.2 point
increase in respiratory agents (55.7% to 58.9%) and a 3.3 point
increase in central nervous system agents (15.5% to 18.8%)
and was offset by a 6.9 point decrease in one or more new
prescriptions or refills for antiinfectives (55.4% to 48.5%). The
adjusted odds that CYSHCN (about 18% of children) had one
or more orders or refills were 5.85 (2001) to 7.12 (2004).
Rates for CYSHCN increased 4.5 points (84.3% to 88.8) while
rates for non-CYSHCN dropped 4.1 points (45.8% to 41.7%).
Hispanic and black children were less likely to have one or
more orders or refills in 2001 thru 2004 (AOR .74 and .52
respectfully in 2004) as were lower income children and
children who were uninsured (AOR .63 in 2004). Few
changes in orders for psycho-therapeutic agents were
observed. After adjusting for other variables, no differences
were seen by whether children had private or public insurance
coverage or language. Additional bivariate and multivariate
findings by intensity of medication use, therapeutic subclasses
and population subgroups will be presented.
Conclusions: Patterns of new prescriptions and refills
between 2001 and 2004 suggest the ongoing presence of
racial and socioeconomic disparities not explained by special
health care needs status and insurance coverage as well as
indication of a positive impact of the concurrent quality
improvement focus on increasing use of medications for
asthma and decreasing use of antibiotics, especially for
younger children.
Implications for Policy, Practice or Delivery: National efforts
advocating for improving the quality of prescription
medication use may have a positive impact in a short period
of time. Differential patterns of use by age, race, insurance
status and income of children require further investigation
regarding impact on the health of children and policy
response.
Funding Source: CDC
ƒ Using Health Status to Measure Quality of Care for
Young Children
Embry Howell, M.S.P.H., Ph.D., Lisa Dubay, Ph.D.
Presented By: Embry Howell, M.S.P.H., Ph.D., Principal
Research Associate, Health Policy Center, The Urban Institute,
2100 M Street, N.W., Washington, DC 20037, Phone: (202)
261-5714, Email: ehowell@ui.urban.org
Research Objective: To identify several dimensions of child
health status that can be measured in parent surveys, and to
use them to evaluate the quality of child health care.
Study Design: In July 2003, a new program called Healthy
Kids began in Los Angeles County, California, with a goal of
extending universal health insurance for children. Healthy Kids
covers uninsured (primarily Latino) children under 300% of
the federal poverty level. A two-wave telephone survey of the
parents of Healthy Kids children ages one to five employed a
longitudinal design, with the first wave of interviews
conducted in 2005 and the follow-up wave (with the same
sample) one year later. The initial sample was 1,430 parents,
with 86% responding to the wave one survey and 75%
responding to both waves. We developed ten measures of
health status, including measures of both acute and chronic
conditions. Some of the measures (eg. health status during
infancy) are used as baseline (control) variables and others
(perceived health status) as outcome measures in an
evaluation of the quality of care under the program.
Population Studied: A sample of children ages 1 to 5 in the
Los Angeles Healthy Kids program.
Principle Findings: A high proportion of Healthy Kids
children had a health condition requiring health care. About
one third had an acute condition that caused the parent a high
level of concern, and about 10 percent had a chronic
condition. A very high proportion of these young children
were reported to be in fair/poor health status (much higher
than national norms, including for Latino children), and over
forty percent had untreated dental care needs. There was a
high correlation between the parent’s perception of their
child's health status and the other measures of health status.
For example, over 50 percent of children with an urgent
condition in the past month were reported to be in fair/poor
health. Children with new insurance coverage obtained health
services at a significantly higher rate, allowing parents to treat
conditions that were previously untreated. At wave one, after
controlling for baseline health status, children who were
enrolled for a year had significantly better perceived health
than newly enrolled children, which is consistent with findings
from a similar study in Santa Clara County. While the
perceived health status of both groups of children improved
between the two waves, there was no significant difference
between new and established groups in the level of
improvement, suggesting that gains from health insurance
continued into the second year of enrollment.
