2009 Child Health Services Research Interest Group
Call for Posters Abstracts
™ Role of Socio-Economic and Demographic
Factors in Preventing Infant Deaths: Historical
Evidence Using Annual Data from Pakistan
Faisal Abbas, Ph.D.
Presented by: Faisal Abbas, Ph.D., Junior Researcher,
Economic and Technological Change, Centre for
Development Research (ZEF), Walter Flex Street 3,
Bonn 53113, DE Phone: 004917620731590 Email:
fabbas@uni-bonn.de
Research Objective: The study aims at answering the
following questions: What factors (economic,
demographic, social and political) determines the
improvement of the health status of infants in Pakistan?
What role health spending and unemployment can play
in explaining infant mortality in historical context?
Whether the improved health status has causal relation
with public health care spending and prevailing
persistent income inequality? What is the likely effect of
policy variables like mothers’ education, immunization of
children, urban population growth in improving health
status?
Study Design: This study is unique in the sense that it
is first of its kind that uses the time series data and
applied cointegration analysis in a developing country
context to draw attention towards the long run
relationship between health status and some important
policy variables. The study employs the Augmented
Dickey Fuller (ADF) and Philip Perron (PP) test to
examine the issue of stationarity and unit root
hypothesis. Johansen full information maximum
likelihood multivariate cointegration approach is used to
determine the factors responsible in explaining the long
run variations in infant mortality and life expectancy in
Pakistan. Engle-Granger (EG) causality test is employed
to see the direction of causality between health status,
public health care spending and other variables of policy
relevance. As Johansen methodology provide long run
estimates therefore following general to specific
modeling approach, a vector error correction model
(VECM) is applied to capture the short run dynamics. An
orthogonalized impulse response analysis (IRA) is
carried out to see the impact of shocks (i.e. innovation
accounting) to health status and its probable impact is
analyzed on other variables of interest.
Population Studied: It is a country level study using
annual data from Pakistan.
Principal Findings: The trace statistics strongly rejects
the null hypothesis that there is no cointegration
between variables (i.e. r = 0), but do not reject the
hypothesis that there is one cointegrating relationship
(i.e. r = 1).It is therefore concluded that our model has
one cointegrating vector (i.e., a unique long-run
equilibrium relationship exists). The maximal Eigenvalue
test also rejects the null of no cointegration and hence it
is also in line with the results of the trace statistics. Total
fertility rate is positively affecting infant mortality rate. It
means that an increasing fertility has a threatening affect
on infant survival chances. The availability of health
personnel per capita also affecting infant mortality
negatively indicating that an increase in health personnel
especially in rural areas, increase the access to health
facilities and has a positive affect on infant survival
chances. Public health expenditures are also affecting
infant mortality negatively, meaning that increasing
public health interventions especially for mother and
child care and shifting emphasis from preventive to
curative care will bring a shift in infant mortality rate.The
sign of unemployment coefficient is a priori and the value
is low because in a traditional society like Pakistan
working women concept is still premature especially in
rural areas where almost 70 percent of the population is
residing.
Conclusions: The analysis helps in better resource
allocation and target intervention, for better population
health, in cost effective manner.
Implications for Policy, Delivery or Practice: Helps in
formulating better policies that help to prevent aviodable
deaths of infants by allocating resources where it is
needed and secondly also helps to build a better link
between improved health status, health spending and
growth nexus in the long run.
™ Children in Upheaval: War Migration and Child
Health in Angola
Winfred Avogo, Ph.D.; Victor Agadjanian, Ph.D.
Presented by: Winfred Avogo, Ph.D., Assistant
Professor, Sociology and Anthropology, Illinois State
University, Campus Box 4660, Normal, IL 61790-4660
Phone: (309) 438-5227 Email: wavogo@ilstu.edu
Research Objective: To investigate the short and long
term impact of the effects of migration induced by war
(war migration) and that motivated by other reasons
besides war (non-war migration) on child health
outcomes in Angola, a country of about 16.8 million
people in South-Western Africa that has endured civil
conflict for most of its independent existence.
Specifically, we test the assumption that although the
antecedents and mechanisms of war migration and nonwar migration are different, they do occur in the same
contexts in settings of prolonged military conflicts that
vary in intensity. Thus the two migration groups are
expected to have different child health outcomes such as
age adequate immunization and under-five mortality in
the short and long term.
Study Design: Cross-sectional analysis of detailed data
on birth and health histories of children under-five using
discrete-time event history models. The unit of analysis
is the person-year and each child is at risk of death for
each year of migration until the child dies or is censored.
To study long term effects of migration on under-five
mortality, we use negative binomial regression to model
cumulative number of children under five years of age
who died per respondent.
Population Studied: A 2004 representative survey of
two peri-u rban municipalities of Greater Luanda-Samba
and Viana. Samba is a long-established peri-urban
community, close to the city center and was chosen as a
community with a relatively small war migrant
population, whereas Viana, a more distant and less
urbanized suburb, was chosen because of a larger
estimated share of war migrants. The survey instrument
gathered detailed data on birth histories (the month and
year of birth and death if the child died) and the
immunization status of the each child by age. Detailed
migration histories were also collected. Respondents
who migrated were asked to give the localities of their
previous residence, the timing of migration and the
reasons why they migrated from their previous locality.
These responses where then classified by interviewers
into six categories (war-related, economic, family,
education, health or other). This data will be relied on to
construct outcome measures (age adequate
immunization and under-five mortality) and key
predictors of this study (war migration, non-war migration
and non-migration). Several correlates of child health
(such as age and gender, birth interval, mother’s age at
birth and mother’s education etc.) exists in the data will
be exploited for this analysis.
Principal Findings: Preliminary findings from discretetime event history models show that in the short term,
results indicate that net of other factors, non-war
migration is associated with higher probabilities of age
adequate immunization and lower probabilities of underfive mortality, compared to war migration. In the long
term, the effects of migration on child mortality and age
adequate immunization are positive but not statistically
significant.
Conclusions: We conclude that selection and disruptive
mechanisms explain child health outcome differences
between war and non-war migrants in the short-term.
Non-war migrants may be self selected based on
unobserved distal factors such as the tendency to space
births, avoidance of nutrient deficiency and personal
illness control and on observed characteristics such as
education and socio-economic status. Whereas, child
health outcomes of war migrants may have suffered
from the disruptive effects of threats to personal security
and inability to prepare before fleeing from war.
Implications for Policy, Delivery or Practice: Our
findings and conclusions have implications for the
attainment of the Millennium Development Goals
(M.D.Gs), which enjoins all countries to reduce by the
year 2015 two thirds of the childhood mortality rates that
prevailed in 1990 (M.D.G Report 2006).
Funding Source(s): Data collection partly funded by
National Institute of Child Health and Development
(NIH/NICHD) of the USA
™ Estimating the Need for Pediatric Subspecialists:
The Case of Pediatric Rheumatology
Heather Beil, M.P.H.; Michelle Mayer, Ph.D., M.P.H.;
Christy Sandborg, M.D.
Presented by: Heather Beil, M.P.H., Ph.D. Student, Health
Policy and Management, University of North Carolina at
Chapel Hill, CB #7411, Chapel Hill, NC 27599 Phone: (919)
966-7769 Email: hbeil@email.unc.edu
Research Objective: In contrast to most physician
specialties, pediatric subspecialties can be characterized
as having relatively small numbers of providers who are
concentrated in urban areas and academic medical
centers. Despite these unique characteristics, few
physician workforce studies have examined pediatric
subspecialties. This study aimed to illustrate an
approach to assessing the supply of pediatric medical
subspecialists and estimate the number needed
nationwide, using pediatric rheumatology as an example.
Study Design: Physician data from the American Board
of Pediatrics (ABP) and population data from Claritas
were used to estimate the number of hospital referral
regions (HRR) without pediatric rheumatologists and
provider to pediatric population ratios for each HRR.
Additionally, we surveyed all pediatric rheumatologists
listed in the American College of Rheumatology
Membership directory (n=236). Survey responses were
used to estimate average patient volume and inform our
need-based estimates. Estimates of the number of
pediatric rheumatologists needed in each HRR are
calculated under three scenarios: 1) based on the
volume of patients per provider reported in the survey
and national prevalence estimates; 2) based on previous
estimates of a needed population size to support one
provider and pediatric population only; and 3) based on
the needed pediatric population size and the number of
general pediatric residencies in each HRR. We also
performed sensitivity analyses at the state level.
Population Studied: This study provided national
estimates on pediatric rheumatologists and the patients
they serve.
Principal Findings: Approximately 200 pediatric
rheumatologists are located in 25% of hospital referral
regions in the United States. Our estimates suggest
that, on average, there are 2500 children with rheumatic
diseases per pediatric rheumatologist per HRR.
Respondents of the survey reported caring for an
average of 464 patients per provider. The current
distribution of pediatric rheumatologists creates a
situation in which a substantial portion of the under-18
population in the U.S. lives more than 40 miles, i.e., an
approximately one-hour drive, from a provider. Of the
providers we surveyed, 80% reported that the farthest
distance 2 or more patients travel to see them is greater
than 80 miles. Using the reported patient volume of 470
patients per provider and prevalence estimates of 390
per 100,000 children, 535 pediatric rheumatologists are
needed nationally. Using HRR level population data, we
estimate that at least 257 pediatric rheumatologists are
needed nationally based on pediatric population only.
When medical education is incorporated into need
estimates, the number of pediatric rheumatologists
needed nationwide is 331.
Conclusions: The current number of pediatric
rheumatologists in the United States is inadequate, and
the patient volume of current pediatric rheumatologists
may be too low. The problem is particularly acute in a
number of heavily populated hospital referral regions
that have either no pediatric rheumatologists or a small
number relative to their pediatric population.
Implications for Policy, Delivery or Practice: Efforts to
increase the availability of pediatric rheumatology
expertise are needed to meet demand for patient care
and medical education. Moreover, the model developed
here could be applied to assess the supply of other
academic pediatric subspecialties.
Funding Source(s): Bureau of Health Professions
™ Surfactant Replacement Therapy May Improve
Survival for Infants Born with Congenital
Diaphragmatic Hernia: An Instrumental Variable
Analysis
Tommy Bird, M.S.; J. Mick Tilford, Ph.D.; Patrick Casey,
M.D.; James Robbins, Ph.D.; Robert Lyle, M.D.
Presented by: Tommy Bird, M.S., Director of Medical
Informatics Research, Pediatrics, Center for Applied
Research and Evaluation, University of Arkansas for
Medical Sciences, 11 Children's Way, Little Rock, AR
72202 Phone: (501) 364-4936 Email:
birdtommym@uams.edu
Research Objective: Congenital diaphragmatic hernia
(CDH) is a major structural birth defect with mortality
rates ranging from 20% to 60%. Large observational
cohort studies examining surfactant therapy in infants
with CDH have shown either no effect on mortality or a
negative effect. Observational studies of CDH are
complicated by many factors, including selection bias
due to both physician preference and clinical severity.
There have been no large randomized controlled trials of
surfactant therapy in CDH. Instrumental variable
analysis is one method of controlling for selection bias
and approximating the results of a RCT with
observational data. This study used instrumental
variable analysis to control for selection bias while
examining the relationship between surfactant therapy
and mortality among infants with CDH.
Study Design: Data came from the Pediatric Health
Information System (PHIS) over years 1999-2008. PHIS
is a detailed hospital discharge database of 40 stand
alone children’s hospitals. PHIS contains demographic,
diagnosis, and procedure data, as well as pharmacy and
clinical service data. A multivariable bivariate probit
model with instrumental variables was used to calculate
the predicted probability of mortality for CDH infants who
did and did not receive surfactant therapy. The model
also controlled for demographics, birth weight, and
clinical factors such as use of ECMO, comorbid birth
defects, surgical repair of intestines, and surgical repair
of liver.
Population Studied: Neonates admitted to one of 40
stand alone children's hospitals within the first 10 days of
life with a diagnosis of congenital diaphragmatic hernia.
Principal Findings: A total of 2,306 infants with CDH
were included in the study, only 114 of whom received
surfactant therapy. Naïve multivariable probit models,
which do not accont for selection bias, indicate a non-
significant increased probability of mortality for infants
receiving surfactant therapy (21.8% (13.5%-30.9%)
compared to 19.2% (17.1%-21.5%), p=0.521). Bivariate
probit models with instrumental variables, which can
account for selection bias, indicate a significant
reduction in the probability of mortality for infants
receiving surfactant therapy (8.0% (3.5%-16.0%)
compared to 20.3% (18.0%-22.7%), p=0.009).
Conclusions: Surfactant replacement therapy, almost
abandoned for the treatment of infants with CDH on the
basis of naïve observational studies, could greatly
reduce mortality rates in these very fragile neonates.
These findings should be confirmed in a multi-center
randomized controlled trial.
Implications for Policy, Delivery or Practice:
Surfactant replacement therapy should be re-evaluated
as a front line treatment option for newborns with CDH.
Funding Source(s): Arkansas Biosciences Institute
™ Deriving Health Status Information for Children
from Pharmacy Codes in Five Spanish Primary Care
Clinics: Implications for Risk Adjustment
Paulo Boto, M.D., M.Sc.; Jonathan Weiner, Dr.P.H.
Presented by: Paulo Boto, M.D., M.Sc., Ph.D.
Candidate, Health Policy and Management, Johns
Hopkins Bloomberg School of Public Health, Av.
Carolina Michaelis, 22, 4º Esq, Linda-A-Velha 2795-049
Phone: +351914595634 Email: pboto@jhsph.edu
Research Objective: Risk adjustment tools have
application for payment, case-management and
research. Originally these tools were based on
diagnostic codes and they are now progressively
deriving information from drug prescription to gain further
insights into health status. Little research has been done
on the application of drug based risk adjustment tools in
children. The objectives of this paper are: 1) to compare
and contrast health status/risk information derived from
the drug prescribing of primary care physicians in a clinic
system in Spain; and 2) to assess the extent to which a
pharmacy based risk adjustment tool - the Johns
Hopkins ACG "Rx-MG" - performs in paediatric
populations, namely its ability to explain variation in total
primary care health care resource use measures, given
these differences.
Study Design: Observational, retrospective, crosssectional. The study uses a dataset with demographic,
diagnostic, pharmacy and cost information on the study
population (see below) for two consecutive years, 2006
and 2007. The Rx-MG method (originally based on the
US FDA's NDC codes) has been calibrated to the
WHO's "ATC" system which is in use in Spain.
Population Studied: The study population includes
approx. 67,000 universally insured persons, attending a
set of 5 primary care clinics in Badalona, Spain; of these,
approximately 11,000 are children aged 0 to 14.
Principal Findings: Prescription of drugs varies widely
with age; adults have higher rates in most Rx-MG
categories, and these are particularly larger in all
categories in the cardiovascular group, most of the
endocrine, and also in more specific areas like
contraception - naturally -, but also glaucoma, gout,
genito-urinary acute minor, most of the psychosocial
conditions with the exception of the ADHD, and
respiratory chronic medical. Adults are also much more
likely to be medicated for general signs and symptoms,
like pain. Children, on the other hand, have higher rates
in only a handful of conditions, mostly the respiratory acute minor, airway hyperreactivity and cystic fibrosis -,
but with much lower ratios. Probably due to these wide
age differences, the tool is able to explain variation in
primary care costs much better in adults than in the
paediatric population - r2=0,55 compared to r2=0,13.
Conclusions: Prescription patterns in children are quite
different from those seen in adult populations. Partly due
to the these variations the Rx-MG system performed
better in explaining variation in terms of resource use
measures between adult patients than in the paediatric
population.
Implications for Policy, Delivery or Practice:
Researchers, managers and policymakers acknowledge
the need for risk adjustment for several purposes.
Results in this paper suggest that children have different
patterns of both morbidity and drug prescription which
might affect the ability of pharmacy based risk
adjustment tools to be effectively used in paediatric
populations, and this population should thus warrant
special attention. While this and other similar pharmacy
based risk adjustment tools have many useful
applications for child health services research, finance
and management, there are also limitations that need to
be acknowledged. This is particularly true if risk
adjustment methods developed for adults are then
applied to paediatric populations.
Funding Source(s): Fundação Gulbenkian, Portugal;
FCT, Portugal
™ Burden of Influenza-Related Hospitalizations
among Children with Sickle Cell Anemia
David Bundy, M.D., M.P.H.; John Strouse, M.D.;
Marlene Miller, M.D., M.Sc.; James Casella, M.D.
Presented by: David Bundy, M.D., M.P.H., Assistant
Professor of Pediatrics, Pediatrics, Johns Hopkins
University School of Medicine, 600 North Wolfe Street;
CMSC 2-121, Baltimore, M.D. 21287 Phone: (410) 5028623 Email: dbundy@jhmi.edu
Research Objective: Children with sickle cell anemia
(SCA) are considered a high risk population for influenza
infection and annual vaccination is recommended. The
burden of influenza infection in this population, however,
is largely unknown. Our objective was to compare the
rates and epidemiology of influenza-related
hospitalizations (IRHs) among children with and without
SCA.
Study Design: We conducted a cross sectional analysis
of the AHRQ-sponsored Healthcare Cost and Utilization
Project State Inpatient Databases from New York,
Florida, and Maryland for the 2003-4 and 2004-5
influenza seasons. US Census data were used to
estimate appropriate denominators for rate calculations.
Population Studied: We analyzed hospitalizations of
children less than 18 years of age with an International
Classification of Diseases, 9th Revision, Clinical
Modification discharge diagnosis code for influenza,
stratified by the presence or absence of a co-occurring
discharge diagnosis code for SCA.
Principal Findings: There were 5,256 pediatric
influenza-related hospitalizations (2003-4: 3,277; 20045: 1,879), 1 in 40 of which included a co-occurring
diagnosis of SCA. Among children without SCA, there
were 2.6 IRHs per 10,000 children per year (2003-4: 3.3;
2004-5: 1.9), compared with 201 IRHs per 10,000
children with SCA per year (2003-4: 254; 2004-5: 148).
Across the 2 influenza seasons, IRHs among children
with SCA occurred at 79 times the rate of IRHs among
children without SCA. IRHs associated with SCA
involved older children (mean age 5.5 years vs. 2.6
years, P<0.001) and were more likely to involve children
from large metropolitan areas (87% vs. 70%, P<0.001),
compared with IRHs not associated with SCA. IRHs
with SCA were more likely to originate in the emergency
department (78% vs. 67%, P=0.03) and be paid for by
Medicaid (64% vs. 54%, P=0.04) than those without
SCA. Mean length of stay was similar for IRHs with and
without co-occurring SCA (3.3 vs. 3.8 days respectively,
P=0.41).
Conclusions: Children with sickle cell anemia are
hospitalized for influenza at substantially higher rates
than those without SCA.
Implications for Policy, Delivery or Practice:
Characterizing children with SCA as high risk for
influenza is justified and supports the need for expanded
efforts to measure and improve influenza vaccination
rates in this population. Medicaid-based immunization
outreach efforts, had they been in effect, could have
reached two-thirds of children with SCA hospitalized with
influenza in this cohort.
™ Pediatric Vaccination Errors
David Bundy, M.D., M.P.H.; Andrew Shore, Ph.D.; Laura
Morlock, Ph.D.; Marlene Miller, M.D., M.Sc.
Presented by: David Bundy, M.D., M.P.H., Assistant
Professor of Pediatrics, Pediatrics, Johns Hopkins
University School of Medicine, 600 North Wolfe Street;
CMSC 2-121, Baltimore, M.D. 21287 Phone: (410) 5028623 Email: dbundy@jhmi.edu
Research Objective: Vaccinations comprise a widely
used and highly efficacious preventive service. Little is
known, however, about the epidemiology and causes of
pediatric vaccination errors. Our objective was to
evaluate the epidemiology of pediatric vaccination errors
using the "5 Rights" framework (right vaccination, right
time, right dose, right route, right patient) and to
determine whether vaccination error types are
predictable based on vaccine and patient attributes.
Study Design: We conducted a cross sectional analysis
of medication errors from a nationwide, voluntary
medication error reporting system (MEDMARX) using
methods which account for possible clustering of error
properties by facility.
Population Studied: We analyzed errors that involved
children ages 0-17 years, involved vaccines, and
occurred in outpatient settings from 2003 to 2006.
Principal Findings: 607 error reports listed 691
vaccines. Influenza was the most commonly reported
vaccine (10% of all reports). Wrong vaccine errors were
more common among look-alike / sound-alike groups
(Td/Tdap/DTaP/DT (36%), pneumococcal conjugate /
pneumococcal polysaccharide (29%), haemophilus
influenzae / influenza (23%)) than among vaccines with
no look-alike / sound-alike group (13%, P=0.008).
Scheduled vaccines (e.g., pneumococcal conjugate)
were more often involved in wrong time errors than
seasonal (e.g., influenza) and intermittent (e.g., tetanus
booster) vaccines (44%, 18%, and 29% respectively,
P=0.006). Wrong dose errors were more common for
vaccines whose dose is weight-based (57% of
palivizumab errors) and age-based (38% of influenza
errors) than for vaccines whose dose is uniform (8.2%,
P<0.0001)). Wrong route errors were rare and more
common in subcutaneous (5.7%) compared with
intramuscular (2.0%) vaccines, although this difference
was not statistically significant. Wrong patient errors
were also rare (4.1% of reports); at least 44% of wrong
patient errors involved sibling confusion.
Conclusions: In this largest-ever analysis of pediatric
vaccination errors, error types were associated with
vaccine and patient attributes. Predictable human
factors challenges, such as confusion between vaccines
with similar names, were associated with which vaccines
and patients were involved in which types of errors.
