Q
Quality
y of Primary
y Care
and Health Care Utilization
A
Among
Child
Children with
ith
Special Health Care Needs
Jean L. Raphael, MD, MPH
Academic General Pediatrics
Background
American Academy of Pediatrics
defines Children with Special
Health Care Needs (CSHCN) as:
“those who have or are at increased risk
for a chronic physical, developmental,
behavioral or emotional condition and
behavioral,
who also require health and related
services of a type or amount beyond that
required by children generally.”
generally ”
McPherson M et al. A New Definition of Children with Special Health
Care Needs. Pediatrics 1998; 102:137-140
Primary
P
i
Care
C
and
d Health
H lth Care
C
Utilization among CSHCN



Account for 42% of total medical
expenditures for US children
Care in ER and inpatient settings
carries risk for CSHCN
High quality primary care has
potential to reduce preventable
utilization
Newacheck et al. Health Services Use and Health Care Expenditures for
Children with Disabilities. Pediatrics 2004; 114:79-85.
Prior Studies


High quality family-centered care and
realized access associated with fewer
non-urgent ER visits among children1
Having a medical home associated with a
reduction in racial/ethnic disparities in ER
utilization among CSHCN2
1Brousseau
et al. Quality of Primary Care and Subsequent Pediatric
Emergency Department Utilization. Pediatrics 2007 Jun;119(6):1131-8.
2Raphael
et al. Association of Medical Home Care and Disparities in Health
Care Utilization Among Children with Special Health Care Needs. Academic
Peds 2009 July-Aug;9(4): 221-7.
Objective and Hypothesis
Objective

To determine
T
d t
i whether
h th parent-reported
t
t d
quality of primary care was associated
with subsequent
q
health care utilization for
CSHCN
Hypothesis

Low quality primary care in the domains
of family-centeredness, timeliness, and
realized access would be associated with
higher rates of subsequent emergency
care (ER) encounters and hospitalizations
Methods





Design: U.S. population-based,
retrospective analysis of prospectively
collected data
Data Source: Medical Expenditure Panel
Survey (MEPS), 2004-2005 and 2005-2006
Participants: 1,591 CSHCN, ages 0
0-17
17
Main exposures: Quality of Primary Care
Main outcomes: ER visits (urgent, non
nonurgent) and hospitalizations


Consumer Assessment of
Healthcare Providers and
Systems (CAHPS)
Valid measure of parent
reported quality of care for
children,, including
g CSHCN
Addresses familycenteredness timeliness,
centeredness,
timeliness and
realized access
Scoring Algorithm



Nine quality of care questions
Composite scores and question
groupings developed by AHRQ
Composite scores obtained by
g g the individually
y
averaging
answered questions that comprise
quality
y of care composite
p
the q
Individual CAHPS Questions Constituting the QualityQualityof--Care Composites
of
Family centeredness (1
(1=never
never, 2=sometimes
2 sometimes, 3=often
3 often, 4
4=always)
always)
How often provider explained things so you understood
How often provider showed respect for what you had to say
How often p
provider spent
p
enough
g time with you
y
How often provider listened carefully to you
Timeliness (1=never, 2=sometimes, 3=often, 4=always)
How often you got an appointment for injury or illness as soon as you
wanted
d
How often you got a routine appointment as soon as you wanted
How often you were able to get help by telephone
Realized access (1=never
(1=never, 2=sometimes
2=sometimes, 3=often
3=often, 4=always)
How big a problem it was to get care you or a doctor thought was necessary
How big a problem it was to get a referral to a specialist
_______________________________________________________________________________
*Highest quality was indicates by a composite score of >3.5 on the 4-point scale for familycenteredness and timeliness and a score of 3 for realized access.
Covariates









Age
Gender
Race/ethnicity
Insurance type
Family Income
Usual source of care
Primary language
Parental education
Health status
Subsequent Health
Care Utilization


ER Visits
Urgent – labs,
labs radiographs
radiographs, EKG
EKG, EEG
EEG, or
admission
g
Non-urgent
Hospitalizations
Only encounters occurring after completion
of CAHPS survey were included in analysis
Analysis



Generalized Poisson regression
analyses
Results reported as incident rate
ratios (IRRs)
(
)
IRR of >1 indicates lower quality of
care is associated with more
encounters
t
per child
hild
Demographics (N=1,591)



97% insured
96% with usual source of care
94% with English as primary
language
Association Between Parent Reported Low Quality of
Care and Urgent and NonNon-Urgent ER Visits
Quality--ofQuality
of-Care Composite
IRR (95%Cl)
____________________________________________
Urgent ER Visits
NonNon-urgent ER Visits
______________________________________________________________________________
Family--centeredness
Family
0.72
0 72 (0
(0.28
(0.2828-1.84)
281 84)
2.23
2 23 (1
(1.31
(1.3131-3.80)
313 80)
Timeliness
1.49 (0.60
(0.60--3.70)
0.59 (0.41(0.41-0.85)
Realized access
0.53 (0.17
(0.17--1.70)
0.82 (0.49
(0.49--1.39)
____________________________________________________________________
*Adjusted for covariates
covariates.
Associations Between Parent Reported Low Quality
of Care and Hospitalizations, Stratified by Insurance
Type
_________________________________
Quality-ofQualityof-care composite
IRR
95%Cl
_____________________________________________________
Private insurance
Family--centeredness
Family
3.79
1.22
1.22--11.72
Timeliness
0.46
0 46
0.140 14-1.44
0.14
1 44
Realized access
3.63
1.39
1.39--9.46
Public Insurance
Family--centeredness
Family
1.43
0.65
0.65--3.11
Timeliness
0.60
0.26
0.26--1.36
Realized access
0.45
0.14
0.14--1.45
______________________________________________________
*Adjusted
j
for covariates.
Cronbach s Alpha
Cronbach’s
Interpretation
p


> 0.7 for intercorrelations
among family-centeredness
and realized access questions
q
<0.3 for intercorrelations
among timeliness questions
Association
A
i ti between
b t
Timeliness
Ti li
Questions and Utilization

Children who got an appointment
(never/sometimes/usually) for an injury or
illness as soon as they wanted had higher
g
ER visits (IRR
(
1.59,,
rates of non-urgent
95% CI 1.07-2.36) compared with those
who always
y g
got appointments.
pp
Summary


Low quality family-centeredness
associated with higher rates of
subsequent non-urgent ER
encounters and hospitalizations
Realized access and timeliness had
less consistent relationships with
utilization
Limitations




CAHPS may not capture all
factors associated with health
care utilization
Recall bias of parent report
Mi l
Misclassification
ifi ti off ER
urgency
Heterogeneity of CSHCN
Future Policy Implications



Enhance the components of familycentered
t
d care
Reorganize health care team to
simultaneously promote quality of
care and preserve physician
productivity
Assess impact
p
of health workers,,
patient navigators on familycentered care
Acknowledgements



Minghua Mei, PhD
Baylor College of Medicine
David Brousseau, MD, MS
Medical College of Wisconsin
Thomas Giordano, MD, MPH
y
College
g of Medicine
Baylor