Conclusions: It is possible to develop measures of health
status in young children that can be used to measure the
outcomes of their health care. This study illustrates how such
measures can be used to measure the quality of newly
available health services.
Implications for Policy, Practice or Delivery: Studies of the
quality of child health care should incorporate measures of
health status outcomes, as well as measures of the process of
care.
Funding Source: First Five Los Angeles
ƒ Drivers of the Quality of Preventive and Developmental
Services for Young Children? Findings from a Multi-Level,
Provider and Patient-Centered Method to Assess Quality
Christina Bethell, Ph.D., M.B.A., M.P.H., Colleen Reuland,
M.P.H., Rasjad Lints, M.D., Scott Shipman, M.D., M.P.H.
Presented By: Christina Bethell, Ph.D., M.B.A., M.P.H.,
Associate Professor, Director, Pediatrics, CAHMI, OHSU, The
Child and Adolescent Health Measurement Initiative, 707 SW
Gaines Street, Mailcode CDRC-P, Portland, OR 97219, Phone:
(503) 494-1892, Fax: (503) 494-2475, Email:
bethellc@ohsu.edu
Research Objective: To evaluate the level and variations in
quality of preventive and developmental services for young
children according to system, office, provider and patient
factors.
Study Design: The Promoting Healthy Development Survey
(PHDS) was administered to children’s parents and quality
measures calculated on six communication-dependent
aspects of developmental services; three anticipatory guidance
and parental education (AGPE); two psychosocial screening
measures and one regarding whether providers ask parents’
about concerns regarding their child's developmental status.
Child-level responses were linked with utilization and provider
survey data on PHDS topics. Logistic and multi-level
regression analyses included child, family and provider
characteristics. Associations were assessed between providerlevel quality scores and their perception of barriers to
providing services, their electronic medical record (EMR) visit
templates and parent education materials in the office. Four
additional tests evaluated whether gaps in care may be due to
provider customization of care to children with greatest risks.
Population Studied: 2173 children under age four enrolled for
at least one year with a managed care organization and having
at least one well-child care visit with one of 56 exclusively
affiliated pediatric well-child care providers in a single
metropolitan area in the last year.
Principle Findings: Children met criteria on an average of
3.08 of six quality measures (2.44 to 3.92 across providers-p <
.03). While only 6.4% had parents reporting discussions with
providers on all PHDS AGPE topics, 39% reported either a
discussion on all topics or that lack of discussion was alright
(they had the information they needed). Over half were asked
about concerns about their child’s development (53.3%) and
substance abuse and/or firearms in the home (53.1%) and
38.1% reported screening on at least one of three
parent/family emotional and mental health issues. No
provider scored highest or lowest on each of quality measure.
Child’s age, race/ethnicity, birth order, developmental status
and parent’s depression status were significant predictors of
quality for 3 to 6 measures each. Provider age, if he/she has
children, and clinical FTE status were predictive of provision of
psychosocial screening. A small clustering effect by the
provider children saw was observed. Small associations
existed between quality and provider use of EMRs and parent
education materials. No evidence emerged that providers
customize care to children most at risk. Providers’ agreement
with potential barriers to delivery quality care, while high, was
not predictive of their scores on any of the six quality
measures.
Conclusions: Higher quality care is systematically provided to
certain groups of children (e.g. by age, birth order, etc.). At
the same time, the probability of receiving quality care varies
nearly as much across children seeing the same provider as
across providers even as no provider had highest or lowest
performance on any aspect of quality. After inherently or
explicitly controlling for eleven types of system, provider, child
and family factors, significant gaps and unexplained variations
exist.
Implications for Policy, Practice or Delivery: Findings
suggest the presence of system level barriers requiring a
broader rethinking of the models, infrastructure, workforce
and resources to support quality well-child care. Parent
reported data was essential to robust and actionable quality
measurement.