Implications for Policy, Delivery or Practice: Efforts to
reduce vaccination errors in children should focus on
these human factors; such approaches may have
medication safety benefits extending beyond
vaccinations.
Funding Source(s): AHRQ
™ Evidence that Systematic Measurement Error as a
Function of Race and Ethnicity Erroneously
Influences Descriptions of Children’s Behavioral
Health
Adam Carle, M.A., Ph.D.
Presented by: Adam Carle, M.A., Ph.D., Assisstant
Professor, Psychology, University of North Florida, 1
UNF Drive, Jacksonville, FL 32224 Phone: (904) 6203573 Email: adam.carle@unf.edu
Research Objective: I examined whether parents’
descriptions of their children’s behavioral health reflect
equivalent levels of behavioral health across nonHispanic (NH) White, NH-Black, and Hispanic US
children, or whether systematic measurement error as a
function of race and ethnicity leads to biased
descriptions. As pediatricians and health analysts
increasingly monitor children’s behavioral health and the
services that support positive behavioral outcomes, it
becomes progressively important to establish whether
behavioral health questions provide equivalently reliable
and valid answers across children of different
backgrounds, especially in light of other health
disparities. Measurement bias refers to the possibility
that individauls from different racial and ethnic
backgrounds respond differently to questions about their
children’s behavioral health as a function of their race
and ethnicity rather than their children’s true behavioral
health. Systematic measurement error of this type can
severely limit health services research addressing
disparities. Without knowing the psychometric properties
of parent’s reports about their children’s behavioral
health across race and ethnicity, efforts to monitor and
evaluate children’s behavioral health, set policy, and
address disparities in behavioral health across the
diverse racial and ethnic population remain impeded.
Study Design: I used confirmatory factor analyses for
ordered-categorical measures to probe for measurement
bias on four items from the 2003-2004 National Survey
of Children’s Health, a large nationally representative,
US telephone survey of children’s physical, emotional,
and behavioral health. Analyses investigated whether
bias influenced parents’ responses to questions
measuring behavioral health and led to erroneous
behavioral health estimates across race and ethnicity.
Population Studied: The National Survey of Children’s
Health represents the non-institutionalized US
population of children. Participants (n = 61,701) were the
complete set of children (aged 0-17) with valid
responses to the four item behavioral health question set
included on the National Survey of Children’s Health.
This included 47,649 NH-White, 6,533 NH-Black, and
7,519 Hispanic children.
Principal Findings: Findings revealed statistically
significant measurement bias that led to relatively large
systematic errors in descriptions of children’s behavioral
health across race and ethnicity. At similar levels of
underlying behavioral health, parents of minority children
more readily endorsed behavior problems relative to NHWhite parents. Measurement bias led to overestimates
of the prevalence of behavioral problems among minority
children, especially NH-Black children, relative to NHWhite children.
Conclusions: Ethnically-based measurement bias leads
to systematically biased behavioral health descriptions
across race and ethnicity, especially for black children.
Reports of children’s behavioral health should include
this qualification or use measurement model-based
estimates of children’s health that eliminate bias.
Further, results indicate that previous research
describing poorer behavioral health among US minorities
partly reflects measurement bias.
Implications for Policy, Delivery or Practice: Findings
indicate that policy analysts should proceed with caution
when using parental reports of behavioral health across
race and ethnicity. Differential policy effects across
minorities may reflect true differences, but they also
reflect some systematic measurement error. Bias may
also cause pediatricians to suspect behavioral problems
among minority children when problems do not exist.
Frequency based questions may help reduce error.
Future research should work to develop a measure that
provides equivalent measurement across the diverse US
child population.
™ Internal Psychometric Properties of the Children
with Special Health Care Needs Screener: Findings
from the National Survey of Children with Special
Health Care Needs
Adam Carle, M.A., Ph.D.; Stephen Blumberg, Ph.D.;
Charlie Poblenz
Presented by: Adam Carle, M.A., Ph.D., Assisstant
Professor, Psychology, University of North Florida, 1
UNF Drive, Jacksonville, FL 32224 Phone: (904) 6203573 Email: adam.carle@unf.edu
Research Objective: Too little research has established
the psychometric (measurement) properties of the
Children with Special Health Care Needs (CSHCN)
Screener. This leaves unclear whether Screener-based
estimates reliably identify CSHCN. To address this, we
sought to establish the CSHCN Screener’s psychometric
properties.
Study Design: The CSHCN Screener asks parents a
series of questions to determine whether children
experience one of five health related consequences and
whether the consequence(s) result from a medical,
behavioral, or other health condition lasting at least 12
months.
Population Studied: Data came from the 2005-2006
National Survey of Children with Special Health Care
Needs (NS-CSHCN). The National Survey of CSHCN
provides state- and national-level data on the prevalence
of special health care needs and their impact on children
and their families. Children (n = 359,154) ranged in age
from 0 to 18 years. Design weights make the data
representative of children nationally and within states.
Principal Findings: Cronbach’s alpha equaled 0.76.
Confirmatory factor analysis for ordered-categorical
measures (CFA-OCM) indicated that a single underlying
health-condition-complexity trait underlies Screener
responses. Item response theory (IRT) showed that
responses provide particularly precise measurement
among children experiencing elevated health-conditioncomplexity levels.
Conclusions: Findings demonstrate that responses to
the CSHCN Screener as used in the NS-CSHCN have
good internal psychometric properties and include
minimal random measurement error. CFA-OCM results
support the suggestion that a health-conditioncomplexity continuum describes CSHCN’s health
conditions. IRT analyses show that Screener responses
provide excellent discrimination among children
experiencing above average health-condition-complexity
levels in concordance with the CSHCN definition.
Implications for Policy, Delivery or Practice: Health
service providers, epidemiologists, clinicians and others
can rely on CSHCN Screener responses to reliably
identify CSHCN experiencing the consequences
included on the CSHCN Screener. Additionally, results
show that children who need specialized physical,
occupational, or speech therapies likely experience the
greatest levels of health-condition-complexity. Programs
designed to improve systems of care for CSHCN with
the greatest health-condition-complexity levels may find
that this question proves particularly useful for identifying
CSHCN with the highest health-condition-complexity
levels.
™ Dental Utilization for Medicaid-Enrolled Children
with a Chronic Health Condition
Donald Chi, D.D.S.; Elizabeth Momany, Ph.D.; John
Neff, M.D.; Peter Damiano, D.D.S., M.P.H.
Presented by: Donald Chi, D.D.S., Ph.D. Student,
Public Policy Center, University of Iowa, 212 South
Quadrangle, Iowa City, IA 52245 Phone: (206) 6507652 Email: donald-chi@uiowa.edu
Research Objective: The purpose of this study is to
compare dental utilization for Medicaid-enrolled children
identified with a chronic health condition and healthy
Medicaid-enrolled children and identify the factors
associated with dental utilization.
Study Design: This study is a secondary data analysis
of Iowa Medicaid enrollment, medical, and dental claims
files from 2003-2005. The 3M Clinical Risk Grouping
(CRG) software was used to identify children with a
chronic health condition based on medical inpatient,
outpatient, and pharmacy claims from 01/01/0312/31/05. To account for possible changes in chronic
health condition over time, a modified CRG protocol was
used to create four mutually exclusive chronic health
condition groups of increasing severity: episodic chronic,
life-long chronic, malignant chronic, and catastrophic
chronic. Healthy children were defined as enrollees with
at least one medical inpatient, outpatient, or pharmacy
claim from 01/01/03-12/31/05 but were not classified
according to claims encounters to have any type of
chronic health condition. The outcome variable was use
of any dental care in 2005. One-way ANOVA was used
to compare dental utilization for health children and
those from the four chronic health condition groups and
conditional multiple variable logistic regression modeling
was used to adjust for covariates (e.g., the child’s age,
gender, family characteristics, county of residence).
Population Studied: We studied children aged 3-17
years who were enrolled in the Iowa Medicaid program
for =11 months in calendar year 2005 (N=97,311).
Principal Findings: Overall, 54.7% of children utilized
dental care in 2005 (n=53,274). There were statistically
significant differences (P<.0001) in dental utilization for
children across the comparison groups: healthy (52.2%),
episodic chronic (58.1%), life-long chronic (60.7%),
malignant chronic (49.6%), and catastrophic chronic
(48.3%). After adjusting for model covariates, children
with an episodic chronic condition were 1.29 times as
likely to have had a dental visit (95% CI = 1.25, 1.33)
and those with a life-long chronic condition were 1.45
times as likely to have had a dental visit (95% CI = 1.39,
1.52) than healthy children. Meanwhile, children with
either a malignant or catastrophic chronic condition were
less likely to have had a dental visit than healthy
children, though these differences were not statistically
significant (P<.571 and P<.06, respectively).
Conclusions: There appears to be a significant
relationship between chronic health condition severity
and access to dental care for Medicaid-enrolled children.
Our results suggest that the likelihood of using dental
care increases for children with episodic and life-long
chronic conditions and decreases for those with the
more complex conditions. One explanation for these
findings is that interactions with the health care system
might make it more likely that a child uses dental care or
receives a referral to see a dentist. Other health care
needs may take priority over dental care needs for
children with more complex conditions.
Implications for Policy, Delivery or Practice:
Understanding the effect of chronic health condition
status and severity on access to dental care for
Medicaid-enrolled children is important for reducing
pediatric oral health disparities. Future efforts should
focus on ensuring that all Medicaid-enrolled children
have access to need-appropriate dental care.
Funding Source(s): NIDCR and the Iowa Department
of Human Services
™ Which Children with Asthma are at Greatest Risk
for Being Overweight?
Janet Coffman, M.A., M.P.P., Ph.D.
Presented by: Janet Coffman, M.A., M.P.P., Ph.D.,
Assistant Adjunct Professor, Philip R. Lee Institute for
Health Policy Studies, University of California, San
Francisco, 3333 California Street, Suite 265, San
Francisco, CA 94118 Phone: (415) 476-2435 Email:
Janet.Coffman@ucsf.edu
Research Objective: Children with asthma are more
likely to be overweight. Furthermore, several studies
suggest that children who have asthma and who are
also overweight are more likely to have poor health
outcomes. To date, little research has been conducted to
identify the children at greatest risk for co-morbid asthma
and overweight. This study uses data from a survey
conducted in four states to assess whether the
demographic characteristics of children with asthma are
associated with being overweight.
Study Design: Data were obtained from the National
Asthma Survey. This cross-sectional random-digit-dial
telephone survey was conducted in 2003 by the National
Center for Health Statistics (NCHS) in four states –
Alabama, California, Illinois, and Texas. For children,
data were obtained from parents or other adults
knowledgeable about the child’s health. Demographic
variables included age, sex, race/ethnicity, and annual
household income. All analyses were performed in
STATA Version 9 using sampling weights provided by
NCHS.
Population Studied: The survey response rate was
48.5%. Complete data on all variables analyzed were
available for 1,562 subjects. Children were classified as
having asthma if, within the past three years, they had
asthma symptoms, had taken asthma medication, or had
visited a physician or other health professional regarding
their asthma. A standard criterion (BMI = 95th percentile)
was used to classify children as overweight or not
overweight. BMI was calculated from data on children’s
height and weight obtained from the adult completing the
survey on the child’s behalf that were not independently
verified.
Principal Findings: Twenty-eight percent of sampled
children with asthma had a BMI above the 95th
percentile. Adolescents with asthma were less likely to
be overweight than children under age 12 (OR 0.38,
95% CI 0.27-0.52) and girls were less likely to be
overweight than boys (OR 0.67, 95% CI 0.48-0.93). NonHispanic white children were less likely to be overweight
than children who were Hispanic, non-Hispanic black, or
from other/multiple racial/ethnic groups (OR 0.40, 95%
CI 0.29-0.55). Children from high-income households (=
$75,000) were less likely to be overweight than children
from low- and middle-income households (OR 0.52, 95%
CI 0.36-0.75). In a multivariate regression that
incorporated all four demographic characteristics, the
associations between the risk of being overweight and
age, race/ethnicity, and household income remained
statistically significant. Sex was not statistically
significant in the multivariate analysis.
Conclusions: Findings from this study suggest that 28%
of children with asthma are overweight, which is greater
than the percentage of all children in the United States
who are overweight (17% per NHANES 2003-2004).
Racial/ethnic minority children and children from lowincome families who have asthma are at increased risk
of also being overweight.
Implications for Policy, Delivery or Practice: These
findings suggest that health professionals who care for
children with asthma from racial/ethnic minority and lowincome population should monitor their BMI and counsel
parents regarding prevention and treatment of obesity. In
addition, these findings suggest a need for holistic
policies and interventions that address the multiple
health care needs of vulnerable populations.
™ Racial and Ethnic Disparities in Health and WellBeing of Iowa Children
Peter Damiano, D.D.S., M.P.H.; Jean WIllard, M.P.H.; Ki
Park, M.A.
Presented by: Peter Damiano, D.D.S., M.P.H.,
Professor and Director, Public Policy Center, University
of Iowa, 212 South Quad, Iowa City, IA 52242 Phone:
(319) 335-6813 Email: peter-damiano@uiowa.edu
Research Objective: To determine if there are
differences by race/ethnicity in the health and well-being
of children in Iowa. Of primary interest were differences
between children of Hispanic ethnicity whose parent
chose to complete the interviews in Spanish vs those
who completed it in English.
Study Design: Telephone interviews were conducted
with a sample of families with children in Iowa in
2005/2006. Both random digit dial and targeted sampling
was used to draw the sample. 77% of families completed
the interview once it was identified as a household with
children. Interviews were up to 180 questions long and
took an average of 22 minutes to complete. Language
choice (Spanish vs English) was used as a measure of
cultural assimilation and comfort with the English
language.
Population Studied: Interviews were conducted with
3863 families with children in Iowa including an
oversample of African American and Hispanic children.
Differences were compared for families with African
American children, White children, Hispanic children
whose parent completed the interview in Spanish and
those who chose to complete it in English.
Principal Findings: Children whose parent completed
the interview in Spanish were significantly less likely to
have a regular source of medical or dental care, were
much more likely to be without health insurance, less
likely to have heard of the Iowa SCHIP program, and
had more unmet need for dental care. Children in these
households, were reported to have a lower health status
but less likely to be defined as having a special health
care need. There were, however, as likely to have had a
preventive health visit in the previous year and more
likely to have eaten a balanced diet, get more regular
exercise and have fewer behavioral problems and
parenting stress issues.
Conclusions: Access to care was generally worse for
children in families where the interview was completed in
Spanish however preventive behaviors were generally
better. Cultural assimilation appeared to be related to
better health insurance coverage and increased options
for coverage by public programs.
Implications for Policy, Delivery or Practice:
Improved outreach is needed to reach families whose
primary health care negotiator is a primary spanish
speaker if access to care is to be improved for children.
Funding Source(s): Iowa Dept of Public Health
™ Do Childrens Hospitals Respond to Predictable
Fluctuations in Patient Volume?
Evan Fieldston, M.D., M.B.A.; Matthew Hall, Ph.D.;
Marion Sills, M.D., M.P.H.; Anthony Slonim, M.D.,
Dr.P.H.; Angela Myers, M.D., M.P.H.; Courtney Cannon,
M.B.A.; Susmita Pati, M.D., M.P.H.; Samir Shah, M.D.,
M.S.C.E.
Presented by: Evan Fieldston, M.D., M.B.A., Robert
Wood Johnson Clinical Scholar, RWJ Clinical Scholars
and Department of Pediatrics, University of
Pennsylvania School of Medicine, 423 Guardian Drive,
1303A Blockley Hall, Philadelphia, PA 19104 Phone:
(215) 573-2585 Email: fieldsto@upenn.edu
Research Objective: To quantify how CH respond to
high hospital occupancy (HHO), which adversely
impacts patient care.
Study Design: Midnight census data from 39 CH in the
2006 Pediatric Health Information System were used to
construct cutoffs for 85, 90, 95% occupancy & for ownhospital %ile occupancy. Dependent variables were: #
medical & surgical elective, <24-hour, low-severity
admissions; # transfers in from & out to other hospitals;
observed-to-expected length of stay for ambulatorysensitive conditions (ASCs) & for non-ASCs.
Generalized linear models quantified the association
between occupancy & responses.
Population Studied: Inpatients at 39 free-standing
children's hospitals in the Pediatric Health Information
System for calendar year 2006.
Principal Findings: 510,616 admissions to CH
frequently result in HHO at midnight: 7.8% at 85-89%,
4.9% at 90%-94%, 3.2% at 95-100%, and 5.5% at
>100%. Annual, hospital-level data show inter-facility
variation. Analyses of occupancy by day & month show
expected periodic variation in some hospitals but not
others. Compared to normative standards of HHO or
within-hospital %iles, few hospitals reacted to HHO with
changes in the potential responses modeled.
Conclusions: This first systematic study of children s
hospitals showed planning for or response to high
hospital occupancy was rare & of small magnitude. Few
are adjusting elective inflow relative to seasonal
fluctuations in non-elective admissions.
Implications for Policy, Delivery or Practice:
Hospitals should engage in local review of flow and
elective scheduling to maximize safety and quality of
care.
Funding Source(s): Child Health Corporation of
American, Pediatric Health Information System
™ Physician Views on Incentives-for-Adherence in
Childhood Asthma
Evan Fieldston, M.D., M.B.A.; Andrea Puig, B.A.; Judy
Shea, Ph.D.; Joshua Metlay, M.D., Ph.D.; Susmita Pati,
M.D., M.P.H.
Presented by: Evan Fieldston, M.D., M.B.A., Robert
Wood Johnson Clinical Scholar, RWJ Clinical Scholars
and Pediatrics, University of Pennsylvania School of
Medicine, 423 Guardian Drive, 1303A Blockley Hall,
Philadelphia, PA 19104 Phone: (215) 573-2585 Email:
fieldsto@upenn.edu
Research Objective: Assess physician views regarding
appropriateness & effectiveness of I4A in childhood
asthma. Asthma is the most common chronic illness of
childhood & leading cause of hospitalization, with costs
of billions of dollars. Adherence rates to medications &
disease maintenance activities are very low. Multiple
approaches have been tried to improve adherence, with
mixed results. Providing incentives-for-adherence (I4A)
to parents has had limited consideration.
Study Design: Cross-sectional, web-based anonymous
survey of 1200 Pennsylvania physicians in general
pediatrics, pediatric pulmonology, pediatric emergency
medicine, pediatric critical care, and allergy.
Population Studied: Pennsylvania physicians who care
for children with asthma.
Principal Findings: 329 physicians (30%) responded,
reflecting demographics and practice patterns of state's
physicians. Overall, 61% said I4A would be appropriate
and 77% effective. Half said I4A would be appropriate &
effective; 12% said I4A would be inappropriate &
ineffective (and did not answer all follow-on questions).
Majority favored linking I4A to 4 activities (asthma well
check-ups, flu shot, refill of controller medicines, and
proven adherence via electronic home monitoring) and
favored only 1 incentive-delivery method (refund of
copayments). A system of accruing points to cash in for
gifts was the next most favored delivery method (35%).
41% said incentives should be valued at no more than
$20/month and 66% said all patients with asthma should
be eligible. Majority of respondents did not think
incentives would threaten patient/parent autonomy,
undercut social fairness, or interfere with patient-doctor
relationships. 56% said I4A would improve asthma
outcomes; 33% were uncertain. Bivariate and regression
analysis did not reveal any substantial differences in
reported attitudes by physician demographic or practice
characteristics.
Conclusions: Majority of physicians viewed I4A in
childhood asthma as appropriate & effective, but some
had reservations about the specific design. Certain
approaches were favored over others, particularly those
emphasizing prevention, but not those that could lead to
adverse outcomes, such as avoiding emergency care.
Implications for Policy, Delivery or Practice:
Incentives for adherence have support among
physicians who care for children with asthma and are
viewed as an appropriate and effective means to
improve adherence and outcomes. A parallel survey will
be undertaken to understand parents views to aid in
design of a pilot program of I4A.
Funding Source(s): RWJF
™ Resident Training in Preventive Services
Mary Pat Frintner, M.S.P.H.; William Cull, Ph.D.; Lynn
Olson, Ph.D.
Presented by: Mary Pat Frintner, M.S.P.H., Senior
Research Associate, Research, American Academy of
Pediatrics, 141 Northwest Point Boulevard, Elk Grove
Village, IL 60007 Phone: (847) 434-7664 Email:
mfrintner@aap.org
Research Objective: Well-child care is the foundation of
preventive pediatrics but little is known about the
consistency of resident training in preventive care.
Various program-level characteristics may be associated
with resident preventive services training including
exposure to Bright Futures, a national health care
promotion and disease prevention initiative. This study
examines the relationship of Bright Futures exposure,
program size, and continuity clinic experience on
resident-rated preparedness for future preventive care.
Study Design: National, random sample of 930
pediatric residents completing training in 2008 was
surveyed with 56% responding, as part of the American
Academy of Pediatrics Graduating Resident Survey.
Logistic regression was used to assess the influence of
Bright Futures exposure, program size - dichotomized: <
20 and > 20, continuity clinic experience in private
pediatrician’s office, and continuity clinic experience in
community health center on resident-reported
preparedness for three core prevention areas: well-child
care, understanding child and adolescent development,
and discussing behavior and discipline. Resident ratings
were dichotomized: very good-excellent and poor-good
preparation. Adjusted odds ratios-AOR and 95%
confidence intervals for the coefficients–CI are reported.
Population Studied: The study population included 930
graduating categorical pediatric residents.
Principal Findings: Most residents reported very goodexcellent preparedness for preventive services/well-child
visits-77%, understanding child and adolescent
development-71%, and discussing behavior and
discipline-52%. Residents in small programs were more
likely to report very good-excellent preparedness in wccAOR=1.9, CI=1.21 to 2.91, understanding child and
adolescent development-AOR=1.7, CI=1.12 to 2.65, and
discussing behavior and discipline-AOR=2.1, CI=1.39 to
3.08. Residents exposed to BF reported they felt more
prepared to understand child and adolescent
development-AOR=2.5, CI=1.59 to 3.78 and discuss
behavior and discipline-AOR=2.2, CI=1.46 to 3.20.
Continuity clinic experience in private pediatrician’s
office and continuity clinic experience in community
health center was not related to better resident-rated
preparedness.
Conclusions: Based on resident self-report, training
programs vary in their preparation of residents to provide
preventive care. Smaller programs and exposure to
Bright Futures were associated with better preparation,
but continuity clinic experience in a private pediatrician
office and continuity clinic experience in a community
health center was not. Prospective research would be
needed to determine the casual influence of program
type and continuity clinic experience on preparedness to
provide preventive care.
Implications for Policy, Delivery or Practice: Future
efforts are needed to fully understand training
components that best prepare residents to provide wellchild care and their career goals.
™ Duration of Child Insurance Coverage as a
Predictor of Health Care Utilization
Anthony Goudie, Ph.D.; Gerry Fairbrother, Ph.D.; Lisa
Simpson, M.B., B.Ch., M.P.H., F.A.A.P.
Presented by: Anthony Goudie, Ph.D., Research
Assistant Professor, Child Policy Research Center,
Cincinnati Children's Hospital, 3333 Burnet Avenue,
Cincinnati, OH 45229 Phone: (256) 343-5121 Email:
Anthony.Goudie@cchmc.org
Research Objective: Recent studies have looked at the
association between the number of gaps in child
insurance coverage with levels of health care utilization.
However, the effect on health care utilization of varying
durations without insurance in a homogeneous low
income population eligible for public insurance is
unknown. The objective of this study is to test the
hypothesis that the duration of health insurance
coverage will determine the level of health care
utilization for office-based physician and hospital
emergency department visits. It is anticipated that the
continuously uninsured will have fewer physician visits
(primarily due to access limitations) but may tend to seek
primary health care within an emergency department
setting. The child population with longer durations of
uninsurance will resemble the continuously uninsured
and those with shorter periods of uninsurance will have a
health care utilization profile more reminiscent of those
with continuous public or private insurance.
Study Design: Data is summarized over 24 months to
create a 6 category insurance status variable
representing uninsured for 24 months, insured for 1-11,
12-17, and 18-23 months, and full two-year coverage
with public or private insurance. The dependent
variables of interest are dichotomized (none or any) to
represent office-based physician visits and the use of a
hospital emergency department over a two-year period.
Logistic regressions incorporating strata and nationally
representative population weights are used to model the
significance of insurance status (continuous public
insurance as the reference class) on the health care
utilization dependent variables. Models are adjusted for
demographics and health status.
Population Studied: Children 2-17 years of age in
families with household incomes <200% of the FPL with
24 months of complete responses to monthly insurance
status from Panel 10 (2005-06) of the Medical
Expenditure Panel Survey (MEPS) were included in this
study.
Principal Findings: The white, non-hispanic population
and those residing in the Northeast or Midwest are more
likely to have continuous public or private insurance than
have any duration of uninsurance. Across constructed
insurance categories there is no significant difference in
the overall child population across age group, gender, or
health status. Continuously uninsured (AOR: 0.307, 95%
CI: 0.180-0.526) or those with less than one year of
insurance (AOR: 0.369, 95% CI: 0.230-0.592) are
approximately 3 times less likely to have had an officebased physician visit compared to those with continuous
public insurance. Also, continuously uninsured (AOR:
0.190, 95% CI: 0.075-0.478) are 5 times less likely to
have incurred an emergency department visit in 2005 or
2006 compared to those with continuous public
insurance.
Conclusions: Over a two-year period the child
population from low income families with no insurance
coverage or with coverage for less than one year is more
likely to have no contact with an office-based physician.
They are not substituting for this lack of health care by
accessing primary care in the emergency department. It
stands to reason that health care is obtained in another
manner or children are going without needed, and
especially preventive, care.
Implications for Policy, Delivery or Practice: The
implication for policy is to intensify efforts to enroll
children into a public health insurance program.
™ Accurately Estimating the Number of Children
Without Access to Healthcare
Roy Grant, M.A.; Sarah Overholt, M.A.; Deirdre Byrne;
Arturo Brito, M.D.
Presented by: Roy Grant, M.A., Director, Applied
Research, Medical Affairs, The Children's Health Fund,
215 West 125th Street, New York, NY 10027 Phone:
(212) 535-9400 Email: rgrant@chfund.org
Research Objective: The Obama administration has
made health care reform a priority. The degree to which
children in the US have inadequate access to health
care has generally been measured by the percent and
number of children without health insurance for a full
year. Other factors, both economic and non-economic,
also affect access. In addition, federal estimates of
uninsured children are inconsistent and understate the
extent of the problem. We set out to contrast the
methodologies of the federal data sets used to estimate
the problem of uninsured children (including MEPS,
CPS, NHIS) to determine the reasons for inconsistency
among these sources. We also used other data sources
to to more accurately estimate the number of children
with inadequate access to healthcare.
Study Design: Starting with a literature review, we
ascertained the inconsistencies and inaccuracies of
federal data sources commonly used to estimate
uninsured children. We applied a methodology
developed by previous investigators to adjust the
number of full-year uninsured children to include the
additional number of partial year uninsured children. We
used original data to estimate the percent and number of
children without transportation access to health services.
Population Studied: Poor and low-income children
including those eligible for and not receiving Medicaid
and SCHIP. This population is disproportionately
impacted by health disparities.
Principal Findings: Current estimates of the percent
and number of uninsured children have two principle
limitations: Sampling bias inherent in their survey
methodologies and an arbitrary upper age limit (e.g., 18
years) which excludes older adolescents and young
adults through age 19 (federal HHS/HRSA upper limit for
pediatrics), 21 (American Academy of Pediatrics upper
limit) or 24 (Society for Adolescent Medicine upper limit).
The result is an artificially low estimate of the percent
and number of uninsured children and youth. Including
children with interrupted coverage who are uninsured for
part of the year yields a 14.4% increase in the number of
children with insurance barriers to access. Additionally,
the percentage of children who are inadequately insured
(e.g., covered for catastrophic illness but not routine and
preventive care) is difficult to estimate. An estimated 4%
of children nationwide do not have transportation access
to healthcare regardless of their insurance status, a
problem which especially affects children in health
professional shortage areas. The magnitude of
difference based on definition and sampling
methodology is indicated by a 2007 report by the
Congressional Budget Office which found that advocates
estimated that up to 6 million uninsured children are
eligible for Medicaid or SCHIP each year compared to
1.1 million estimated by the Bush Administration.
Conclusions: When appropriately calculated, the
number of children with significant economic and noneconomic barriers to healthcare access increases from
approximately 8.1 million (full-year uninsured) to more
than 20 million children.
Implications for Policy, Delivery or Practice:
Accurately determining the magnitude of the problem of
US children without adequate access to healthcare
underscores the importance of developing and
implementing a national strategy for universal coverage
of children and adolescents. Having accurate data and
understanding the limitations of generally accepted
federal estimates helps advocates respond to conflicting
points of view.
Funding Source(s): Diverse private sources
™ Identifying Communities with Transportation
Barriers to Child Health Access
Roy Grant, M.A.; Stephen Borders, Ph.D.; Dennis
Johnson
Presented by: Roy Grant, M.A., Director, Applied
Research, Medical Affairs, The Children's Health Fund,
215 West 125th Street, New York, NY 10027 Phone:
(212) 535-9400 Email: rgrant@chfund.org
Research Objective: Most discussions of child
healthcare access focus on economic barriers especially
whether the child has health insurance. There are
additional non-economic barriers to health access,
involving the supply and distribution of health
professionals and the availability of transportation to get
care when it is sought. Our 2006 survey found that 4% of
children (more than 3 million) miss at least one
healthcare appointment each year because of
transportation irrespective of insurance status. Our data
also show that one-third of the missed health
appointments resulted in later use of emergency
department services. Most affected by inadequate
transportation are rural communities, which also have
the highest rates of HPSA-designated counties and child
poverty. There are federally designated primary care
health professional shortage areas (HPSAs); however,
there is no such designation to identify or track
transportation-disadvantaged communities. We set out
to develop a methodology to identify communities that
are “transportation-disadvantaged” focusing on primary
care HPSAs.
Study Design: A variety of data sources were sought
out to determine transportation access to child
healthcare at the community or county level. These
include a) the ambulatory sensitive condition (ASC)
hospitalization rate; b) the quality of the primary care
pediatric safety net, using the presence of federally
qualified health centers (which are required to provide
care regardless of ability to pay) as a proxy; c) the
availability of the indigenous public transportation
infrastructure including demand-response systems as
are sometimes implemented in rural communities; and d)
to the extent possible, superimposing transit routes with
the location of community health centers and hospitals.
Population Studied: Medically underserved children.
Principal Findings: Not surprisingly, there were
enormous difficulties obtaining these child health status
data points, such as hospitalization (discharge) rates for
ASCs and county-level availability of transit resources.
While on a national level our data are very preliminary,
we have identified several communities where the
combination of health professional shortages and
restricted transportation access contribute to missed
opportunities for children to obtain health care and
increased use of hospital (in-patient and emergency
department) resources for non-urgent care. As additional
data become available, the model proposed has the
promise to identify other such communities. Using geomapping, a grid of transportation disadvantaged
communities can be superimposed over one of primary
care HPSAs that also lack an adequate primary care
safety net. The communities characterized by both sets
of problems would be at the highest risk for limited child
health care access.
Conclusions: The combination of health professional
shortages, poor distribution of health professionals, and
restricted availability of transportation resources affects
many US communities and counties especially in rural
regions. Identifying these communities allows them to be
targeted for interventions to improve transportation
resources which would be predicted to strengthen child
health access.
Implications for Policy, Delivery or Practice: Investing
in interventions to improve the transportation
infrastructure of federally designated HPSAs especially
those that lack primary care safety net services is
anticipated to both improve child health access and
health status and reduce preventable hospital and
emergency department use.
Funding Source(s): WKK
™ Food Allergy Knowledge, Attitudes and Beliefs of
Primary Care Providers in the United States
Ruchi Gupta, M.D., M.P.H.; Jennifer Kim, M.D.;
Elizabeth Springston, B.A.; Bridget Smith, Ph.D.;
Jacqueline Pongracic, M.D.; Jane Holl, M.D., M.P.H.
Presented by: Ruchi Gupta, M.D., M.P.H., Assistant
Professor of Pediatrics, Smith Child Health Research,
Children's Memorial Hospital, 2300 North Children's
Plaza, Box 157, Chicago, IL 60614 Phone: (312) 5737747 Email: rugupta@childrensmemorial.org
Research Objective: Primary care providers play a
pivotal role in the health and well-being of food allergic
children, as they are often the first and sometimes the
only clinicians to diagnose and manage childhood food
allergy. Therefore, our objective was to provide insight
into food allergy knowledge and perceptions among
pediatricians and family physicians in the US.
Study Design: A national sample of pediatricians and
family physicians was recruited between April and July
of 2008 to complete the validated, web-based Chicago
Food Allergy Research Survey for Primary Care
Physicians. Findings were analyzed to provide
composite/itemized knowledge scores, describe
attitudes and beliefs, and examine the effects of
participant characteristics on participant response.
Population Studied: Pediatricians and family
physicians across the United States.
Principal Findings: A sample of 407 respondents was
obtained. Participants answered 59% of knowledgebased items correctly. Strengths were identified in areas
related to triggers/environmental risks,
susceptibility/prevalence, and treatment/utilization of
healthcare. For example, 80% of physicians knew that
the flu vaccine is unsafe for egg-allergic children, 90%
recognized that the number of food-allergic children is
increasing in the US, and 80% were aware that there is
no cure for food allergy. Weaknesses were identified in
areas related to definition/diagnosis, symptoms/severity,
and triggers/environmental risks. For example, 24%
knew that oral food challenges may be used in the
diagnosis of food allergy, 12% correctly rejected chronic
nasal problems as a symptom of food allergy, and 23%
recognized that yogurts/cheeses from milk are unsafe for
children with IgE-mediated milk allergies. Fewer than
30% of participants felt comfortable interpreting lab tests
to diagnose food allergy or felt adequately prepared by
their medical training to care for food-allergic children.
Conclusions: Knowledge of food allergy among primary
care physicians was fair, with little variation between
pediatricians and family physicians.
Implications for Policy, Delivery or Practice:
Opportunities exist for the improvement of primary care
providers' knowledge of food allergy. The need for such
efforts was acknowledged by participants’ own
perceptions of their clinical abilities in the management
of food allergy.
Funding Source(s): The Food Allergy Initiative
™ Enhancing Measurement of Pediatric Patient
Safety Indicators through Data Linkage: the
Canadian Experience
Astrid Guttmann, M.D.C.M., M.Sc; Anne Matlow, M.D.,
F.R.C.P.C.; Geta Cernat, M.D.; Christopher Parshuram,
M.D., M.B., Ch.B., Ph.D., F.R.A.C.P.; Jennifer Bennie,
M.Ed., C.Psych.; Geoffrey Anderson, M.D., Ph.D.
Presented by: Astrid Guttmann, M.D.C.M., M.Sc.,
Scientist, Institute for Clinical Evaluative Sciences, 2075
Bayview Avenue, G1 06, Toronto, ON, M4N3M5 Phone:
(416) 480-4055 x3783 Email:
astrid.guttmann@ices.on.ca
Research Objective: To determine the impact on rates
of pediatric safety indicators of 1) increasing the
denominator of eligible cases by including same day
surgery (SDS) as well as inpatient surgery cases and 2)
broadening the search for adverse events (i.e.,
numerator) through linkage to post-discharge rehospitalization and emergency department (ED) visits.
Study Design: We used a Canadian expert panel to
develop a set of safety indicators based on AHRQ
pediatric safety indicators that could be applied to
inpatient and SDS cases. We identified ICD-10 codes
for each of these indicators. We applied these codes to
a comprehensive set of inpatient and SDS data for the
province of Ontario to identify eligible index cases and to
determine the number of safety events recorded in these
cases. We used unique identifiers to link the index cases
to subsequent inpatient hospitalizations and ED visits to
widen the window to detect safety events.
Population Studied: All pediatric inpatients and SDS
patients in Ontario, Canada for 2003-2007.
Principal Findings: Overall, 2/3 of all operations on
children in Ontario are performed in the SDS setting.
There were more than double the number of cases of
post-operative hemorrhage in SDS patients compared
with inpatients (401 vs. 170), and these events occurred
in 63/133 of all community hospitals in Ontario.
Postoperative pneumonia and sepsis were the next most
common adverse events in SDS patients, and although
the rates were relatively low (0.6 and 0.14 per 1,000)
there were 173 cases of pneumonia detected in SDS vs.
204 in the inpatient sample. Rates per 1,000 of the
inpatient indicators using the original AHRQ definitions
were lower in Ontario than reported in the US for postoperative sepsis (9.33 vs 27.39), decubitus ulcer (1.43
vs 3.6), selected infections (1.91 vs. 3.25) and foreign
body (0.001 vs. 0.03). Ontario had higher rates per
1,000 of post-operative hemorrhage (3.78 vs 1.76) and
pneumothorax (0.4 vs 0.37 in neonates, and 0.33 vs
0.21 in non-neonates). Linking to subsequent
hospitalizations and/or ED visits (for decubitus ulcer
only) up to 21 days post-discharge for some indicators
increased the number of cases detected over the 3
years –from 204 to 431, 229 to 522, and 331 to 764 for
post-operative pneumonia, sepsis and selected
infections respectively. This also increased the number
of hospitals with events in all cases.
Conclusions: Although the rates of adverse events are
low in SDS cases, the large volume of these cases
means that including SDS substantially increases the
number of patient safety incidents detected. Using data
linkage to detect adverse events that result in ED visits
or return hospitalizations can substantially increase the
number of patient safety incidents detected. Further
work needs to be done to assess the validity of using
these measures.
Implications for Policy, Delivery or Practice:
Expanding the scope of pediatric patient safety
indicators to include SDS and to include events
subsequent to discharge from the index hospitalization
could provide a more complete view of pediatric patient
safety issues. Policy makers and administrators should
consider these issues when developing accountability or
payment tools based on adverse event measurement.
Funding Source(s): Ontario Ministry of Health & LongTerm Care and Canadian Insitutes of Health Research
™ The Role of Identity, Trust and Place in Access to
Pediatric Primary Care Among Poor, Urban
Adolescent Mothers
Jennifer Hebert-Beirne, Ph.D., M.P.H.; Michele Kelley,
Sc.D., M.S.W.
Presented by: Jennifer Hebert-Beirne, Ph.D., M.P.H.,
Director of Research, Research, Women's Health
Foundation, 632 West Deming Place, Chicago, IL 60614
Phone: (773) 305-8206 Email:
jennifer@womenshealthfoundation.org
Research Objective: Despite the presence of multiple
safety net providers, disparities in access to care exist
for disenfranchised, special populations such as
adolescent mothers and their children. Consumer
perceptions of the health care system may play a role in
these disparities as they shape health seeking behavior
and health care utilization. The aims of this study were:
(1) To describe adolescent mothers’ perceptions of and
experiences with pediatric primary care within a
community context ( 2) To identify the possible
influences of community context and sense of place on
navigating resources for child health care.
Study Design: An exploratory, qualitative study using
semi-structured interviews and two group discussions
was conducted.
Population Studied: Adolescent mothers were recruited
from a small, alternative educational program for
parenting teens in a multicultural, medically
underserved, urban community with a significant health
safety net. All 21 mothers who were students at the time
agreed to be interview participants. The participants’
ethnic breakdown was: 8 Mexican; 7 Puerto Rican; 1
“other” Hispanic cultural groups; and 5 African-American.
Principal Findings: Through maternal narratives of
health care utilization, perspectives of the health care
system were discerned suggesting findings with respect
to identity, trust and place. Negative interactions with
health care providers where the young mothers
experienced an awareness of social distance and limited
power threatened these women’s sense of maternal and
social identity. Dimensions of distrust and skepticism of
the health care system emerged in the data, likely
contributing to a strong reliance on maternal social
networks for health advice with selective adherence to
provider recommendations. Place played a significant
role in health-seeking behavior as adverse community
influences including poverty, gangs and rapid sociodemographic change undermined the establishment of a
pediatric medical home. Identity threats, distrust and
community context seemed to influence erratic patterns
of health care utilization including deliberate, consistent
use of multiple providers (“stand alone” clinics, E.Rs.),
and use of providers outside of the community.
Conclusions: Despite the relative availability and
affordability of local heath care services, poor adolescent
mothers lacked the recommended medical home for
their children and were largely disengaged with the
health care system, as evidenced by variable utilization
and significant disinterest in provider recommendations.
Nevertheless, the young women exhibited agency in
their determination to make sense out of a disarray of
health services and varied experiences. Their rich
narratives provided insights into possible influences on
their health-seeking behaviors, including deliberate use
of disparate medical care resources and lay consultation
- information unavailable from routine public health
systems data. Place influences access. Future research
should further investigate place effects on access to
care, as well as how issues of identity and trust are
especially significant for adolescent mothers with regard
to provider interactions, access and choice.
Implications for Policy, Delivery or Practice: Public
health strategies to ensure a relevant medical home for
all children need to be attentive to consumer’s
developmental needs, culture, community and life
experiences. Community-level education is needed to
increase family and peer health literacy and health care
system knowledge. Cultural sensitivity of community
providers must be improved, with community
involvement in local reforms.
™ Influences on Use of "Rescue" Medications During
Hospitalizations of Children at Academic Medical
Centers
Samuel Hohmann, Ph.D.; Michael Oinonen, D.Pharm.,
M.P.H.
Presented by: Samuel Hohmann, Ph.D., Senior
Manager, Clinical Data and Informatics, University
HealthSystem Consortium, 2001 Spring Road, Suite
700, Oak Park, IL 60523 Phone: (630) 954-1740 Email:
hohmann@uhc.edu
Research Objective: Explore medication safety issues
among hospitalized children at academic medical
centers. IOM and more recently JCAHO have identified
medication administration safety issues as a significant
opportunity for improving the care of patients. Most
recently, IOM has been reviewing appropriateness of
various medications for children. University
HealthSystem Consortium has flagged hospitalized
patients receiving index medications as well as rescue
medications to alert hospital clinicians and
administrators to potential patient safety issues for
nearly 10 years. This analysis identifies variation in
practice and outcome among more than 50 academic
medical centers submitting data to identify patterns of
practice.
Study Design: Retrospective cohort study
Population Studied: Children hospitalized at academic
medical centers between October 2005 and September
2008 who received at least one of six index medications.
The University HealthSystem clinical database was the
source of hospital discharge and medication
administration information used for this analysis.
Outcomes of care (length of stay, total cost, mortality,
ICU length of stay, etc.) were compared for children
receiving index medications only and children receiving
both index and rescue medications. Patients were
stratified into three age cohorts: newborns (0 to 30 days
of age), infants (1 to 12 months of age), and other
children (1 to 17 years of age).
Principal Findings: Several factors were associated
with the use of rescue medications including hospital
that provided care, reason for care, and age. There was
considerable variability across academic medical centers
in use of rescue medications when patients had received
index medications. More surgical patients received
index medications (and rescue medications) than
medical patients. Some index/rescue pairs were more
prevalent among newborns than infants or other children
while other were more prevalent among non-newborns.