Clinical Care for Children
Chair: David Bergman, M.D.
Monday, June 4 • 9:00 a.m.-10:30 a.m.
ƒ Assessing the Role of Physicians in Child Health
Disparities
Lauren Smith, M.D., M.P.H., Carol Simon, Ph.D., William
White, Ph.D., Andrew Johnson, M.A., Alyssa Pozniak, Ph.D.,
Lois Olinger, M.C.P.
Presented By: Lauren Smith, M.D., M.P.H., Associate
Professor of Pediatrics, Pediatrics, Boston University School of
Medicine, 91 E. Concord Street, 4th Floor, Boston, MA 02118,
Phone: (617) 414-7911,
Email: lauren.smith@bmc.org
Research Objective: To examine racial variation in clinical
pediatric decision making for 2 conditions with a high degree
of clinical discretion, asthma and depression, and to explore
the extent to which pediatric racial and ethnic disparities are
affected by the characteristics of providers, the nature of
physician practices, and the managed care environment.
Study Design: Despite major advances in the clinical
capability to prevent and treat many of the most important
threats to child health, a growing literature has documented
substantial racial/ethnic disparities in utilization and quality of
health services and child health outcomes. Research has
suggested that clinician discretion in decision-making may
play a role in the significant racial/ethnic variation in care.
Managed care, through use of service coordination, clinical
guidelines and gate-keeping arrangements is hypothesized to
reduce disparities in access to primary care, but financial
incentives and controls may increase disparities in access to
specialty and diagnostic services. The studied involves a
mixed-mode survey linking physician prescribing and
management behavior to characteristics of the physician,
his/her practice setting and the managed care environment.
Survey domains include: physician demographics and income,
practice revenue, financial condition, use of health information
technology, patient population characteristics, such as
proportion who are minority or have limited English
proficiency, and physician perceptions of barriers to
medication adherence. Pediatric providers are presented with
2 pediatric clinical vignettes in which the race/ethnicity of the
child is randomly varied among the sample. Multivariate
weighted regression and logistic regressions were used to
analyze reported physician behavior and factors associated
with diagnosis and management. Data are weighted to
account for sampling design.
Population Studied: A random sample of 1200 primary care
physicians, including pediatric providers in 5 states (California,
Georgia, Illinois, Pennsylvania and Texas). The sample was
derived from the American Medical Association Physician
Masterfile and included oversampling of pediatric and
minority physicians.
Principle Findings: Preliminary findings show differences in
reported prescribing and management behavior when the
race/ethnicity of the patient was varied. Practice setting and
resources were related to prescribing patterns, as were
physician perception of the likelihood of adherence and
patient population characteristics. Further analyses will
estimate the relative contribution of each of these factors to
decision-making patterns and will compare the pattern of
influences for pediatric vs. adult providers and for minority vs.
non-minority providers.
Conclusions: The findings suggest that there is racial/ethnic
variation in prescribed care for 2 common pediatric health
conditions, asthma and depression and that practice setting
and patient population characteristics are associated with this
variation.
Implications for Policy, Practice or Delivery: This research
contributes to a better understanding of the physician and
practice-level factors that are associated with disparities in
pediatric clinical decision making and suggests that efforts to
reduce racial/ethnic disparities in child health care should take
into account the contribution of these factions, while
organizing systems of care to buffer children from these
effects.
Funding Source: AHRQ, The California Endowment, The
Commonwealth Fund
ƒ Effects of Expanding Preventive Dental Care in Medical
Offices for Young Children Covered by Medicaid
Sally Stearns, Ph.D., R. Gary Rozier, D.D.S., M.P.H.,
Jeongyoung Park, M.P.H., Bhavna T. Pahel, B.D.S., M.P.H.,
Rocio Quinonez, D.M.D., M.S., M.P.H.