There were also statistically significant differences in
many patient cohorts' outcomes: length of stay, total
cost, mortality, and ICU length of stay.
Conclusions: Hospitals could benefit from developing
performance improvement initiatives focused on
appropriate dosing either throughout the organization ro
within particular clinical services.
Implications for Policy, Delivery or Practice: An
analysis of index/rescue medication administration
occurrences among hospitalized children can be an
indication of the safety of the care provided. These
results should serve as an impetus for developing
patient safety initiatives related to use of medications in
the care of hospitalized children.
™ Risk Assessment for Pediatric Emergency
Transfers
Jane Holl, M.D. M.P.H.; Donna Woods, Ed.M., Ph.D.;
Olivia Ross, M.P.H.; Anna Torricelli, B.A.
Presented by: Jane Holl, M.D. M.P.H., Associate
Professor of Pediatrics and Preventive Medicine,
Institute for Healthcare Studies, Northwestern University,
750 North Lake Shore Dr. 10th Floor, Chicago, IL 60611
Phone: (312) 503-5565 Email: j-holl@northwestern.edu
Research Objective: To identify and address risks in
the emergency transfer of pediatric patients between
hospitals.
Study Design: Each of the six hospitals with
comprehensive pediatric services that comprise the
Chicago Pediatric Patient Safety Consortium
(Consortium) selected a specific emergency transfer
process (e.g., outside emergency department (ED) to
intensive care unit) to evaluate using a prospective risk
analysis method: the Failure Mode Effects and Criticality
Analysis (FMECA). Initial FMECA sessions focused on
the creation of a process map of the selected emergency
transfer process. Next, each FMECA team evaluated
the identified steps in their emergency transfer process
for potential failure modes and causes. Then, the teams
determined the frequency, consequence, and
safeguards of each failure mode. Finally, results were
“binned” or aggregated across all six participating
hospitals into generalizable risk categories. Solutions to
address the major risks were designed.
Population Studied: The FMECA teams were
comprised of: (1) clinicians (e.g., emergency department
nurses and physicians, pediatric intensivists, transfer
team members) involved in the emergency transfer of
pediatric patients at the Consortium hospitals and (2)
clinicians involved in the emergency transfer process at
two referring hospitals from which each Consortium
hospital receives pediatric emergency transfers. The
inclusion of clinicians from both referring and Consortium
hospitals provided a comprehensive mapping of each
selected transfer process.
Principal Findings: Inaccurate and delayed
communication about the patient was identified as a
major risk with significant consequences. Key causes of
this risk included lack of pediatric-specific training at the
referring hospitals and significant variation in the format
and content of data communicated about the transfer
patient. Within institutions, the FMECA process also
revealed a general lack of knowledge and awareness by
many clinicians of their colleagues’ roles and
responsibilities during the pediatric emergency patient
transfer process. A standardized pediatric emergency
transfer form was then developed. A review of the
existing transfer forms from both Consortium and
referring hospitals was conducted and a draft
standardized form was developed. Clinicians from the
FMECA teams reviewed and revised the form.
Additionally, three hospitals pilot tested the form while
continuing to use their existing transfer process and
forms. FMECA clinicians evaluated the effectiveness of
the form to accurately capture the necessary transfer
information. Final revisions were made based on the
pilot test results.
Conclusions: The six FMECAs, involving clinicians from
eighteen hospitals, identified generalizable risks during
pediatric emergency transfers. A standardized pediatric
emergency transfer form was developed and tested.
Participation and enthusiasm for the FMECA sessions
enhanced intra- as well as inter-institutional
communication.
Implications for Policy, Delivery or Practice: In 2005,
over 3,500 pediatric patients were transferred between
the referring and Consortium hospitals. All hospitals
have started to move towards adoption of the
standardized pediatric emergency transfer form. In
addition, the form is currently being integrated into a
newly-funded AHRQ project (Risk Informed Clinical
Information Network for Safe Pediatric Emergency
Transfers: R18 HS 017912-01), for development and
evaluation of a web-based version of the form that would
be transmitted and used in real time by clinicians at both
the referring and Consortium hospitals.
Funding Source(s): AHRQ
™ Mother-Child Interactions as Mediators of the
Impact of Maternal Depression on Child Emergency
Department Visits
Margaret Holland, M.S., M.P.H.; Byung-Kwang Yoo,
M.D., Ph.D.; Harriet Kitzman, Ph.D.; Linda Chaudron,
M.D., M.S.; Peter Szilagyi, M.D., M.P.H.; Helena
Temkin-Greener, Ph.D., M.P.H.
Presented by: Margaret Holland, M.S., M.P.H., Ph.D.
Candidate, Community & Preventive Medicine,
University of Rochester, 601 Elmwood Avenue Box 644,
Rochester, NY 14642 Phone: (585) 273-2549 Email:
margaret_holland@urmc.rochester.edu
Research Objective: Studies have noted that children
of depressed mothers have more emergency
department (ED) visits than other children. Poor motherchild interactions may contribute to this association by
delaying the mother’s recognition of symptoms of illness
or risks of injury. In addition, when an illness or injury
becomes apparent, mothers with poor interactions may
interpret the problem as worse than it is. We examined
whether mother-child interactions are mediators between
maternal depression and child ED visits.
Study Design: Women were interviewed 12 months
after their first child's birth. Depressive symptoms were
measured by the Mental Health Inventory-5 (5-item
Likert scale). Mother-child interactions were measured
using the Nursing Child Assessment Satellite Training
subscale for child’s responsiveness to parent (count of 0
to 13 behaviors observed) and the Home Observation
for Measurement of the Environment subscale for
mother’s emotional & verbal responsiveness (count of 0
to 11 behaviors observed). Data on child ED visits from
birth to 24 months were available from medical records.
We fit two ordered logistic regression models with an
outcome variable of the number of child ED visits (3
categories: 0/1/2+). In the first model, the key
explanatory variable was maternal depressive
symptoms. In the second, a mother-child interaction
measure was added. All models controlled for children's
chronic conditions, birth weight, and demographic
factors.
Population Studied: Data from the Nurse-Family
Partnership trial in MeM.P.H.is, TN were used (n=432;
control group only). Pregnant women were recruited at
an obstetrical clinic, met two of three criteria (unmarried,
unemployed, with less than 12 years of education), and
were randomly assigned to control or intervention
groups. The resulting sample was primarily black (92%)
and poor (47% at or below $3000 annual income).
Principal Findings: Twenty-one percent of children had
1 ED visit and 59% had 2 or more, 23% of mothers had
high depressive symptoms, 40% of mothers had higher
emotional & verbal responsiveness than the sample
mean, and 31% of children had high responsiveness to
parent. Using linear regression, increased maternal
depressive symptoms were found to predict lower
maternal responsiveness (-0.324; 95% CI: -0.805,
0.157). Using ordered logistic regression, lower maternal
responsiveness was found to predict more child ED
visits (OR: 1.25, 95% CI: 1.91, 0.82). When these two
paths were combined by multiplying the coefficients,
maternal self-efficacy was shown to be a mediator
(p<0.001). When the child’s responsiveness was
included, the OR for child’s responsiveness indicated
increased responsiveness associated with more ED
visits (opposite of hypothesis) and the increased
depressive symptoms OR was not consistent with
mediation.
Conclusions: Among this urban, mostly minority
population, mother’s emotional & verbal responsiveness
was found to be a mediator between maternal
depressive symptoms and child ED visits, but child’s
responsiveness was not.
Implications for Policy, Delivery or Practice: When
treating a depressed mother, additional interventions
specifically targeting mother‘s responsiveness to her
child may decrease the child's ED visits.
Funding Source(s): AHRQ
™ Self-Efficacy as a Mediator Between Child
Hospitalizations & Maternal Depression
Margaret Holland, M.S., M.P.H.; Byung-Kwang Yoo,
M.D., Ph.D.; Harriet Kitzman, Ph.D.; Linda Chaudron,
M.D., M.S.; Peter Szilagyi, M.D., M.P.H.; Helena
Temkin-Greener, Ph.D., M.P.H.
Presented by: Margaret Holland, M.S., M.P.H., Ph.D.
Candidate, Community & Preventive Medicine,
University of Rochester, 601 Elmwood Avenue Box 644,
Rochester, NY 14642 Phone: (585) 273-2549 Email:
margaret_holland@urmc.rochester.edu
Research Objective: Several studies have noted that
children of depressed mothers have more
hospitalizations than other children. Self-efficacy (the
belief that one is able to be effective at a certain task)
has been suggested as a mechanism contributing to this
association.
Study Design: Women were interviewed 12 and 24
months after their first child's birth. Depressive
symptoms were measured by the Mental Health
Inventory-5 (5-item Likert scale) and were considered
consistently high if above the cut-off at both 12 and 24
months. Parenting self-efficacy was measured by a 10item Likert scale developed and validated for this study.
Data on child hospitalizations from 12 to 24 months were
available from medical records. We fit two logistic
regression models. One or more child hospitalization
was the outcome variable in each model. In the first
model, the key explanatory variable was maternal
depressive symptoms. In the second, self-efficacy was
added. All models controlled for children's chronic
conditions, birth weight, and demographic factors.
Population Studied: Control group data from the
Nurse-Family Partnership trial in Memphis, TN were
used (n=432). Pregnant women were recruited at an
obstetrical clinic and had to meet two of three high-risk
criteria: unmarried, unemployed, with less than 12 years
of education, and were randomly assigned to control or
intervention groups. The resulting sample was primarily
black (92%) and poor (47% at or below $3000 annual
income).
Principal Findings: Twelve percent of children had 1 or
more hospitalizations, 14.3% of mothers had
consistently high depressive symptoms, and 48% had
lower maternal self-efficacy than the sample mean. In
the first model, the adjusted odds ratio (OR) for
depressive symptoms was 1.98 (95% CI: 0.86, 4.00). In
the second model, the OR for depressive symptoms
decreased to 1.89 (95% CI: 0.81, 4.40) and the OR for
self-efficacy was 0.77 (95% CI: 0.40, 1.49). Because the
addition of self-efficacy decreased the OR of depressive
symptoms, self-efficacy is concluded to be a mediator as
hypothesized (95% CI for change in coefficient: -0.043, 0.008; p<0.01).
Conclusions: Among this urban, mostly minority
population, maternal self-efficacy is shown to be a
mediator between maternal depression and child
hospitalizations.
Implications for Policy, Delivery or Practice: When
treating depressed mothers, additional interventions
specifically targeting self-efficacy may decrease their
children's hospitalizations.
Funding Source(s): AHRQ
™ A Medical Home for Children with InsulinDependent Diabetes: Parental Views of Primary &
Subspecialty Physician Roles
Charles Humble, M.S.P.H., Ph.D.; Steven E. Wegner,
M.D., J.D.; Christine Lathren, M.D., M.S.P.H.; Michelle
Mayer, M.P.H., Ph.D.; Alan Stiles, M.D.
Presented by: Charles Humble, M.S.P.H., Ph.D.,
Director, Analytic Services, AccessCare, 3500 Gateway
Centre Blvd, Suite 130, Morrisville, NC 27560 Phone:
(919) 380-9962 Email: chumble@ncaccesscare.org
Research Objective: To examine parental views of
primary care physicians’ (PCP) and endocrinologists’
roles in the management of routine preventive and acute
care, diabetes-specific care, and family education and
care coordination for children with insulin-dependent
diabetes (IDDM). Understanding how parental views
align with those of PCPs and subspecialists is important
for building a more efficient medical home.
Study Design: Collaboration within the medical home
model of care is recognized as a critical element of care
by the American Academy of Pediatrics, by Healthy
People 2010 goals and by the New Freedom Initiative’s
core outcomes. The benefits of collaboration between
PCPs and subspecialists can include improvements in
access, reduced frequency and inappropriateness of
referrals, better communication, improved outcomes and
satisfaction, and lower costs. This study used a mixedmode survey of parents of children with IDDM in one
Medicaid Managed Care Network in North Carolina.
Results were compared with previously-described
provider attitudes regarding best sources of care.The
survey examined routine preventive and acute care,
diabetes-specific care, family education and care
coordination. Parents were asked which physician type
they usually use for 17 specific services: the PCP
(“regular doctor”), “diabetes doctor”, or both. The
remainder of the survey focused on demographics and
more general factors influencing parental decisions
regarding where to seek care. Completed surveys were
returned by mail to ensure confidentiality of responses.
Population Studied: The target sample was parents of
249 pediatric patients prescribed insulin by member
physicians participating in AccessCare, a providerowned, not-for-profit medical home managed care
organization serving more than 200,000 Medicaid child
and adult enrollees statewide. Children with IDDM were
selected because they require ongoing contact with
PCPs and subspecialists to improve short- and longterm outcomes. The response rate was 43.4%.
Principal Findings: A majority of parents reported
usually taking their children with IDDM to PCP for all
aspects routine primary care queried and for referrals to
eye doctors and mental health providers. The
subspecialist was the preferred provider for most
aspects of diabetes-specific care, family education,
referrals to nutritionists and for talks with school or
daycare personnel. Preferences were more divided as
to where to perform kidney and cholesterol checks. High
proportions of parents said they would be willing to travel
“a long way” to a subspecialist for serious problems.
Most parents have discussed which doctor to see in
different situations with both types of providers. Parent
and provider attitudes regarding best sources of care
generally agree.
Conclusions: An effective medical home model of care
depends on establishing clear lines of responsibility
between the PCP and subspecialist and sharing this
information with patients and caregivers. Our findings
suggest that parents and doctors have clear preferences
for where to seek different types of care for diabetic
children and tend to agree on these preferences for most
aspects of care.
Implications for Policy, Delivery or Practice:
Knowledge of parental preferences regarding division of
care between PCPs and subspecialists can facilitate comanagement when it is needed and optimize care for
patients with IDDM in their medical homes.
Funding Source(s): Department of Pediatrics, NC
Children's Hospital
™ Beyond Coverage: Interventions that Improve
Preventive Health Services for Children Enrolled in
Medicaid
Anjali Jain, M.D.; Jennifer Sheer, M.P.H.; Dawn
Valentine, M.P.H.; Seiji Hiyashi, M.D.; Joel Teitelbaum,
J.D.; Jill Joseph, M.D., Ph.D.
Presented by: Anjali Jain, M.D., Assistant Professor of
Pediatrics and Health Policy, Pediatrics and Health
Policy, Children's National Medical Center and George
Washington University, 111 Michigan Avenue NW,
Washington, DC 20817 Phone: (202) 476-2933 Email:
ajain@cnmc.org
Research Objective: To determine from the literature
the most effective interventions to improve the delivery
of EPSDT services to children enrolled in Medicaid.
Study Design: Comprehensive and systematic literature
review of peer-reviewed literature via Medline and
Google Scholar from 1980 to July 2008 using the
following search terms: EPSDT, Medicaid, preventive
care, well child care, children, managed care,
immunizations, and interventions. Abstracts and related
articles were reviewed as well as other publications from
the primary authors of the relevant articles and studies.
We also used Google to search for print- or internetpublished reports from policy organizations centered on
the health care of children on Medicaid, such as the
Center for Health Care Strategies and the
Commonwealth Fund.
Population Studied: Literature as defined above
pertinent to children from low-income families insured or
eligible for Medicaid.
Principal Findings: Interventions fell into three broad
categories: those that target the behavior of the patient
or family; those that target the behavior of the provider or
clinical practice; and those that target the behavior of the
Medicaid program or health system and its
administration more generally. Overall, no single,
universally effective single intervention was found.
Outreach interventions targeting the patient/family
(phone calls, reminders, home visits) were partially
effective in increasing receipt of preventive care, with
telephone reminders being the most effective and costeffective as a single intervention but limited by the
frequent inaccuracy of contact information. At the
provider or practice level, interventions that enhanced
the personal connection or relationship between
physician and patient increased receipt of preventive
care. These included assigning providers to families,
providing after hours advice and care, and care
coordination. "Flagging" patient files for missed
preventive care opportunities during acute visits
improved well child care. In contrast, emergency room
interventions and increased fees for physicians were not
shown to be effective. At the level of the Medicaid
program or health system, more continuous enrollment
and coordination or co-location of social, educational
and health services improved the receipt of preventive
care.
Conclusions: In order to optimize the delivery of
preventive care for children insured by Medicaid,
enhancements are needed at every level, for the patient
and family directly, for health care providers and
practices, and for the Medicaid program and its
administration. Best practices include telephone
reminders for preventive care appointments, and a
medical home model for clinical practices. Easing the
administrative burden of enrolling in Medicaid, staying
enrolled and accessing needed services supports the
receipt of good preventive care for children and families.
Implications for Policy, Delivery or Practice: A
"continuous outreach" model is needed for families with
children on Medicaid, from eligibility to continuity of care.
Funding Source(s): District of Columbia Department of
Health Care Finance
™ Advancing Child Health in Low Resource
Environments by Matching Health Care Delivery with
Population Needs
JoAnne Natale, M.D., Ph.D.; Ben Gitterman, M.D.;
Jennifer Egelseer, D.O.; Pediatric Faculty of OPRH; First
Class of OPRH pediatric residents; Jill Joseph, M.D.,
Ph.D.
Presented by: Jill Joseph, M.D., Ph.D., Director, Center
for Clinical and Community Research, Children's
National Medical Center, 111 Michigan Avenue NW,
Washington, DC 20010 Phone: (202) 476-6439 Email:
jjoseph@cnmc.org
Research Objective: To reduce self-referral of low
acuity pediatric patients to the outpatient facility of a
nation's only pediatric referral hospital in a resourcelimited environment. This objective is a priority for the
Eritrean Ministry of Health as it works to build a health
care system rationally distributing scarce pediatric
resources.
Study Design: Longitudinal monitoring (nine months) of
outpatient visits to both Orotta Pediatric Referral Hospital
(OPRH) and primary health facilities (PHFs) following
implementation of a multiple-component intervention.
This intervention was designed with local practitioners
and residents as part of a community health rotation in a
newly-established pediatric residency program; it
included group education for parents attending OPRH as
well as feedback to the PHFs regarding parental
concerns. In addition, cross-sectional quantitative and
qualitative data were obtained at 2 time points from both
PHF providers and selected parents regarding use of
health care resources.
Population Studied: We examined pediatric outpatient
visits (newborn through 14 years old) in Asmara, Eritrea
March-November 2008. During this period of time, a
multi-faceted intervention was implemented to
discourage self-referral to OPRH and increase use of
PHFs. Twelve PHFs staffed by non-physicians provide
pediatric preventive and primary care services in Asmara
using standard WHO protocols for patient assessment,
treatment, and referral. Staff of PHFs, as well as
sampled parents seeking care for their children,
participated in brief interviews to develop and refine the
interventions.
Principal Findings: At baseline (March 24-29, 2008)
there were 1,648 outpatient pediatric visits in Asmara, of
which 1210 (73%) were at PHFs and 438 were at
OPRH. Of the children seen at PHFs, 12 (1%) were
referred to OPRH and of these, 50% required admission
either to emergency or inpatient unit. In comparison, of
the 438 outpatient visits to OPRH, 416 (95%) were selfreferrals with parents by-passing an initial evaluation in a
PHF. Among these self-referred patients, only 33 (8%)
required admission. Both PHF staff and parents reported
that the desire to be seen by a pediatrician and concerns
about the quality of care at the PHFs motivated selfreferral. We analyzed 5,639 visits between baseline and
follow-up (8 months), documenting a decline in selfreferral among OPRH outpatients from 95% to
approximately 75%. During this same period of time,
outpatient visits to PHFs increased 38% (from 1,210 to
1,667/week). Interviews with parents demonstrated that
the educational intervention increased the proportion of
parents intending to use PHF for future outpatient care
from 28% to 82%. PHF staff responded enthusiastically
to this intervention program and requested further
activities. Additional interventions are currently being
implemented.
Conclusions: 1) It is possible to model and conduct
research designed to understand and alter patterns of
healthcare utilization in resource-limited environments.
2) Straightforward and easily designed/implemented
interventions reduced self-referral of low-acuity pediatric
patients inappropriately seeking care at pediatric referral
hospital.
Implications for Policy, Delivery or Practice:
Collaborative research with trainees and practitioners in
a low resource environment can address important
issues related to health care utilization. Such research
can both train local practitioners and contribute to
national efforts to link resource use to population needs
Funding Source(s): Partnership for Eritrea; Physicians
for Peace; Eritrean Ministry of Health
™ Quality Improvement Intervention to Reduce
Delivery Room Cold Stress in Very Low Birthweight
Infants
Heather Kaplan, M.D., M.S.C.E.; Robin Breig, R.N.,
B.S.N.; Carrie Hallett-Voss, R.N., B.S.N.; Dionni MeekSilvers, R.N., M.S.N.; Neka Corcoran, R.N.; Peter
Margolis, M.D., Ph.D.
Presented by: Heather Kaplan, M.D., M.S.C.E.,
Assistant Professor of Pediatrics, Neonatology; Health
Policy & Clinical Efectiveness, Cincinnati Children's
Hospital Medical Center, 3333 Burnet Avenue, MLC
7009, Cincinnati, OH 45229 Phone: (513) 803-0478
Email: heather.kaplan@cchmc.org
Research Objective: The National Quality Forum (NQF)
has endorsed the proportion of very low birthweight
(VLBW <1500 grams) infants with an admission
temperature < 36°C as a measure of quality of care.
The objective of this research is to evaluate a quality
improvement (QI) intervention to reduce the number of
VLBW infants with low neonatal intensive care unit
(NICU) admission temperatures.
Study Design: We used QI methods and reliability
principles to implement a “bundle of interventions”
suggested in the literature to reduce the number of
infants admitted to the NICU with significant cold stress.
The intervention bundle included staff education;
consistent room set up prior to delivery including setting
room air temperature >77°C; attention to
thermoregulation during resuscitation including use of
polyethylene bags; and transfer to the NICU in a warmed
incubator. Staff used checklists to encourage adherence
with the bundle. Historical data on admission
temperatures was obtained for the 6 months prior to the
intervention (n=97 infants) and prospectively after the
intervention (n=144 infants through 10/31/2008).
Proportions of infants with temperatures < 36.5°C were
compared before and after the intervention using
student’s t test and statistical process control methods.
Population Studied: All VLBW infants admitted to the
Good Samaritan Hospital NICU (Cincinnati, Ohio) were
included. The Good Samaritan Hospital NICU is a 56bed level III NICU with an annual volume of 264 VLBW
admissions (2007).
Principal Findings: In the post intervention period, 64%
of VLBW births had an intervention checklist completed,
and of those, compliance with the complete intervention
bundle reached 43% by 10/31/2008. The proportion of
infants with temperatures <36.5°C was reduced from
92% to 38% (p<0.001) over a 7 month period. In the
post intervention period, there was no difference in the
proportion of infants with temperatures <36.5°C based
on delivery in the operating room (35%) versus labor and
delivery room (36%).
Conclusions: There was a significant reduction in the
number of VLBW infants with a low NICU admission
temperature indicating improving quality of care.
Increased compliance with the intervention bundle and
addition of other high reliability strategies may result in
further reductions.
Implications for Policy, Delivery or Practice: We have
demonstrated successful application of quality
improvement methods and reliability principles that can
be used by other neonatal-perinatal care providers to
improve their performance and quality of care as
measured by the NQF endorsed metric.
™ Large Variation in Neonatal Intensive Care Unit
Use of Evidence Based Care: The Example of
Vitamin A
Heather Kaplan, M.D., M.S.C.E.; Meredith Tabangin,
M.P.H.; Diana Henderson, M.P.H., M.S.W.; Peter A.
Margolis, M.D., Ph.D.; Edward Donovan, M.D.
Presented by: Heather Kaplan, M.D., M.S.C.E.,
Assistant Professor of Pediatrics, Neonatology and
Health Policy & Clinical Effectiveness, Cincinnati
Children's Hospital Medical Center, 3333 Burnet
Avenue, MLC 7009, Cincinnati, OH 45229 Phone: (513)
803-0478 Email: heather.kaplan@cchmc.org
Research Objective: Vitamin A supplementation has
been identified as an effective strategy for prevention of
bronchopulmonary dysplasia (BPD) in premature infants.
Our objective was to determine variation in the use of
evidence-based Vitamin A supplementation among
neonatal intensive care units (NICU).
Study Design: Retrospective cohort study of extremely
low birthweight (ELBW <1000 grams) infants admitted to
a children’s hospital NICU participating in the Pediatric
Health Information System (PHIS) database from
January 1, 2005 to March 31, 2008. Use of Vitamin A
was defined as receipt of at least one dose because this
reflects clinician intent to use Vitamin A. We calculated
each center’s rate of Vitamin A use among ELBW infants
along with 95% Confidence Intervals (CI). Generalized
Estimating Equation models were used to examine
Vitamin A use over time, accounting for clustering by
center.
Population Studied: Patients receiving care in a
hospital participating in the PHIS administrative
database were eligible for inclusion. The PHIS database
contains inpatient data from 40 not-for-profit, tertiary
care pediatric hospitals in the United States affiliated
with the Child Health Corporation of America, a business
alliance of children’s hospitals. Patients with a BW 500999 grams, determined using ICD-9-CM diagnosis
codes, admitted within 7 days of birth were included.
Infants with congenital anomalies or length of stay < 4
days were excluded. We excluded centers with <30
infants in the study period and those not submitting
utilization data.
Principal Findings: Among 3,022 eligible infants cared
for in 26 NICUs, 2,361 (78%) infants received no Vitamin
A. Fourteen (54%) centers used Vitamin A in some
patients, while 12 (46%) centers did not use Vitamin A at
all. Across NICUs using Vitamin A, the proportion of
infants receiving any Vitamin A ranged from 0.9% [95%
CI: 0.05-4%] to 92% [95% CI: 88-96%]. Infants
discharged in 2007 and 2008 were more likely to receive
Vitamin A compared to 2005, OR 2.3 [95%CI: 1.3-4.3]
and 2.4 [95%CI: 1.2-4.5], respectively.
Conclusions: This study confirms the large variation in
Vitamin A use reported by neonatologists [Ambalavanan
2004]. Although use of Vitamin A is increasing over time,
adoption has been slow, and marked variation across
NICUs remains. This variation may reflect lack of
awareness and agreement with published evidence. It
may also be attributable to differences in organizational
factors associated with reliable implementation of
evidence.
Implications for Policy, Delivery or Practice: The first
step in achieving high quality health care requires
identifying a gap between the evidence and existing
practice, as this study has done. Based on published
efficacy (risk difference 7%) and prevalence (62%) data
[Tyson 1999], we estimate that as many as 165
instances of BPD or death may have been prevented if
untreated infants in this study population were given
Vitamin A. The results of this study will promote efforts
to change physician behavior leading to improved use of
Vitamin A and improved quality of care for neonates.
Funding Source(s): Cincinnati Children's Hospital
Medical Center Outcomes Research Award (Internal
Grant Mechanism)
™ “I Don’t Know Much about the Vaccine. I Haven’t
Heard Anything.” - Cervical Cancer, HPV & HPV
Vaccine Awareness among Rural Latino Parents
Deanna Kepka, M.P.H., Ph.D.; Beti Thompson, Ph.C.;
Gloria Coronado, Ph.D.; Hector Rodriguez, Ph.D.,
M.P.H.
Presented by: Deanna Kepka, M.P.H., Ph.C., Ph.D.
Student, Health Services, University of Washington, Box
357660, Seattle, WA 98195 Phone: (206) 321-0936
Email: kepka@u.washington.edu
Research Objective: Latinas have almost a two-fold
higher incidence of cervical cancer compared to nonHispanic white women. Little research has been carried
out with Latino parents related to assessing awareness
and acceptability of the new HPV vaccine to prevent
cervical cancer. The CDC recommends the vaccine for
girls at ages 11 and 12 years old but it can also be given
to girls between the ages of 9 – 26. This study aims to
specifically explore rural Latino parents’ knowledge and
beliefs related to HPV and the HPV vaccine in the Lower
Yakima Valley of the state of Washington.
Study Design: Purposive sampling was used to recruit
Latino parents to participate in in-depth qualitative semistructured interviews that investigated cervical cancer,
HPV, and HPV vaccine awareness, knowledge, beliefs,
and attitudes rooted in local socio-cultural perspectives.
Data were analyzed using Atlas.ti and grounded theory
methodology.
Population Studied: 26 Latino parents (16 mothers and
10 fathers) of daughters ages 9-14 living in an
agricultural region of the state of Washington
participated in this study. Half of the participants were
between the ages of 41 and 50 years old (Age Range:
31-60), 89% were born in Mexico, and an average of 8.9
years of formal education was reported. Most of the
families earned less than $30,000 per year, 69% of the
participants knew only or mostly Spanish, and most
attended local community health centers.
Principal Findings: Overall, participants demonstrated
large gaps in knowledge of cervical cancer, HPV, and
the HPV vaccine. Most participants had not heard of
cervical cancer or HPV. A few had heard of the HPV
vaccine. However, most did not know the cause of
cervical cancer, the number of vaccines in the series,
recommended ages for vaccine uptake, vaccine costs,
side effects, and where it may be administered. Most
participants were supportive of the vaccine but would
like more information about it. Although most participants
had a medical home for their daughters at a local
community based health center, few received
information from their medical providers about the HPV
vaccine. Local community health centers stated that
most of their patients qualified to receive the HPV
vaccine at little or no cost. Most parents felt that they
would be interested in speaking with a medical provider
about their questions related to cervical cancer, HPV,
and the HPV vaccine.
Conclusions: Nearly all of the participants
demonstrated limited exposure to and knowledge of
cervical cancer, HPV, and the HPV vaccine. The
majority of participants demonstrated insufficient levels
of knowledge related to the logistics of vaccine
administration to seek the vaccine for their daughter(s).
Few received information related to the HPV vaccine
from their medical providers.
Implications for Policy, Delivery or Practice:
Culturally and linguistically appropriate cervical cancer
prevention and HPV vaccine awareness programs are
needed that specifically target rural Latino parents at
local community based health centers and in rural
communities. Promoting parental engagement in actively
learning more about cervical cancer, HPV, and the HPV
vaccine may improve parental decision making ability
related to supporting HPV vaccine uptake for their
daughter(s). Without these targeted interventions,
health disparities related to cervical cancer incidence
and mortality may further widen.
Funding Source(s): NCI
™ Better VLBW Infant Outcomes in Nursing Magnet
Hospitals
Eileen Lake, Ph.D.; Jeannette Rogowski, Ph.D.; Jeffrey
Horbar, M.D.; Douglas Staiger, Ph.D.; Michael Kenny,
M.S.; Thelma Patrick, Ph.D.
Presented by: Eileen Lake, Ph.D., Associate Professor,
Center for Health Outcomes and Policy Research,
University of Pennsylvania, 543 Sussex Road,
Wynnewood, PA 19096 Phone: (610) 896-3631 Email:
elake@nursing.upenn.edu
Research Objective: VLBW infants are high-risk
patients. These infants are treated in NICUs where they
are closely monitored and given life support measures
and intensive interventions. Large variations in
outcomes exist across NICUs that cannot be explained
by patient or NICU characteristics. Since NICU cases
are nurse-intensive, nursing care may provide an
opportunity to improve outcomes. In this first large-scale
U.S. study of nursing effects on NICU outcomes, we
examine whether acuity-adjusted nurse staffing and
environments contribute to the variation in NICU patient
outcomes.
Study Design: In this observational study, we collected
data in March 2008 on patient acuity and the practice
environment via web survey of 6400 nurses in 104
NICUs from the Vermont Oxford Network (VON), an
international quality improvement collaborative. The
independent variables were acuity-adjusted nurse-toinfant ratio, compositional features of the staff
(education, certification, experience), the professional
practice environment and the hospital’s certified magnet
status. Infant outcomes (N=8490) were measured from
the 2007 VON database. We also analyzed magnet
status and outcomes for the entire VON comprising 505
hospitals and 30,000 infants. Outcomes were analyzed
in random-effects logit models which correct for patient
clustering within hospitals and controlled for patient
characteristics, including gestational age, APGAR score,
race, gender, and prenatal care.
Population Studied: Very low birth weight infants in
neonatal intensive care units
Principal Findings: The average nurse cared for two
infants, but this varied by infant acuity. For the highest
and lowest acuity infants, the average nurse-to-infant
ratio was 0.95 and 0.34. The proportions of staff with
bachelor’s degrees, neonatal specialty certification, and
five or more years of nursing experience were 56%, 19%
and 74%. The hospital sample is exceptional in the
large fraction (42%) with magnet certification based on
achieving exemplary nursing standards, compared to the
entire VON (19%) and hospitals nationally (6%). Infant
outcomes varied considerably. The average rates were
mortality, 11%, nosocomial infection, 17%, severe
intraventricular hemorrhage (SIVH), 7% and chronic lung
disease, 26%. Nurse staffing and staff composition
variables did not explain the variation. A more
professional practice environment appears to be
associated with a lower likelihood of infection. Analyses
of the entire VON revealed significantly lower likelihood
of death (OR = .86, p = .05) for VLBW infants in magnet
hospitals and similar lower odds ratios for infection and
SIVH, albeit at marginal significance levels.
Conclusions: Nurse staffing and environment explains
a small amount of the variation in VLBW infant outcomes
across NICUs. While nursing magnet hospitals achieve
better infant outcomes, the preponderance of magnet
hospitals in the sample cohort makes it difficult to
differentiate which aspects of these hospitals are
influential. After adjusting for multiple nursing factors,
significant variation in outcomes across units remains.
Future work should investigate the reasons for this
outcome variation.
Implications for Policy, Delivery or Practice: Our
research findings will support evidence-based
management decisions to improve the quality of NICU
care by informing managers about staffing ratios and
staff qualifications and identifying the features of practice
environments that are most influential for infant
outcomes.
Funding Source(s): RWJF
™ Nursing Unit Organization and Very Low Birth
Weight Infant Outcomes in Neonatal Intensive Care
Units
Eileen Lake, Ph.D., R.N., F.A.A.N.; Jeannette Rogowski,
Ph.D.; Jeffrey Horbar, M.D.; Douglas Staiger, Ph.D.;
Thelma Patrick, R.N., Ph.D.; Robyn Cheung, R.N., Ph.D.
Presented by: Eileen Lake, Ph.D., R.N., F.A.A.N.,
Associate Professor, Center for Health Outcomes and
Policy Research, University of Pennsylvania School of
Nursing, 418 Curie Boulevard, Philadelphia, PA 19104
Phone: (215) 898-2557 Email: elake@nursing.upenn.edu
Research Objective: Very low birth weight infants are
among the highest-risk patient populations. These
infants are treated in NICUs where they are closely
monitored and provided with an array of life support
measures and intensive interventions. Large variations
in outcomes across NICUs currently exist that cannot be
explained by differences in patient or NICU
characteristics, such as volume or NICU level. Since
NICU cases are among the most nurse-intensive
hospitalizations, nursing care may explain some of this
variation and provide an opportunity for improving
outcomes for these high-risk infants. In this first largescale U.S. study of nursing effects on NICU outcomes,
we examine whether variation in acuity-adjusted nurse
staffing and environments contribute to the variation in
NICU patient outcomes.
Study Design: In this observational study, we collected
data in March 2008 on patient acuity and the practice
environment via web survey of 6400 nurses working in
104 NICUs from the Vermont Oxford Network (VON), an
international quality improvement collaborative. The
independent variables were the ratio of the observed to
expected nurse-to-infant ratio for each unit,
compositional features of the nursing staff (education,
certification, experience), the professional practice
environment and the hospital’s ANCC certified magnet
status. Infant outcomes were measured from the
Vermont Oxford Network Database for calendar year
2007 (N=8490). Outcomes were analyzed in randomeffects logit models which correct for the clustering
within hospitals of patient outcomes. Patient
characteristics, including gestational age, 1-minute
APGAR score, race, gender, and prenatal care were
included as control variables.
Population Studied: Very low birth weight infants in
neonatal intensive care units
Principal Findings: The average nurse cared for two
infants, but this varied considerably by infant acuity. For
the highest and lowest acuity infants, the average nurseto-infant ratio was 0.95 and 0.34, respectively. The
overall proportions of staff with bachelor’s degrees,
neonatal specialty certification, and five or more years of
nursing experience were 56%, 19% and 74%
respectively. The sample of hospitals is exceptional in
the large fraction (42%) with certified nursing magnet
status based on achieving exemplary nursing standards,
compared to hospitals nationally (6%). There was
significant variation across units in both infant survival
and infection, with average mortality rates of 11% and
nosocomial infection rates of 17%. Preliminary analyses
indicate that nurse staffing and staff composition
variables are not able to explain this variation. A more
professional practice environment appears to be
associated with a lower likelihood of infection.
Conclusions: Nurse staffing and environment explains
a small amount of the variation in VLBW infant outcomes
across NICUs. After adjusting for multiple nursing
factors, significant variation in outcomes across units
remains. Future work should investigate the reasons for
this outcome variation.
Implications for Policy, Delivery or Practice: Our
research findings will support evidence-based
management decisions to improve the quality of NICU
care by informing managers about staffing ratios and
staff qualifications and identifying the features of practice
environments that are most influential for infant
outcomes.
Funding Source(s): RWJF
™ Well-Child Care as a Predictor of Emergency Care
in Connecticut’s Medicaid Managed Care Program
Mary Alice Lee, Ph.D.; Karen Sautter, M.P.H., Dr.P.H.;
Amanda Learned, B.A.
(OR: 1.09; 95% CI: 1.05-1.13). The odds of having had
emergency care, including non-urgent emergency care,
were significantly increased for children 2 to 5 and
Hispanic children.
Conclusions: Children who had emergency care were
more, not less, likely to have had well-child care. Future
investigation of this association should include
evaluation of the quality of primary care.
Implications for Policy, Delivery or Practice:
Emergency care is often used as an indicator of
problems with access to primary care. Results of this
study suggest however that we should look beyond
primary care access to the other personal, social, and
health care systems factors that may contribute to
parents using the emergency department for care of
their children.
Funding Source(s): Hartford Public Giving
™ Ready4Changes.com: A Computer-Tailored
Approach for Human Sexuality Education for Middle
Schoolers
Mia Liza Lustria, Ph.D.; Juliann Cortese, Ph.D.; Ivee
Rosario, M.Ed.; Casey McLaughlin, B.S.
Presented by: Mary Alice Lee, Ph.D., Senior Fellow,
Connecticut Voices for Children, 33 Whitney Avenue,
New Haven, CT 06510 Phone: (203) 498-4240 Email:
malee@ctkidslink.org
Presented by: Mia Liza Lustria, Ph.D., Assistant
Professor, College of Information, Florida State
University, 270 Louis Shores Building, 142 Collegiate
Loop, Tallahassee, FL 32306 Phone: (850) 644-6237
Email: mlustria@ci.fsu.edu
Research Objective: To determine whether children
with access to primary care, as indicated by having had
a well-child visit, are less likely to have emergency care
than children who did not have well-child care.
Study Design: A retrospective cohort study design was
used to assess utilization of emergency care among
children and adolescents aged 2 to 19 enrolled in a
Medicaid managed care program during 2006. Logistic
regression was used to calculate the odds of emergency
care utilization by receipt of well-child care services
during the same year.
Population Studied: The study population included
128,132 children and adolescents aged two to nineteen
who were continuously enrolled in Connecticut’s
Medicaid managed care program during the 2006
calendar year. Continuous enrollment was defined as
enrollment between January 1 and December 31, 2006,
with no more than one month interruption in enrollment.
Enrollees were not excluded if they switched managed
care plans during the study period.
Principal Findings: Contrary to expectations, the
unadjusted emergency care rate was higher for children
with well care (38%) than the rate for those without well
care (33%). After adjusting for age, gender,
race/ethnicity, primary household language, residence
and managed care plan, the likelihood of children with
well-child care having had emergency care remained
significantly higher (OR: 1.13; 95% CI: 1.10-1.16). The
unadjusted rate of non-urgent emergency care was also
higher for those with well-child care (13%) than those
without well-child care (10%). Non-urgent emergency
care was significantly associated with well-child care
Research Objective: Current pedagogical philosophy is
increasingly supportive of the notion that tailoring health
communications to the needs of each individual can
enhance learning and improve comprehension of health
content. Limited research in this area has generally
indicated that the tailored approach can be successful at
engaging individuals, promoting learning and fostering
positive attitudes about behavior change. The “effects” of
tailoring health communications are based on the
premise that individualizing the approach and the
content to the individual can increase their motivation to
attend to the messages, engage in the content and
eventually engage in elaborative processing of the
information presented. The primary purpose of this study
is to develop and evaluate a Tailored Web-Based
Educational System to help middle-schoolers learn
about puberty and human sexuality. Specifically, the
study seeks to explore the following research questions:
1. What is the relationship between computer-tailoring of
online health content and elaboration and
comprehension?; 2. What variables might moderate
such an effect?
Study Design: A pretest-treatment-posttest
experimental design will be used to test differences in
the main dependent variable (comprehension) among
middle schoolers randomly assigned to each
experimental group or treatment. About 400 middle
schoolers will be randomly assigned to explore one of
three conditions: a generic site, a tailored site and a
“placebo” tailored site, in three 50-minute sessions. This
design allows us to examine the critical components as
they work together in a fully tailored website. At the end
of the trial, subjects will be given a post-test to assess
their elaboration of the content and knowledge gain and
also asked to respond to some scenario-based and
problem-solving questions to assess their
comprehension of the topic area.
Population Studied: The trial is being conducted in
Leon County middle schools (in Tallahassee, FL) using a
sample of 7th and 8th graders (13-15 year olds).
Principal Findings: This is a two-phase project: phase
1 focuses on the development of the tailoring system
and educational website, while phase 2 involves the
randomized controlled trial. We are currently pretesting
the system and should have preliminary results of the
trial by June.
Conclusions: Advances in artificial intelligence and
computing technologies has made it entirely possible to
provide personalized health education and individualized
learning on a mass scale. Interactive web technology not
only provides an opportunity to present tailored health
information in a number of formats, but it also provides
the greatest ability to toggle between modalities, further
enhancing learners’ experiences and understanding of
the material. However, development and deployment of
these types of approaches often requires a high capital
overlay or initial investment. This cost, however, is often
justified based on wide assumptions about its
effectiveness for achieving learning outcomes (e.g.,
mastery and deeper understanding of the course
material). But, while there is growing evidence about the
efficacy of computer-tailoring and adaptive learning
environments on learning, we have yet to fully
understand the mechanisms by which this affects how
individuals process information.
Implications for Policy, Delivery or Practice: Taking a
closer look at how individual users access interactive
information systems (e.g., their cognitive skills, ability to
solve problems and form searches, etc.) will have a
significant bearing on our ability to fully exploit this
technology for health education purposes.
Understanding differences in the way learners process
similar content delivered using different levels of
specificity and peripheral cue complexity (e.g., tailored
vs. generic content) will also better inform us about the
nature of tailored web-based health interventions and its
critical components and how to design adaptive
algorithms more effectively to tailor health content for
specific learners. The project is one of the first attempts
to systematically tease out the effective components of a
tailored health education website and to examine its
effects singly and in combination on the comprehension
of a complex health domain.