Presented By: Sally Stearns, Ph.D., Associate Professor,
Health Policy and Administration, University of North Carolina
at Chapel Hill, CB #7411, Chapel Hill, NC 27599-7411, Phone:
(919) 843-2590, Fax: (919) 966-6961,
Email: sstearns@unc.edu
Research Objective: Dental decay is the most common
preventable chronic disease encountered among children of
preschool age in the U.S. Clinical guidelines recommend that
primary care providers take an active role in preventive oral
health, and physicians historically have provided a dental
assessment and oral health counseling of parents during wellchild visits. In January 2000, North Carolina initiated a
comprehensive preventive dental program for Medicaidenrolled children birth through 35 months of age (Into the
Mouths of Babes, or IMB) offered in medical offices by
providers who completed continuing medical education
related to these services. This study assesses the effects of
the IMB program, which included the application of a fluoride
varnish to children’s teeth in addition to screening, risk
assessments and counseling, on access to preventive dental
care and subsequent use of restorative dental treatments.
Study Design: The observational longitudinal analysis uses
child-month indicators of IMB visits in medical offices and
dental visits (preventive and restorative) in dental offices.
Because the program was implemented gradually throughout
the state over several years, a difference-in-differences
regression approach is used to analyze the effect of the IMB
program on access to dental care. Regression analyses also
are used to compare subgroups of children receiving four or
more of a possible six IMB visits with children receiving no
IMB visits to determine whether the IMB program results in
reduced use of caries-related treatment.
Population Studied: The analysis uses Medicaid claims and
enrollment data from the NC Division of Medical Assistance
for all children from 6 through 35 months of age who were
enrolled in Medicaid from January 2000 through June 2003.
Principle Findings: The IMB program led to a substantial
overall increase in access to preventive dental care without
reducing preventive care by dentists. The program increased
visits to dentists for treatment of existing disease. Despite the
increased referral to treat identified disease, the program
reduced the need for dental treatment by 3 years of age among
children with four or more IMB visits.
Conclusions: Analysis of the program during the
implementation phase means the high magnitude of referrals
for existing disease could decrease over time. The IMB
program increased access to preventive dental care, improved
dental health due to timely treatment of existing disease, and
reduced total restorative treatment with likely associated
improvements in dental health. Reductions in rates of dental
restorations by 3 years of age suggest that the need for dental
restorations may also be reduced beyond that age.
Implications for Policy, Practice or Delivery: Dentists are in
short supply in many areas, and access to preventive dental
care historically has been very poor for young Medicaideligible children. Expanding access to preventive dental care
in medical offices does not decrease use of dentists for
preventive care, improves dental health through referrals to
dentists, and appears to result in long-run decreases in need
for restorative dental services. Because a number of visits are
required to obtain the full preventive benefits, the costeffectiveness of the program ultimately rests on reductions in
dental restorations beyond age 3.
Funding Source: National Institute for Dental and
Craniofacial Research
ƒ Recurrent Urinary Tract Infections: Risk Factors and
Effectiveness of Prophylaxis in a Primary Care Cohort
Patrick Conway, M.D., Brandon Henry, B.S., Robert
Grundmeier, M.D., M.S., Theoklis Zaoutis, M.D., M.S.C.E.,
Ron Keren, M.D., M.S.C.E., Avital Cnaan, Ph.D.
Presented By: Patrick Conway, M.D., Robert Wood Johnson
Clinical Scholar and Instructor, RWJ Clinical Scholars and
General Pediatrics, University of Pennsylvania, 423 Guardian
Drive, Blockley 1303A, Philadelphia, PA 19104-6021, Phone:
(215) 573-2573, Fax: (215) 573-2742,
Email: pconway2@mail.med.upenn.edu
Research Objective: In a primary care cohort, no published
studies have evaluated the risk factors for recurrent UTI and
the risks and benefits of prophylactic antibiotics. Therefore,
we aimed: 1. To identify factors associated with recurrent UTI
in a primary care pediatric cohort; 2. To determine the
effectiveness of prophylactic antibiotics for preventing
recurrent UTI and their effect on the development of resistant
infections.
Study Design: In a primary care network of 27 pediatric
practices sharing a common electronic health record, we
identified all children younger than 6 years who had an initial
UTI between 7/1/2001 and 5/31/2006 and tracked them until
they developed a recurrent UTI or their last clinic visit. We
used survival analysis to identify risk factors for recurrent UTI,
including age at first UTI, gender, race, presence of
vesicoureteral reflux (VUR), and prophylactic antibiotic
exposure (defined as a time varying covariate). In a nested
case-control study, we utilized logistic regression to determine
risk factors for resistant vs. pan-sensitive bacteria as the cause
of recurrent UTI.
Population Studied: Identified children with first UTI from all
children younger than 6 years of age seen within primary care
pediatric network.
Principle Findings: During the study period, 81,997 children
had a clinic visit within network, 612 children had a first UTI,
and 82 children had a recurrent UTI. Mean observation time
was 408 days. The incidence rate for recurrent UTI was
0.12/person-year. In multivariate survival analysis, only white
race (HR 2.0, 95% CI 1.2-3.3) and age over 2 years (HR 2.0,
1.2-3.3) were associated with increased risk of recurrent UTI.
Prophylactic antibiotics, VUR, and gender were not
significantly associated with risk of recurrent UTI. Among
recurrent UTIs, antibiotic resistance was associated with
prophylactic antibiotic exposure (OR 7.1, 1.5-33.3), non-white
race (OR 4.6, 1.5-13.9), and age less than 2 years (OR 3.9, 1.311.8).
Conclusions: The rate of recurrent UTIs from this primary
care population was significantly lower than reported in
previous studies that were typically small clinical trials or from
referral populations (12% per year vs. 21-69% recurrence
within 6-12 months). VUR, for which prophylaxis is currently
recommended, was not associated with increased risk of
recurrent infection. Prophylactic antibiotics did not protect
against recurrent UTI and were associated with increased risk
of resistant infections.
Implications for Policy, Practice or Delivery: This further
calls into question the AAP guidelines for prophylaxis
following first UTI. Since it is unclear that prophylaxis is
beneficial and may pose a risk of resistant infections, this
information should be shared with families and joint decisions
on prophylaxis made with physicians.
Funding Source: RWJF
ƒ Impact of Emergency Department Asthma Management
Strategies on Return Visits in Children: A Populationbased Study
Astrid Guttmann, M.D.C.M., M.Sc., Brandon Zagorski, M.Sc.,
Asma Razzaq, M.P.H., Geoff Anderson, M.D., Ph.D.
Presented By: Astrid Guttmann, M.D.C.M., M.Sc., Scientist,
Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, G1
06, Toronto, ON, M4N 3M5, Canada, Phone: (416) 480-4055
ext 3783, Fax: (416) 480-6048,
Email: astrid.guttmann@ices.on.ca
Research Objective: To describe the characteristics of
children treated in Emergency Department (EDs) for asthma,
the management strategies used in a range of ED settings and
their effect on 72 hour return visit rates (a hospital quality
measure).
Study Design: Population-based cohort study using both
comprehensive administrative heath and survey data from all
152 EDs in Ontario, Canada.
Population Studied: All children ages 2 - 17 years who had a
visit to the ED for asthma during April 2003 to March 2005.
Principle Findings: 32,996 children (over 9% of children with
asthma in Ontario) had at least one visit to an ED for care of
asthma and the majority of visits (68.5%) were high acuity.
The vast majority (148/152, 97%) of EDs reported using at
least one asthma management strategy and 74% used three
or more. Less than half reported routine use of peak flow
monitoring. The overall return visit rate was 5.6%. Logistic
regression models that accounted for the clustering of
patients in EDs and controlled for patient and ED
characteristics indicated that standard, pre-printed order
sheets (OR 0.68, 95% CI 0.55 to 0.88) and access to a
pediatrician for consultation in the ED (OR 0.64, 95% CI, 0.52
to 0.79) were the only two individual strategies that had a
significant impact on return visits. The 11 (17%) EDs that
used both of these strategies had return visits rates of 4.4%
compared to 6.9% in the 95 (63%) that used neither.