Funding Source(s): Florida State University Center for
Research and Creativity
™ Increase in Time Pediatric Patients Spend with
Doctors
Alicia Merline, Ph.D.; Lynn Olson, Ph.D.; William Cull,
Ph.D.
Presented by: Alicia Merline, Ph.D., Senior Research
Associate, Research, American Academy of Pediatrics,
141 Northwest Point Boulevard, Elk Grove Village, MI
60618 Phone: (847) 434-7619 Email:
amerline@aap.org
Research Objective: While length of pediatric visits to
primary care doctors increased between 1979 and 1994,
increasing productivity demands on primary care have
led many physicians to feel that insufficient time is
available during visits. Therefore, the purpose of this
research is to investigate changes in the length of
pediatric office visits to primary care doctors from 1994
to 2006 and to identify variations in visit length related to
visit characteristics.
Study Design: Nationally representative data from the
National Ambulatory Medical Care Survey (NAMCS)
from 1994-2006 were used. NAMCS samples office
visits to doctors in non-hospital, ambulatory settings.
Analyses are performed using weights to ensure that the
data accurately represent the number of ambulatory
visits in a given year. Multivariate regressions were
performed to investigate change in visit length while
controlling for visit characteristics (patient age, patient
race, insurance type, health supervision visit and
physician’s specialty).
Population Studied: The unit of analysis was visits to
primary care physicians (General Practitioners, Family
Physicians, Pediatricians and Adolescent Medicine) by
patients from birth to age 17. The number of visits per
year ranged from 1,893 (1999) to 3,657 (2002) resulting
in a total sample size of 34,074 visits.
Principal Findings: Average visit length increased 14%
from 1994 (14.2 min) to 2006 (16.4 min). The increase
was consistent and widespread; visit length increased
for all racial/ethnic groups, all age groups and for both
pediatricians and other primary care physicians. The
length of visits also varied on other key dimensions. In
2006, the average health supervision visit was 18.2 min
versus 14.4 min for all other visits, and visit length
increased with child age, ranging from 14.6 min (0 to 5
yrs) to 15.4 min (13 to 17 yrs). When visit characteristics
were controlled within a multivariate model, the increase
in visit length across time remained significant (B = 0.14,
95% CI = 0.12, 0.17).
Conclusions: Contrary to the time crunch that many
primary care clinicians report, the measured length of
pediatric primary care visits has continued to gradually
increase. The feeling of insufficient time may be a
reflection of additional time available during visits not
keeping pace with additional expectations of providers
during visits and the complexity of child needs.
Implications for Policy, Delivery or Practice: More
comprehensive measures than visit length are likely
needed to assess the pressures on visit length and the
appropriateness of time spent with clinicians during
visits.
™ Utilization of Dental Services by Children in Foster
Care in Iowa
Paul Colthirst, D.D.S., M.P.H.; Peter Damiano, D.D.S.,
M.P.H.; John Warren, D.D.S., M.S.
Presented by: Elizabeth Momany, Ph.D., Associate
Research Scientist, Public Policy Center, The University
of Iowa, 209 South Quadrangle, Iowa City, IA 52242
Phone: (319) 335-6812 Email: elizabethmomany@uiowa.edu
Research Objective: The dental literature has a
plethora of information on utilization of dental services;
however, there is very little on the utilization of dental
services by children in foster care. The aim of this study
is to(a)compare dental utilization rates for children who
are eligible for Medicaid due to income with those of
children eligible for Medicaid through foster care (b)
identify utilization rates for different placements, and (c)
identify the factors that are related to utilization of dental
services.
Study Design: Utilization of dental services was
assessed by using Iowa Medicaid dental claims for
children who were in foster care for at least 11
continuous months during calendar year 2005.
Previously published Iowa Medicaid dental utilization
rates for Medicaid income eligible children were used for
comparison. Factors including type of living situation,
age, gender, residing in a dental health profession
shortage area were studied. The dependent variable
was whether or not a child had an annual dental visit as
defined in the HEDIS 2008 specifications.
Population Studied: 2099 children who were enrolled in
Medicaid for at least 11 months and part of the Iowa
foster care program.
Principal Findings: 2099 children were included in the
study. Of these, 65% (n=1356) utilized diagnostic
services, 56% (n=1172) utilized preventive services, 6%
(n=135) utilized restorative services and 3% (n=66)
utilized complex restorative services. The rates for
treatment, restorative and complex restorative care were
lower than has been found in our previous work with
children enrolled in an income eligible category in
Medicaid. Regressions analysis indicated that children
living in group care on average had higher utilization
rates. Age, gender, placement and living in a dental
Health Professional Shortage Area were all factors that
were related to dental services utilization for children in
foster care.
Conclusions: The overall utilization of dental services
by children in foster care was positive when compared to
utilization rates of income eligible children on Medicaid;
however, further research is needed in this area in order
to facilitate greater utilization of dental services for foster
care children. Most importantly, the pattern for dental
care among foster children is opposite that for other
children. In most instances the proportion of children
with an annual dental visit goes down as children age,
however in the foster care group the rate increased with
age. In addition, though foster children are more likely to
experience primary access with a diagnostic or
preventive visit they are less likely to experience
secondary access in the form of restorative or complex
restorative treatment.
Implications for Policy, Delivery or Practice: These
data indicate that foster children living in a dental health
profession shortage area are less likely to obtain dental
care than others. Once again the need for health
professionals to provide services is highlighted leading
us to a discussion of the methods for recruiting and
retaining dentists.
™ Evaluation of Health Plans’ HEDIS Measures by
Ethnicity, Language & Geographic Region for
California’s SCHIP (Healthy Families Program)
Muhammad Nawaz, Ph.D; Mary Watanabe, B.A.; Shelly
Rouillard, B.A.
Presented by: Muhammad Nawaz, Ph.D, Research
Manager II, California Managed Risk Medical Insurance
Board, California Managed Risk Medical Insurance
Board, 1000 G Street, Sacramento, CA 95814 Phone:
(916) 324-7444 Email: mnawaz@mrmib.ca.gov
Research Objective: Comparative evaluation of the
quality of care provided to Healthy Families Program
(HFP) children by 24 managed health care plans and to
examine the differences between ethnicity, language
and geographic regions for 12 Healthcare Effectiveness
Data and Information Set (HEDIS) measures.
Study Design: The California Managed Risk Medical
Insurance Board (MRMIB) analyzed data for 12 HEDIS
measures using Proc Logistic, Proc Multtest, CA test,
Bonferroni’s Method and Contrast Statement tests in
SAS.
Population Studied: Data from 24 health plans for 12
HEDIS measures collected by administrative and hybrid
methods following the National Committee for Quality
Assurance (NCQA) guidelines were used. Nearly
700,000 HFP children under 19 years of age were
included in this study. HFP is California’s State
Children’s Health Insurance Program (SCHIP) and is the
largest SCHIP in the country.
Principal Findings: The percentage rates for Childhood
Immunization Combination 3, Well-Child Visits in the
First 15 Months of Life and, Adolescent Well Care Visits
improved by at least 3% from 2006. However, average
percentages for 4 measures remained the same or
showed slight improvements. The HFP averages for
Childhood Immunization, Well-Child Visits and Access to
Primary Care Practitioners exceeded the national
Medicaid average, whereas the averages for Well-Child
Visits exceeded the national Commercial average. The
Adolescent Well-Care Visits averages increased by 4%
and 7% from 2006 and 2005, respectively. Significant*
improvements of 6% from 2006 and 23% from 2005
were observed in the number of children that received all
of the recommended Combination 3 vaccinations.
Demographic analysis revealed that Chinese speaking
children received child immunization and Well Child
Visits at the highest rates (89% and 67%, respectively),
while English speaking children had the lowest rates of
78% and 51% in the same measures. In ethnic
comparisons, African American, Asian/Pacific Islander
and Hispanic children received the highest rates child
immunizations (85%, 82% and 82%, respectively)
compared to White children who received the lowest
(71%). Similarly, Asian/Pacific Islander children had the
highest rates of Well Child Visits at 58% compared to
49% for Whites. Comparison between regions showed
that the Bay Area region had 85% child immunization
rates compared to 69% for Northern and 78% for Los
Angeles regions. Similarly, the Bay Area had
significantly* higher (66%) rates of Well Child Visits
compared to 54% for the Los Angeles region. Among
gender, males received all recommended visits and
Adolescent Well-Care Visits at a higher rate than
females. However, males over age 16 received a wellcare visit at a significantly* lower rate than females.
MRMIB also studied three new measures introduced in
2007: Appropriate Treatment for Children with Upper
Respiratory Infections, Appropriate Testing for
Pharyngitis, and Chlamydia Screening. Significant*
differences were observed for all three new measures
across ethnicity, language and geographic regions.
Chlamydia Screening was highest for African American,
English speakers and Bay Area children (58%, 41%, and
52%, respectively) compared to 36% Whites, 29%
Chinese speakers, and 29% for Northern region. For
ranking, health plans were evaluated relative to the HFP
average by assessing 12 individual HEDIS measures
and by combining these measures into to a single
cumulative HEDIS measure using cluster analysis.
Based on this analysis, Alameda Alliance for Health,
Kaiser Permanente North and Central Coast Alliance for
Health were up to 20% superior to other health plans for
the cumulative HEDIS performance measure. *(p<.01)
Conclusions: HFP children received the recommended
services at a rate that is higher than the national
Medicaid average and close to national Commercial
averages. The percentage of cumulative measure varied
from 56% for poor cluster to 78% for the superior cluster.
Implications for Policy, Delivery or Practice:
Significant differences observed across ethnicity,
language, and geographic regions suggest more
research is needed to establish whether true disparities
in the quality of care exist or whether the differences are
due to cultural factors, access, or other
™ Quality of Care & Pediatric Nonurgent Emergency
Department Utilization: A Qualitative Analysis
Mark Nimmer, B.A., David Brousseau, M.D., M.S.;
Nichole Yunk, B.A.
Presented by: Mark Nimmer, B.A., Clinical Research
Assistant II, Pediatrics, Medical College of Wisconsin,
999 North 92nd Street, Milwaukee, WI 53226 Phone:
(414) 337-7184 Email: mnimmer@mcw.edu
Research Objective: Previous research has shown that
parents often bring their children to the emergency
department for nonurgent care because of primary care
referrals and perceived emergency department
convenience. We sought to explore, through in-depth
narratives, additional and underlying motivations for
parents to bring their children to the emergency
department for nonurgent conditions.
Study Design: Purposeful sampling was used to select
participants with both high and low parent reported
quality of primary care. Two domains of care were
analyzed: family-centeredness and timeliness. Parent
narratives were obtained through semi-structured
interviews for all events that preceded the decision to
seek emergency department care. Parents were also
asked to describe their child’s physician practice and
past experiences with the physician’s office. Transcribed
interviews were coded with the aid of qualitative software
and analyzed for patterns related to quality of primary
care.
Population Studied: Parents of children presenting to
the emergency department who were triaged at the
lowest of five acuity levels were sampled based on high
versus low parent reported quality of primary care.
Twenty-five eligible parents agreed to be interviewed at
a later date.
Principal Findings: All but three parents whose primary
physicians scored high on family-centeredness called a
medical professional and were referred to the
emergency department. Five of the referrals were
physician referrals, five were nurse referrals, and one
was an office staff referral. Primary physician expertise
was a decision-making factor for five parents who
reported low family-centeredness, with four of those five
stating there was no reason to call because they were
coming to the emergency department anyway. Many
parents reported that long delays in the availability of a
primary care visit were responsible for their emergency
department visits, including a lack of calling for advice
prior to seeking emergency department care. Nine visits
occurred outside of regular office hours, but only three of
these visits were by parents who reported low quality
family-centeredness.
Conclusions: Families with physicians having high
family-centeredness ratings seem to have different
reasons for seeking emergency department care than
those with low physician ratings. Primary care referrals
and after hours care most often explained visits among
parents reporting high family-centeredness while poor
physician expertise occurred more often than any other
theme among parents reporting low familycenteredness. Further exploration of the results revealed
that primary care referrals often include not only
physician referrals, but also nurse and office staff
referrals.
Implications for Policy, Delivery or Practice: The
reasons for nonurgent pediatric emergency department
utilization vary by perceived quality of primary care.
Emergency department referrals might be reduced by
educating office staff on appropriate criterion for referral
or having physicians screen referrals made by office
staff. Extra efforts by physicians to build and maintain
trust during well-child visits may also lead more parents
to contact their physicians prior to visiting the emergency
department. Blocking more time for acute care
appointments may also reduce nonurgent emergency
visits for parents who reported scheduling frustrations.
Regarding after hours care, a better explanation from the
primary physician of why a situation is nonurgent may
make parents with high family-centeredness ratings
more willing to wait and schedule an appointment.
Funding Source(s): Agency for Healthcare Research
and Quality
™ A Systematic Review of Maternal & Child Health
Outcomes for Community Health Workers
Interventions
Brett Nishikawa, M.D.; Meera Viswanathan, Ph.D.;
Jennifer Kraschnewski, M.D.; Laura Morgan, M.A.;
Patricia Thieda, M.A.; Dan Jonas, M.D., M.P.H.
Presented by: Brett Nishikawa, M.D., Chief Resident,
Preventive Medicine, University of North Carolina at
Chapel Hill, MacNider, CB #7240, Chapel Hill, NC 27599
Phone: (919) 843-8077 Email:
brett.nishikawa@unc.edu
Research Objective: Community health workers
(CHWs) can serve as a bridge to the health care system
for maternal and child health care needs. We aimed to
conduct a systematic review of the effectiveness of CHW
interventions in the areas of maternal and child health.
Study Design: We conducted a systematic review using
standard Evidence-based Practice Center methods. We
searched Medline, the Cochrane Database, and CINAHL
from their inception through October 2008 using a
variety of terms for CHWs. We included studies with a
comparison group that were conducted in the United
States, published in English, with at least 40 participants.
Two reviewers independently assessed each abstract
and full-text article for inclusion, resolving disagreements
by consensus. One reviewer abstracted data onto a
standard form; a second reviewer checked for
completeness and accuracy. Trained reviewers
abstracted data and assessed the methodologic quality
of studies using predefined criteria from international
standards.
Population Studied: Studies that primarily involved
interventions targeted toward pregnant women and/or
children were selected for the maternal and child health
subset of this systematic review. Of 992 abstracts we
identified, 17 studies meeting our inclusion criteria
involved primarily maternal and/or child health. Of these,
12 focused exclusively on potentially vulnerable
populations (e.g., racial or ethnic minorities, recent
immigrants, low income families, inner city residents).
Another three targeted families identified as high risk for
child maltreatment. Pregnant women were part of the
target population for 8 studies. One study each
addressed pregnant women with phenylketonuria (PKU),
children with failure to thrive, and children with “chronic
disease” (not otherwise characterized).
Principal Findings: Outcome measures assessed in
the studies included adequacy of prenatal care, birth
outcomes including incidence of low birth weight and
very low birth weight, breastfeeding initiation and
continuation, and presence of neonatal health problems.
Child development was frequently considered among
outcomes, e.g., cognitive development, language
development, and physical growth. Many of the
measured outcomes involved factors that could
contribute to childhood health and well-being. Among
these outcomes were environmental tobacco exposure,
incidence of child maltreatment, parent-child interaction,
assessments of appropriateness of home environment
for child development, and parental stress or psychiatric
well-being. Preliminary results indicate a wide range of
effectiveness to CHW interventions without a clearly
discernable pattern emerging to determine which
interventions or population types would be most
effectively served by CHWs.
Conclusions: Most studies involving CHWs for maternal
and child health have been concerned with high-risk
populations. For maternal and child health, the evidence
on CHW interventions appears to be most consistent
when addressing existing health conditions instead of
potential conditions, i.e., primary prevention. A minority
of the studies evaluated reported statistically significant
results, suggesting a paucity of evidence from which to
draw further conclusions.
Implications for Policy, Delivery or Practice: The
evidence for effectiveness of community health workers
in improving key health outcomes relating to maternal
and child health such as prematurity, low birth weight,
sustained breastfeeding, or child maltreatment remains
unclear. The lack of such findings suggests that further
research is needed to determine true benefit.
Funding Source(s): AHRQ
™ Oral Health Screening Among Pediatricians: A
National Study
Karen O'Connor; Suzanne Boulter, M.D.; Martha Ann
Keels, D.D.S., Ph.D.; David Krol, M.D., M.P.H.; Charlotte
Lewis, M.D., M.P.H.; Wendy Mouradian, M.D., MS
Presented by: Karen O'Connor, Survey Manager,
Research, American Academy of Pediatrics, 141
Northwest Point Boulevard, Elk Grove Village, IL 600071098 Phone: (847) 434-7630 Email: koconnor@aap.org
Research Objective: To assess pediatricians’ attitudes
and current practices regarding oral health (OH)
assessment and counseling.
Study Design: A national random sample, mailed
Periodic Survey of Fellows conducted by the American
Academy of Pediatrics (AAP) in 2008 (N=1618;
response=68%). Questions assessed pediatricians’
practices regarding oral health assessment, counseling
and referrals among patients birth to 3 years of age, as
well as barriers to providing and patients’ obtaining oral
health care.
Population Studied: 698 nonretired, United States
members of the AAP who provide health supervision.
Principal Findings: About one-half of pediatricians
(54%) report assessing the majority (>50%) of their
patients birth to 3 years of age for dental caries and 25%
say they screen for plaque. Nearly all (91%) agree they
should assess for dental caries and 65% so agree for
plaque, however, only 41% and 23%, respectively, rate
their ability to identify these conditions as very good or
excellent. A large majority of pediatricians say they
inform parents on the OH effects of putting their child to
bed with a bottle (82%) and on sugary food/drink (77%),
and 52% inform parents on how to brush their child’s
teeth. More than 8 out of 10 believe pediatricians should
provide this information and 89%, 83% and 52%,
respectively, are confident in their ability to do so. Only
4% of pediatricians report they or their staff apply
fluoride varnish to a majority of young patients; 19%
believe pediatricians should perform this task while only
8% are confident in their ability to do so. Fewer than
one-fifth (17%) of pediatricians think children should
have their first dental visit by 1 year of age. The most
frequently named barriers to very young patients
obtaining care from a dentist include a perceived lack of
dentists who accept Medicaid/SCHIP health insurance
(74% reporting), patients’ lack of dental
insurance/inability to pay for care (72%) and parents not
perceiving dental visits as necessary for children < 3
years old (52%). Many pediatricians named the lack of
professional training in OH care (41%), inadequate time
during health supervision visits (35%) and lack of ability
to bill separately for OH assessments or counseling on
preventive oral hygiene (34%) as moderate to significant
barriers to providing OH preventive care.
Conclusions: Provision of OH screening varies among
pediatricians by specific task. Most pediatricians believe
they should perform OH assessments/counseling yet
few are confident in their ability to perform more specific
screening tasks. Many pediatricians identified their lack
of professional education as a barrier to OH screening;
they also identified payment issues and parent
misinformation regarding the need for dental visits as
barriers to very young children receiving care.
Implications for Policy, Delivery or Practice: Dental
caries is the most common childhood disease, with
increased rates of disease among the youngest age
group. With frequent health supervision visits among
children 0-3 years, pediatricians potentially are in a
unique position to provide OH preventive services.
Continued educational efforts in OH
assessment/counseling and the benefits of early age
screening, as well as adequate
financing/reimbursement, may help assure the
preventive oral health needs of very young patients are
met.
Funding Source(s): HRSA
™ Stakeholder Attitudes Towards Influenza
Vaccination Policy in the U.S.
Pamela Protzel Berman, M.P.H.;Walter Orenstein, M.D.;
Alan Hinman, M.D., M.P.H.; Julie Gazmararian, M.P.H.,
Ph.D.
Presented by: Pamela Protzel Berman, M.P.H., Ph.D.
Candidate, Associate Director for Program Development
& Integration, CDC, Division of Cancer Prevention and
Control, MS K-52, 4770 Buford Highway, NE, Atlanta,
GA 30341 Phone: (770) 488-3016 Email:
pxp5@cdc.gov
Research Objective: There is growing interest in
simplifying influenza recommendations to include all
Americans. The benefits of universal vaccination have
been well documented (Jordan et al., 2006; Mair, Grow,
Mair, & Radonovich, 2006). Universal vaccination might
reduce the serious morbidity and mortality due to
influenza in high risk persons, provide personal and
societal benefits to all who are vaccinated and promote
better pandemic preparedness due to expanded
capacity for vaccine production and improved
infrastructure for vaccine delivery. A growing body of
literature supports universal vaccination of children as a
way to reduce the spread of influenza in households and
communities (King et al., 2006; Monto, Davenport,
Napier, & Francis, 1970; Piedra et al., 2005; Reichert et
al., 2001). As a result of this, the Advisory Committee
on Immunization Practices (ACIP) voted to expand the
recommended ages for annual vaccination of children to
include all children from 6 months through 18 years of
age (CDC, 2008). Increased focus on children can
provide a platform for future vaccination as adults. In
addition, a change in vaccination policy for children is
seen as a stepwise approach to universal vaccination,
allowing for steady growth in vaccine infrastructure and
an opportunity to document the protection afforded
others from universal childhood vaccination. Challenges
remain, however, to achieving universal vaccination and
to overcoming issues related to vaccination of children
through age 18.
Study Design: To better understand the potential
barriers to policy change and implementation, interviews
with 35 stakeholders from the medical, public health,
educational, insurance and vaccine industry sectors
were conducted. Interviewees were asked about
attitudes toward current and future influenza vaccination
policy and potential barriers to policy change.
Population Studied: Key stakeholders from the
medical, public health, educational, insurance and
vaccine industry.
Principal Findings: Over 97% of respondents
supported the expansion of vaccination for all schoolage children. Roughly 95% supported universal
vaccination, but despite the level of support for this
policy change, respondents raised reservations. Issues
related to financial and human resources are major
challenges that could impede further policy change and
implementation of universal vaccination. School
representatives were hesitant about implementation of
vaccination programs in schools given resource
constraints and competing agendas.
Conclusions: Coalition building to facilitate
implementation should include more non-traditional
partners in the education and insurance communities, in
addition to the essential stakeholders in the healthcare
and public health disciplines. This study further clarifies
the policy issues ahead, particularly the need to address
policies which guide the implementation of universal
childhood vaccination. The findings point out the need
for more in depth studies on how to overcome the
barriers identified by stakeholders essential to
vaccination policy implementation.
Implications for Policy, Delivery or Practice:
Policymakers and practitioners could use the results of
the study as they consider further changes to U.S.
vaccination policy.
Funding Source(s): NIAID
™ Parent Perspectives on Immunization Messages
Linda Radecki, M.S.; Lynn Olson, Ph.D.; Mary Pat
Frintner, M.S.P.H.
Presented by: Linda Radecki, M.S., Senior Research
Associate, Research, American Academy of Pediatrics,
141 Northwest Point Boulevard, Elk Grove Village, IL
60007 Phone: (847) 434-7625 Email:
LRadecki@aap.org
Research Objective: Amid increasing questions from
parents regarding immunizations, pediatric professionals
seek to best address families’ needs for guidance and
information. Little is known about parent preferences for
communication about immunizations. This study
examines parent perspectives on vaccine promotion
messages.
Study Design: Three focus groups targeted to middleclass families were conducted to gather in-depth
feedback on different types of immunization messages.
Parents were asked to review and rank order 5
messages. Discussion followed, facilitated by a standard
list of questions to elicit reactions (positive and negative)
to each message and ideas to make statements more
meaningful. Sessions were recorded and transcribed for
review of key themes. Based on the primary theme
conveyed, messages were categorized as scientific and
emotional for analyses.
Population Studied: Parents of children age =36
months were recruited through flyers distributed to day
care facilities, libraries, and parent groups. 23 mothers, 1
father participated. The sample was largely white (88%)
and educated (88% =4-yr college degree). 50% were
first-time parents. Most children saw a pediatrician for
well-child care. All children had received some or all
recommended vaccines, though many parents
expressed concerns about safety and the schedule.
Several had delayed some vaccines. Parents of children
age =36 months were recruited through flyers distributed
to day care facilities, libraries, and parent groups. 23
mothers, 1 father participated. The sample was largely
white (88%) and educated (88% =4-yr college degree).
50% were first-time parents. Most children saw a
pediatrician for well-child care. All children had received
some or all recommended vaccines, though many
parents expressed concerns about safety and the
schedule. Several had delayed some vaccines.
Principal Findings: Scientific messages – Two
statements addressed autism and concern about
vaccine overload. Parents valued an emphasis on
scientific studies but requested further supporting
evidence to make the statement more meaningful.
“…where’s the proof in that? …who said that?” “…I want
to know what those studies are. Where can I find them?
Where can I read them and why should I value those
studies above others?” “…to me, facts are more
important than emotions…I’d rather hear ‘we did a
study…and this is what turned out…” “It doesn’t give you
‘why’ – why is timing so important? I’ve never
understood that.” Emotional messages – Generally,
parents rejected perceived use of fear or guilt to promote
immunization. Statements encouraging vaccination to
prevent illness or death were viewed negatively by
almost all participants. “I thought it was alarmist and
negative…that might turn people off.” “You’re playing on
fears.” “…messages about kids should be more positive
for parents…” Parents valued messages that created a
personal connection or could be used to facilitate further
discussion. “…makes you feel like you and your
pediatrician make the decision….” “I think this opens up
communication with your doctor…maybe it needs
something in there about ‘Talk to your doctor about
making the choice that’s right for your child’…”
Conclusions: Regardless of theme, messages that
lacked in substantive/scientific explanation or evoked
parental fear or guilt were generally viewed unfavorably.
Participants affirmed statements that respect them as
parents and acknowledge their concerns in a
nonthreatening way. Feedback suggests that families
value messages that provide explanation from trusted
sources, with appropriately tailored evidence and
supporting information.
Implications for Policy, Delivery or Practice: While
the large majority of US parents continue to vaccinate
their children, many likely have questions and concerns
about vaccines. Understanding parents’ perspectives
and developing messages and materials to address their
concerns is critical to assure public trust and support for
immunizations. Ongoing research with multiple
populations will be valuable.
Funding Source(s): American Academy of Pediatrics
™ Barriers to Care Prospectively Predict Primary
Care Characteristics for Vulnerable Children with
Asthma
Lisa Opipari-Arrigan, Ph.D.; Adam Carle, Ph.D.; Michael
Seid, Ph.D.
Presented by: Michael Seid, Ph.D., Director, Health
Outcomes and Quality of Care Research and Professor
of Pediatrics, Pulmonary Medicine and Center for Health
Care Quality, Cincinnati Children's Hospital Medical
Center, 3333 Burnet Avenue, MLC 7014, Cincinnati, OH
45229 Phone: (513) 803-0083 Email:
Michael.Seid@cchmc.org
Research Objective: We sought to test the following
two hypotheses in a sample of vulnerable children with
asthma. 1) Barriers to care would prospectively predict
primary care experiences after accounting for
demographic characteristics, disease severity and
financial, potential and realized access. 2) Barriers
related to the process of care would account for more
variance in primary care experiences than barriers
related to accessing care.
Study Design: Bilingual, bicultural interviewers
administered surveys in participants’ homes at baseline,
3-month and 9-month follow-up. Validated instruments
were used to measure barriers to care (Barriers to Care
Questionnaire) and primary care experiences (Parent’s
Perceptions of Primary Care measure).
Population Studied: Children (n = 252; ages 2-14
years) with persistent asthma and their parents (83%
Hispanic, 56.6% monolingual Spanish; 72.6% mother
had less than a high school diploma) were recruited
primarily from urban, Federally Qualified Health Centers.
Asthma severity was 27% mild persistent, 40.9%
moderate persistent, and 32.1% severe persistent. At
baseline, most children (68.7%) had health insurance
(financial access), an identified primary care provider
(91.7%) (potential access) and had not experienced
forgone care (79.8%) (realized access).
Principal Findings: Consistent with our first hypothesis,
generalized estimating equations accounting for the
repeated measures over time showed that fewer barriers
to care (Barriers to Care Questionnaire) prospectively
predicted better primary care experiences (Parents
Perceptions of Primary Care), after controlling for
demographics, disease severity, and financial, potential
and realized access (p < .001). While having insurance
(standardized beta = -.12) and an identified care
provider (standardized beta = -.18) did significantly
predict better primary care experiences; barriers to care
(standardized beta = .47) accounted for the most
variance in outcome. In terms of unstandardized
regression coefficients, a 1-point change on the Barriers
to Care Questionnaire predicted a .69-point change in
Parent’s Perceptions of Primary Care. Consistent with
our second hypothesis, fewer process of care barriers (p
< .001), but not access barriers (p = NS), predicted
better primary care experiences after controlling for,
demographics, disease severity and financial, potential
and realized access. A 1-point change in process of
care barriers predicted a .60-point change in Parent’s
Perceptions of Primary Care.
Conclusions: For vulnerable children with asthma,
barriers to care prospectively predict primary care
experiences after accounting for demographic factors,
disease severity and financial, potential and realized
access. Furthermore, barriers related to the process of
care as opposed to those related to accessing care, are
central in predicting primary care experiences overtime.
Implications for Policy, Delivery or Practice: Primary
care is important, especially for children with special
health care needs. These findings offer insight into how
and why disparities in primary care experiences develop.
As barriers are clearly modifiable, these findings can be
used to inform practice and policy interventions designed
to reduce health care disparities among vulnerable
children with asthma. While access to care is
necessary, it is not sufficient. Barriers in the actual
delivery of care are important to address.
Funding Source(s): HRSA
The Role of Parent Health Literacy Among Urban
Children with Persistent Asthma
Laura Shone, Dr.P.H., M.S.W.; Kelly Conn, M.P.H.; Lee
Sanders, M.D., M.P.H.; Jill Halterman, M.D., M.P.H.
Presented by: Laura Shone, Dr.P.H., M.S.W., Assistant
Professor, Pediatrics, University of Rochester School of
Medicine & Dentistry, 601 Elmwood Avenue, Box 777,
Rochester, NY 14642 Phone: (585) 273-4084 Email:
laura_shone@urmc.rochester.edu
Research Objective: Health literacy (HL) affects adult
asthma management, yet less is known about how
parent HL affects child asthma care. Our objective was
to examine associations between parent HL and
measures related to child asthma.
Study Design: We performed secondary analyses of
baseline data from the School Based Asthma Therapy
randomized trial. Data were collected via school health
forms and structured in-home interviews. Measures
included the Rapid Estimate of Adult Literacy in
Medicine for parent HL; NHLBI criteria for asthma
severity, and validated measures of asthma knowledge,
beliefs, and experiences. We conducted bivariate and
multivariate analyses of associations between parent HL
and measures related to child asthma.
Population Studied: Parents of 499 pre-school and
school-age urban children with persistent asthma in
Rochester, New York.
Principal Findings: Our response rate was 72% and
mean child age was 7.0 years (range 3-10 years). Thirtytwo percent had a Hispanic parent; 88% had public
insurance. Thirty-three percent had parents with limited
HL. Low parent HL was independently associated with
greater parent worry parent perception of greater asthma
burden, and lower parent-reported quality of life.
Measures of health care use (e.g., emergency care,
preventive medicines) were not associated with parent
HL.
Conclusions: Parents with limited HL worried more and
perceived greater overall burden from the child’s
asthma, even though reported health care use did not
vary.
Implications for Policy, Delivery or Practice:
Improved parent understanding and provider-parent
communication about child asthma could reduce parentperceived asthma burden, alleviate parent worry, and
improve parent quality of life.
Funding Source(s): National Heart, Lung, and Blood
Institute; Centers for Disease Control and Prevention,
Office of the Director
™ Unexpected Differences in the Dietary Intakes of
Obese, Overweight, and Healthy Weight
Adolescents: Implications for Obesity Interventions
Asheley Cockrell Skinner, Ph.D.; Eliana Perrin, M.D.,
M.P.H.; Suzanne Havala Hobbs, Dr.P.H., M.S., R.D.
Presented by: Asheley Cockrell Skinner, Ph.D.,
Postdoctoral Fellow, Healthy Policy and Management,
University of North Carolina at Chapel Hill, CB 7411,
Chapel Hill, NC 27599 Phone: (919) 966-6394 Email:
asheley@unc.edu
Research Objective: Attempts to reduce weight in
obese children through dietary interventions have
yielded little to no sustained success. There is little
previous research on the dietary consumption
differences between obese and healthy weight children,
though a few small studies report obese children
consume no more or only slightly more. In order to
develop and promote public health and clinical
recommendations, we need data demonstrating how
diets of obese and healthy weight children differ.
Study Design: We analyzed data from six years (20012006) of repeated cross-sections from the National
Health and Nutrition Examination Survey (NHANES).
Measured height and weight were used to calculate BMI
percentile and categorize weight status according to
accepted standards: >=95th percentile were obese;
>=85th & <95th percentile were overweight; and <85th
and >5% percentile were healthy weight. Food intake
was collected using the Automated Multiple Pass
Method (AMPM), which involves a computer-assisted
interview with multiple food-specific questions, and a
collection of measuring devices to help participants
estimate portion sizes. This method has been repeatedly
validated and prior research has indicated weight-related
reporting bias is unlikely in this sample. Dietary
information about the foods consumed was then
determined based on the Food and Nutrient Database
for Dietary Surveys. “Adequate intake” of calories and
micronutrients was based on current Dietary Reference
Intakes. We use adjusted Wald tests to compare
nutrition intake differences by weight status. We then
used multiple logistic or ordinary least squares
regression as appropriate to control for age, sex,
income, race, ethnicity, and insurance status.
Population Studied: Adolescents aged 12-17 years in
NHANES (2001-2006).
Principal Findings: Obese adolescents reported
consuming fewer total calories than either overweight or
healthy weight adolescents (2028 vs. 2175 vs. 2373
kcal, p<0.001). Additionally, obese adolescents are more
likely than overweight or healthy weight adolescents to
have inadequate caloric intake (27% vs. 18% vs. 16%,
p<0.001), as well as inadequate intake of fiber, most B
vitamins, calcium, phosphorous, iron, zinc, and sodium
(all p<0.01). These differences persisted in multivariate
analyses.
Conclusions: Our findings challenge the prevailing
wisdom that overweight and obese adolescents eat
significantly more than healthy weight adolescents, and
indicate they actually likely consume less food than their
healthy weight counterparts. Of additional concern is
that obese children may be at greater risk for nutrient
deficiencies than healthy weight children. Our results
suggest weight differences may be more related to
variations in activity levels or metabolism than dietary
differences.
Implications for Policy, Delivery or Practice: Although
improving dietary habits in all children is a worthy goal,
obesity interventions focusing on dietary changes may
be asking children who are already eating less than their
peers to restrict consumption further. In doing so, we
may be placing them at risk of dietary deficiencies as
well as risking significant unintended consequences,
including negative effects on self-esteem, mental health,
and physical health. Our findings suggest that dietary
advice needs to be carefully planned and individualized.
It is possible that weight loss may be more appropriately
targeted by physical activity than by calorie restriction.
Funding Source(s): NINR & NICHD
™ BMI versus BMI Percentile to Estimate
Cardiovascular Risk Factors in Children
Asheley Cockrell Skinner, Ph.D.; Michael Steiner, M.D.;
Frederick Henderson, M.D.; Eliana Perrin, M.D., M.P.H.
Presented by: Asheley Cockrell Skinner, Ph.D.,
Postdoctoral Fellow, Healthy Policy and Management,
University of North Carolina at Chapel Hill, CB 7411,
Chapel Hill, NC 27599 Phone: (919) 966-6394 Email:
asheley@unc.edu
Research Objective: Interventions to improve weight
and health in children use BMI percentile cut-offs to
identify which children are overweight or obese and thus
at risk for future weight-related health problems.
However, the absolute BMI value corresponding to a
given BMI percentile changes dramatically through
childhood. Because the BMI percentile cutoffs are
based on historical distributions, not the current
population, children of different ages classified as obese
using BMI percentile vary in their actual adiposity and
cardiovascular (CV) risk factors. We examined the
relative strength of associations between CV risk factors
and both BMI percentile or absolute BMI in order to
determine which best identifies children at risk for future
weight-related health problems.
Study Design: We performed a cross-sectional analysis
of eight years of the National Health and Nutrition
Examination Survey, 1999-2006. Measured height and
weight were used to determine absolute BMI and ageand sex-specific BMI percentiles according to CDC
growth charts. CV risk factors included were total
cholesterol, HDL, LDL, triglycerides, blood pressure and
a marker of inflammation, C-reactive protein (CRP).
Ordinary least squares regression was used to compare
the relationships between log-adjusted, standardized
values for risk factors, BMI, and BMI percentiles,
controlling for race/ethnicity and income. We then used
adjusted Wald tests for differences in the magnitude of
the coefficients relating CV risk factors and either 95%
BMI or absolute BMI cutoffs across different ages.
Population Studied: Children ages 2-17 years in
NHANES.
Principal Findings: The mean BMI in the sample was
19.8 and mean BMI percentile was 63.9 (N=13,328).
Absolute BMI was more strongly related than BMI
percentile to HDL (b=-0.33 vs. b=-0.21, p<0.001),
triglycerides (b=0.25 vs. b=0.14, p<0.001), and CRP
(b=0.43 vs. b=0.28, p<0.001), but there were no
significant differences for total cholesterol, LDL, or blood
pressure. The risk for abnormal CV risk factors using
BMI percentile increased with age in every measure.
However, an absolute BMI value was associated with
more consistent risk of abnormal results regardless of
patient age.
Conclusions: Absolute BMI is a stronger and more
consistent predictor of abnormal CV risk factors across
different ages than is BMI percentile. This could be due
to clustering of an increasingly heterogeneous group of
obese children above the 95% BMI, while absolute BMI
values allow for a continuous distribution. Alternatively,
CV risk factors may be dependent on absolute fat mass,
which is more consistently reflected by actual BMI
instead of BMI percentile.
Implications for Policy, Delivery or Practice: While
BMI percentile predicts future weight, absolute BMI is
more strongly associated with the current presence of
abnormal cardiovascular (CV) risk factors. Clinical
practice and public health interventions aimed at
identifying and treating the negative health effects of
obesity will require consideration of actual BMI in
addition to percentile-based obesity definitions. Further
research is needed to clarify the best use of the two
measures to identify children most likely to develop
clinically-significant CV disease.
Funding Source(s): NINR & NICHD
™ Why Do Children with ADHD Discontinue Their
Medication?
Sara Toomey, M.D., M.P.H., M.Phil., M.Sc.; Colin Sox,
M.D., M.P.H.; Donna Rusinak; Jonathan Finkelstein,
M.D., M.P.H.
Presented by: Sara Toomey, M.D., M.P.H., M.Phil.,
M.Sc., Pediatric Health Services Research Fellow,
Department of Ambulatory Care and Prevention,
Harvard Medical School, 33 Inman Street, #3,
Cambridge, MA 02139 Phone: (617) 509-9320 Email:
sara.toomey@childrens.harvard.edu
Research Objective: The aim of our study was to
identify factors associated with parents’ self-reported
discontinuation of medication for children with ADHD.
Study Design: We conducted a telephone survey of
parents of children with ADHD who recently initiated
ADHD medication. Survey domains included our primary
domain of interest, self-reported reasons for
discontinuation or continuation, and also the following:
(1) ADHD characteristics; (2) pattern of medication use;
(3) parental understanding of and beliefs about ADHD;
and (4) satisfaction with ADHD care.
Population Studied: This study included 127 parents
(42.5% response rate) of children with ADHD ages 6-18
who had recently initiated ADHD medication and were
insured by Harvard Pilgrim Health Care. 77% were male
and 87% were White/Non-Hispanic. 45% were between
the ages of 6-11. 33% had a family income = $50,000.
Principal Findings: 21% of parents discontinued their
child’s ADHD medication. Of those who discontinued,
42% did so within 1 month of initiation, 33% within 2-3
months, 21% within 4-6 months and 4% in greater than 6
months. 71% of all participants reported side effects to
ADHD medication. In comparison to those who
continued medication, significantly more children who
discontinued medication reported side effects (92% vs.
65%, p=.007) and reported the side effects to be severe
or very severe (52% vs. 14%, p=.002). Children who
discontinued were also less likely to report that the
medication worked very well (13% vs. 62%, p<.001). No
difference was detected in characteristics of care except
that discontinuers were less likely to have discussed the
risks and benefits of medication use with their primary
care providers (23% vs. 48%, p=.04). Parents of children
who discontinued ADHD medication were more likely to
agree that ADHD is best treated with counseling (44%
vs. 22%, p=.05) and that ADHD medications have “bad”
side effects (69% vs. 35%, p=.03). No difference in
satisfaction with ADHD care was found between the
parents of discontinuers and continuers. Multivariate
models showed that perceptions of both side effects and
medication effectiveness are associated with
discontinuation.
Conclusions: A significant proportion of children with
ADHD who initiate medication discontinue. Parents who
discontinue their children’s ADHD medication more often
report side effects and lack of effectiveness of
medication.
Implications for Policy, Delivery or Practice:
Discontinuation of ADHD medication is common and is
likely responsible for significant unnecessary morbidity.
To improve adherence to medication, improved systems
for early identification and management of side effects,
setting realistic medication goals, and assessing
therapeutic success are needed in primary care.
Funding Source(s): Harvard Pilgrim Health Care
Foundation
™ Coordinating and Integrating Behavioral Health
with Child Welfare in Florida: Process and Impact
Amy Vargo, M.A.; Patty Sharrock, M.S.W.; Patricia
Robinson, Ph.D.; Roger Boothroyd, Ph.D.
Presented by: Amy Vargo, M.A., Faculty, Child &
Family Studies, Florida Mental Health Institute, 13301
Bruce B. Downs Boulevard, MHC 2413, Tampa, FL
33612 Phone: (813) 974-5356 Email:
avargo@fmhi.usf.edu
Research Objective: Given the high rate of trauma and
corresponding mental health needs among foster
children, access to behavioral health services is critical.
Challenges to meeting the needs of children and families
involved with the child welfare system have been
associated with the lack of formal policies to provide
behavioral health services, the lack of timely
assessment, and failure to communicate with multiple
providers and caretakers. Although managed care
systems have been devised to improve health care
services by emphasizing primary and preventative care
and system coordination, conflicts among the various
child welfare and behavioral health managed care
stakeholders can interfere with mental health service
delivery.
Study Design: The Florida Mental Health Institute at the
University of South Florida is funded by the Agency for
Health Care Administration to conduct an independent
evaluation of the CW-PMHP. The overall purpose of the
CW-PMHP Evaluation is to determine the extent to
which the mental health service needs of children in
Florida's child welfare system are being met by the CWPMHP. In addition to examining the experiences of
consumers and providers, it is important to understand
the contextual and organizational features of the Child
Welfare Prepaid Mental Health Plan (CW-PMHP)
through an investigation of the features of its
implementation. Therefore, the evaluation consists of
two components: 1) an implementation/process analysis
examining the financial, structural, and clinical aspects of
the carve out program; and 2) a quality of care/impact
analysis utilizing semi-structured interviews and focus
groups with parents and service providers to examine
quality of care received, as well as a mail survey sent to
foster parents to obtain their perspectives regarding the
mental health needs of foster children and to document
their experiences in accessing mental health services.