Conclusions: EDs use a range of strategies to manage
asthma in children but some are more effective in improving
care. Pre-printed order sheets and access to pediatric
consultations are associated with important reductions in
return visit rates.
Implications for Policy, Practice or Delivery: Imbedding
guideline care into practice, as with standard order sheets,
improves patient and ED outcomes. This intervention is
highly feasible and should be undertaken by EDs to ensure
high quality asthma care.
Funding Source: Ontario Hospital Report
ƒ Variations and Deviations in the Use of Tympanostomy
Tubes for Children with Otitis Media
Salomeh Keyhani, M.D., M.P.H., Lawrence C. Kleinman, M.D.,
M.P.H., Michael Rothschild, M.D., Rebecca Anderson, M.P.H.,
Melissa Simon, B.S., Mark Chassin, M.D., M.P.P., M.P.H.
Presented By: Salomeh Keyhani, M.D., M.P.H., Assistant
Professor, Health Policy, Mount Sinai School of Medicine, 1
Gustave L Levy Place, New York, NY 10029, Phone: (212) 6599563, Email: salomeh.keyhani@moutnsinai.org
Research Objective: To describe variations in practice among
children who received tympanostomy tubes in the New York
Metropolitan area in 2002, and to contrast practice with the
1994 and 2004 clinical practice guidelines (developed by the
American Academies of Pediatrics, Family Medicine, and
Otolaryngology------Head and Neck Surgery) that generally
recommend delaying the insertion of tympanostomy tubes
until bilateral otitis media with effusion (OME) persists for 4
months or longer with hearing loss or other signs and
symptoms.
Study Design: Retrospective cohort study
Population Studied: Clinical analysis was performed for 682
children (under 18) for whom it was possible to abstract data
for the year preceding surgery from the medical records of the
surgeon, the hospital, and the primary care provider. The
sample represents 65% of all children who received tubes in
any of five New York City area hospitals (2 academic medical
centers, one tertiary care teaching hospital, one private not for
profit community hospital, and one teaching public hospital);
social and demographic of variables were similar for those
children not included in the sample.
Principle Findings: Mean age was 3.8 years, 57% were male
and 74% had private insurance. More than 25% had received
tubes previously. Common reason for surgery included OME,
(60.4%), recurrent acute otitis media (RAOM, 20.6%), and
Eustachian tube dysfunction (10.6%). Children with RAOM
averaged 3.1±0.2 episodes (median=3) in the previous year;
those with OME averaged 29±1.7 (median= 16, standard
deviation = 35.3, coefficient of variation=120%) consecutive
days of bilateral effusion documented immediately prior to
surgery. 75% of children with OME had less than 42
consecutive days of bilateral effusion, with 5% having bilateral
effusions for at least 120 days. 78% of children with OME had
documented hearing loss. Overall, 17.3% of all children were
identified with a condition that may put them ‘‘at risk’’ for
developmental delays that exempted them from the
guidelines’ general recommendation.
Conclusions: The clinical characteristics of children who
received tympanostomy tubes in this sample varied widely.
Many had very little ear disease at the time of surgery. The
variations were not accounted for by reported speech or
hearing problems, reported disruptions of family life,
insurance status, ethnicity, hospital, or other commonly
considered clinical or demographic variables. A substantial
amount of practice departs from expert recommendations.
These findings suggest significant over utilization of
tympanostomy tube insertions in children persists despite the
publication of guidelines by professional societies.
Implications for Policy, Practice or Delivery: Clinicians and
parents should consider these findings when caring for
children with otitis media. The extent of variation in treating
this familiar condition with limited treatment options suggests
both the importance and difficulty of managing common
clinical practice to comport with accepted guidelines, even one
that was developed by three leading clinical Academies.
Funding Source: AHRQ