Population Studied: Historically, children enrolled in
Florida’s child welfare system have been exempt from
Medicaid managed care. In 2004, Florida passed
legislation requiring children in child welfare to receive
behavioral health services under a managed care
arrangement. In 2006, The Florida Coalition for Children
(FCC) formed a Behavioral Health Network Board with
Magellan Behavioral Health of Florida, Inc. and was
awarded the contract. Implemented February 1, 2007
and under a contract with the Agency for Health Care
Administration, the Child Welfare Prepaid Mental Health
Plan (CW-PMHP) is intended to provide a
comprehensive set of behavioral health services to
children who are eligible for Medicaid and involved with
Florida’s child welfare system. This population
previously received such services via a traditional feefor-service arrangement.
Principal Findings: This presentation will offer detailed
findings regarding process and impact collected across
three years of study in geographically diverse areas of
Florida. Detailed descriptive information on
implementation of this unique managed care
arrangement and partnership between behavioral health
and child welfare service systems will be shared in
combination with caregiver and provider satisfaction
data.
Implications for Policy, Delivery or Practice: The
findings from this study have important policy and
practice ramifications for both the behavioral health and
child welfare reforms taking place nationally, since entry
into the child welfare system provides an opportunity for
secondary prevention with regard to child mental health
problems.
Funding Source(s): Florida's Agency for Health Care
Administration
™ The Design, Development and Evaluation of a
Comprehensive Pediatric Asthma Project: The Merck
Childhood Asthma Network (MCAN)
Meera Viswanathan, Ph.D.; Lucia Rojas Smith, Dr.P.H.;
Carol Woodell, B.S.P.H.; Linda Lux, M.P.A.; Yvonne
Ohadika, Ph.D.; Floyd Malveaux, M.D., Ph.D.
Presented by: Meera Viswanathan, Ph.D., Health
Services Research Analyst, RTI International, 3040
Cornwallis Road, Research Triangle Park, NC 27709
Phone: (919) 316-3930 Email: viswanathan@rti.org
Research Objective: Pediatric asthma is a multifactorial disease, requiring multi-layered interventions
addressing children, families, schools, and communities.
Asthma continues to result in a high burden of morbidity
despite the existence of interventions proven to improve
health and quality of life. The Merck Childhood Asthma
Network (MCAN) is a major new funding initiative that
seeks to translate these proven interventions from
research to practice. This paper highlights lessons
learned in the selection, implementation, and evaluation
of the effort with regard to integrating and translating
evidence-based interventions across varied settings.
Study Design: The MCAN request for proposals, issued
in May 2005
(http://www.mcanonline.org/sites/pdf/MCAN_call_for_pro
posal.pdf) was based primarily on a systematic review to
identify pediatric asthma interventions implemented in
urban, U.S. settings, with demonstrated effectiveness
and materials for replication. Sites were required to
implement these or other interventions with proof of
efficacy, and to address multiple contexts of pediatric
asthma prevention. The evaluation triangulates data
from several sources: site-specific monitoring and
evaluation data; site documents; qualitative
assessments of families, organizational partners, and
other stakeholders; and quantitative data from a
common instrument on health indicators before and after
the intervention.
Population Studied: MCAN grantees and
organizational partners
Principal Findings: MCAN selected five sites (New
York, Puerto Rico, Chicago, Los Angeles, and
Philadelphia) with high asthma need and established
asthma programs that addressed the needs of patients
and families but were ready for a higher level of program
integration across schools, healthcare systems, and
communities. MCAN supports a community-based
approach that is tailored to the specific needs of each
site, allowing sites to pick from a menu of evidencebased interventions. As a result, each site is unique in its
specific combination of interventions, but all sites serve
common goals of integration of care, incorporation of
evidence-based programs and improvement in
knowledge, self-management, health, and quality of life.
MCAN sites achieve service and system integration
through created or enhanced linkages between health
care providers, schools, community-based
organizations, patients, parents, and other caregivers
through care coordination, school interventions,
community events, internal leadership team meetings,
external coalition development, participation in external
policy groups, and collaborations across MCAN sites.
Sites report comparatively greater success in
implementing interventions involving families and
healthcare settings, and comparatively less success in
involving schools in policy change; the degree of
success varies by the organizational setting of the
grantee.
Conclusions: Preliminary results suggest that
community-based implementation of evidence-based
interventions often requires significant modification from
protocol to allow for translation to a wider range of
settings. The organizational setting and prior
partnerships of the grantee are strong facilitators of
translation.
Implications for Policy, Delivery or Practice: Lessons
relevant to policy makers and funders include the
importance of a planning period and the selection of
sites with clear lines of authority to ensure accountability.
Lessons relevant for practitioners include the need for
clarifying roles and expectations with partners and for
developing realistic goals despite the breadth of the
stated goals. Lessons relevant for evaluators include the
importance of participatory methods and the need for
collaborative assessment of the balance between
burden of data collection and rigor.
Funding Source(s): Merck Childhood Asthma Network
™ Validation of Area-Level Pediatric Prevention
Quality Indicators at the Sub-County Level in the
Dallas Area
Brad Walsh, M.P.H.; Sue Pickens, M.Ed.
Presented by: Brad Walsh, M.P.H., Strategic Planning
Project Administrator, Strategic Planning, Parkland
Health & Hospital System, 5201 Harry Hines Blvd,
Dallas, TX 75235 Phone: (214) 590-8707 Email:
bwalsh@parknet.pmh.org
Research Objective: To evaluate how well
hospitalization rates for AHRQ’s Pediatric Prevention
Quality Indicator (PDI) area-level categories correlate
with income and insurance coverage parameters for
children, and with rates of potentially avoidable pediatric
ER visits per the New York University Algorithm rules,
for 28 sub-county areas in four Dallas, TX, area
urban/suburban counties.
Study Design: Statistical analysis of existing datasets
for hospitalizations, ER visits and census-derived
economic parameters.
Population Studied: All children and all adults in four
Texas counties (Dallas, Tarrant, Collin and Denton) who
had an inpatient stay or ED visit in 2007.
Principal Findings: For 28 sub-county service areas in
the Dallas area, AHRQ's adult Prevention Quality
Indicators are almost all significantly positively correlated
with measures of socioeconomic need (the Community
Need Index), and with potentially preventable ED visits
as defined by the NYU ED Algorithm. However the
picture is much more mixed with AHRQ's newer arealevel Pediatric Prevention Quality Indicators (PDIs).
While rates for two of the five PDIs studied are
significantly positively correlated with child poverty rates
and with age-adjusted avoidable pediatric ED visits, two
others are not significantly correlated, and one, PDI 16
gastroenteritis, is significantly negatively correlated with
child poverty rates and with avoidable pediatric ED visit
rates, the only area-level PDI or PQI rate to be so.
Conclusions: PDIs 15 and 17 do not correlate with an
independent measure of access to pediatric primary care
(avoidable ED utilization), nor do they correlate
significantly with child poverty rates, in the Dallas area.
This suggests that these two PDIs are not useful
measures of pediatric access to care. Because PDI 16
correlates negatively with child poverty and avoidable
ED use, users are cautioned to interpret PDI 16
hospitalization rates with this inverse relationship in
mind. One important limitation of our study is that the
age categories in the databases for hospitalized children
and ED visits by children did not match the exclusion
criteria in the AHRQ PDI definitions.
Implications for Policy, Delivery or Practice: We
recommend that two of the area-level PDI categories
(PDI 15 diabetes short-term complications and PDI 17
perforated appendix rates) should not routinely be used
for policy analysis regarding adequacy of access to
pediatric primary care, and PDI 16 gastroenteritis should
only be used with the understanding that rates are
negatively correlated with socioeconomic measures and
with independent measures of access to care such as
avoidable ED utilization.
™ Unmet Need Among Children with Special Health
Care Needs: Results from the 2005/6 National Survey
of Children with Special Health Care Needs
Wendy Weller, Ph.D.
Presented by: Wendy Weller, Ph.D., Assistant
Professor, Health Policy, Management, and Behavior,
University at Albany, SUNY, School of Public Health,
One University Place, Room 167, Rensselaer, NY 12144
Phone: (518) 402-0302 Email: wweller@albany.edu
Research Objective: This study uses data from the
2005/6 National Survey of Children with Special Health
Care Needs (2005/6 NS-CSHCN) to examine unmet
need for 13 medical and health services often required
by children with special health care needs (CSHCN).
Study Design: This is a cross-sectional study based on
the 2005/6 NS-CSHCN.
Population Studied: The study population included
40,840 children identified as having a special health care
need based on parental response to a previously
validated CSHCN screener that is consistent with the
MCHB definition of CSHCN.
Principal Findings: The prevalence of unmet need
among CSHCN was highest for communication aids
(23.9%), substance abuse treatment (20.7%), mental
health care (15.0%), physical/occupational/speech
therapy services (13.6%), and home health (10.6%).
Unmet need was lowest for medical supplies (2.5%),
routine preventive care (2.4%), and prescription
medications (1.8%). With the exception of therapy
services and home health, the prevalence of unmet need
remained approximately the same or declined slightly
between the 2001 and the 2005/6 NS-CSHCN.
Although mental health care was among the services
with higher unmet need in 2005/6, it was the service with
the most noticeable decline in unmet need between the
two survey years (18.1% vs. 15.0%). Multiple regression
analysis revealed that type of insurance, income, having
a usual source of care, and health status are significantly
associated with unmet need for multiple types of
services. Compared to CSHCN in nonpoor families,
CSCHCN in poor families were significantly more likely
to report an unmet need for 9 of the 13 services
examined, while those in near poor families were
significantly more likely to report an unmet need for 7 of
the 13 services. Children who were uninsured for any of
the 12 months prior to the survey were significantly more
likely to report an unmet for 10 of the 13 services
compared to children who were insured for the entire 12
months. For some services, Medicaid and SCHIP
provided a protective effect. CSHCN covered by either
Medicaid or SCHIP were significantly less likely to report
an unmet need for therapy services and medical
supplies compared to privately insured children.
CSHCN covered by Medicaid were also less likely to
report an unmet need for specialty care and mental
health care; those covered by SCHIP were also
significantly less likely to report an unmet need for vision
care. CSHCN without a usual source of care were
significantly more likely to report an unmet need for
routine preventive services, prescription drugs, mental
health care, medical supplies, and vision care. Health
related need factors were strong predictors of unmet
need across multiple services in the fully-adjusted
models. Overall, as severity increased the odds of
unmet need increased.
Conclusions: Unmet need continues to be a concern
for the most vulnerable CSHCN (e.g., low-income,
uninsured).
Implications for Policy, Delivery or Practice: Policies
are needed that address both the financial and
nonfinancial barriers to care to meet the needs of
CSHCN. As more children lose private insurance and
states look for ways to reduce Medicaid spending,
monitoring unmet need among this population is
especially important during the current economic
downturn.
™ Development of a Computerized Chart Review
Tool Sensitive to Patient Safety Problems in
Communication
Donna Woods, Ed.M., Ph.D.
Presented by: Donna Woods, Ed.M., Ph.D., Assistant
Professor and Co-Director of the Graduate Programs in
Healthcare Quality and Patient Safety, Institute for
Healthcare Studies, Northwestern University, 750 North
Lake Shore Drive 10th Floor, Chicago, IL 60611 Phone:
(312) 503-5550 Email: woods@northwestern.edu
Research Objective: Communication has been found to
be the most frequent root cause for sentinel events
reported to the Joint Commission. Effective methods to
assess of communication related to patient safety risk
has remained a challenge. To track communication
related problems and assess improvement there is a
need for medical chart review tool that will identify
medical errors and adverse events and is sensitive to
patient safety communication problems and
improvement. The aim of the Chart Review project is to
develop a medical chart review tool sensitive to
problematic clinical communication and safety-related
pediatric patient care.
Study Design: This study was conducted in two phases.
First to determine the feasibility of identifying patient
safety related clinician communication problems from the
clinical documentation in a medical chart and the nature
of and types of these, a free form open ended qualitative
review of pediatric medical charts was conducted.. Case
medical charts were selected from records for patients
who have experienced a high risk event (e.g. transfer
from another facility, medical emergency team activated,
Safety Event Reporting System cases, transfer to the
PICU within 24 hrs of being admitted to the floor).
Control medical charts were identified from records in
which none of the above nine experiences are known to
have occurred, and were then matched with case charts
based on age, gender, admitting unit, and date of
admission. Research nurses with pediatric expertise,
blinded to whether a medical chart was a case or
control, were asked to read through a specific episode of
care and note any clinician communication problems and
safety issues. In the second phase, from the results of
the free form open ended qualitative review, the types of
communication problems reliably identified in the
medical chart were used to form the basis of a chart
abstraction tool for testing. The chart abstraction tool
was tested by four pediatric research nurses.
Seventeen charts including eight case and nine control
charts were tested. The tool was tested by nurses who
had worked on the original free-form reviews as well as
nurses who were new to the project. This allowed for a
comparison of the findings from each type of review and
helped to gain insight about the tool’s ability to identify all
the potential communication and safety-related errors.
Population Studied: Case medical charts were
selected from records for patients who have experienced
a high risk event (e.g. transfer from another facility,
medical emergency team activated, Safety Event
Reporting System cases, transfer to the PICU within 24
hrs of being admitted to the floor). Control medical charts
were identified from records in which none of the above
nine experiences are known to have occurred, and were
then matched with case charts based on age, gender,
admitting unit, and date of admission.
Principal Findings: The computerized chart abstraction
tool was able to identify communication related safety
issues in a medical chart. Reviews of case charts
included documentation of pediatric care problems
related to problematic clinician communication, errors
and preventable adverse events. Control chart reviews
included some documentation related to problematic
clinician communication and adverse events, although
the reviews were shorter and fewer specific problems
were noted. The chart abstraction tool specified fields of
patient safety related clinical communication problems
and related consequences. General categories and
categories to further specify the location aspect of care
and the nature of the communication problem were
provided as drop-down menu options. In addition a in a
free text area is provided to allow reviewers the option
to describe the issue in their own words. General
categories of problematic communication related context
included Imaging, Labs, Medications, Nosocomial
Infections, Operating Room, Orders, Plan of Care and
Procedures, Forms, Code/medical emergency team
activated, Death and the free form option of Other.
Conclusions: By collecting and organizing information
into the chart review tool, the medical record can be
used to 1) identify general and specific patient safety
events, medical errors and problems and 2) identify
communication-related patient safety events, medical
errors and problems.
Implications for Policy, Delivery or Practice: The final
chart abstraction tool will be tested for external validity at
other pediatric healthcare institutions. The Illinois
Department of Healthcare and Family Services (IDHFS)
Quality Control Contractor will identify medical charts
from the 5 Chicago hospitals with large pediatric
services called the Pediatric Patient Safety Consortium
hospitals. The chart abstraction tool may be revised
further or be shown to be effective for use.
Funding Source(s): The Michael Reese Health Trust
™ Leveraging Existing Assessments of Risk Now
(LEARN) for Patient Safety: A Meta-Analysis of Risk
Results
Donna Woods, Ed.M., Ph.D.
Presented by: Donna Woods, Ed.M., Ph.D., Associate
Professor, Institute for Healthcare Studies, Feinberg
School of Medicine, Northwestern University, 750 North
Lake Shore Drive, 10th Floor, Chicago, IL 60611 Phone:
(312) 503-5550 Email: woods@northwestern.edu
Research Objective: Prospective identification of
specific paths and mechanisms of medical care risks is a
challenge to patient safety improvement. While
institutional differences do exist, frequently safety
vulnerabilities and risks that exist at one institution also
exist at other institutions. However, when specific
vulnerabilities leading to preventable risks are uncovered
through a risk assessment at one institution these results
are rarely shared to help other institutions address
potential latent risks. The objective of this study was to
identify generic risks across institutions.
Study Design: The LEAR.N. method consists of
conducting a meta-analysis of the medium and high risk
fail-points from the risk assessment results. Risk
assessments were collected from institutions across the
country. Risk assessment process steps and failure
modes from all the collected studies were entered into
database. Medium to high risk failure modes and failure
mode causes were cataloged across risk assessments.
Review across the failure modes and failure mode
causes revealed common failure modes and common
causes. In addition, an assessment of the quality of risk
assessments was conducted.
Population Studied: Risk assessment results of
healthcare processes from institutions across the US.
Principal Findings: Sixteen risk assessments were
collected from across the country. The topics of the
collected risk assessments included: Interventional
Radiology; Blood Transfusion; Digital Imaging –
Sending; Digital Imaging - Receiving; and Pediatric
Emergency Transport. Across these risk assessments,
over 400 fail-points are described. Of these 296 had a
risk priority number designating them as medium to high
risk. Meta-analysis of medium and high fail-points
identified several generic underlying systemic issues
which lead to harmful errors and patient safety risk with
relative frequency. Examples of prominent generic risks
included: Unreliable hand-off of clinical information
regardless of the process or context; Missing
information; Lack of mechanisms of systems for
verification of the stage of completion of clinical tasks;
Lack of feedback in medical care systems; and Patient
identification. Assessment of the quality of cross
institutional risk assessments revealed that these
assessments did not represent the possibility of both
omission and co-mission events in most assessments.
Conclusions: New and existing foci for patient safety
improvement were revealed. Hand-offs and patient
identification are known contexts of risk. The three newly
described pervasive contexts of risk related to the
verification of the stage of task progress, the need for
feedback systems in healthcare, and missing information
described through this meta-analysis of risk
assessments will require significant and fundamental
approaches to address and describe new directions for
research and improvement.
Implications for Policy, Delivery or Practice: Sharing
risk results from FMEA and other risk assessments
across institutions is possible and will enable
fundamental learning about existing risk to establish the
necessary understanding to direct significant safety
improvement.
Funding Source(s): AHRQ
™ Identifying and Managing Overweight/Obesity in a
Medicaid Health Plan Environment
Constance Yancy, M.B.A., B.S.N., R.N., C.P.H.Q.
Presented by: Constance Yancy, M.B.A., B.S.N., R.N.,
C.P.H.Q., Director, Quality/Accreditation,
Quality/Accreditation, Health Services for Children with
Special Needs, 1101 Vermont Avenue NW, Suite 1201,
Washington, DC 20005 Phone: (202) 721-7163 Email:
cyancy@hscsn.org
Research Objective: The American Academy of
Pediatrics noted in its 2003 Committee on Nutrition
Policy Statement on the Prevention of Pediatric.
Overweight and Obesity (OW/OB), that “The dramatic
increase in the prevalence of childhood overweight and
its resultant co- morbidities are associated with
significant health and financial burdens warranting
strong and comprehensive prevention efforts”. Early
identification of excess weight by the PCP is vital to
prevent overweight/obesity and the application of dietary
and physical activity intervientions. The most effective
measure for early identificaitni is calculationof the body
mass index (BMI). 1)Outline screening mechanisms and
appropriate treatment protocols for identifying,
measuring and managing overweight/obesity conditions.
2)Identify key barriers influencing the assessment and
treatment practices of of PCPs regarding overweight/
obesity. 3) Identify strategies to combat pediatric
overweight/obesity.
Study Design: A random sample of HSCSN Medicaid
enrollees who had at least one EPSDT visit during the
measurement year. Medical records were reviewed for
1. Documentation of ht/wt, which could be used to
calculate BMI, 2. Enrollees documented as overweight
or obese, 3. Enrollees who had diagnosis of overweight/
obesity who also had documentation of education,
intervention, and/or follow-up for weight manangement.
Population Studied: HSCSN Medicaid enrollees six (6)
to 19 years of age.
Principal Findings: 1)Documented Height & Weight:
2005-91.2% 2006-93% 2007-93% 2)BMI Calculation
2005-15% 2006-40% 2007-60% 3)Documented
Diagnois of Obesity/Overweight 2005-31% 2006-38%
2007-38% 4)Received Behavioral or Health Education
Counseling 2005-12.5% 2006-21% 2007-41%
5)Received Follow-Up with PCP for Weight Management
2005-11% 2006-11% 2007-27% 6)Referral to a
Nutritionist
2005-11% 2006-14% 2007-34%
Conclusions: Through the implementation of the
following interventions/strategies: a) Adoption of Clinical
Practice Guidelines b) Adoption of NICHQ Childhood
Obesity Action Network Implementation Guide
c) Development of Obesity Toolkit for Providers d) CME
Events e) HSC Foundation Research Initiative "Obsity in
Lower-Income Communities" f) HSC Foundation Obesity
Awareness Campaign g) City-wide Pediatric Obesity
Summit h) HSC Foundation:Healthy Living Center
Initiative i) Publication of a Healthy Living Resource
Directory, and j) Free Movement Classes. HSCSN
addressed identified provider barriers, such as, 1)
Awareness & Adherence to Clinical Practice Guidelines
2)Failure to document screening, treatment plan, and
outcomes. HSCSN pracitioners positively impacted
enrollee prevention and assessment through screening
and diagnosis. Treatment through setting goals/
objectives as well as appropriate referrals.
Implications for Policy, Delivery or Practice: The
findings indicate movement by the pracitioner community
from publication to practice of clinical practice guidelines
and action plans whereby positively impacting the
community as a whole.
™ Ensuring Appropriate Care in the Homecare
Utilization Management of Children in a Special
Needs Population
Constance Yancy, M.B.A., B.S.N., R.N., C.P.H.Q.; De
Coleman, R.N.; Robin Pirtle, R.N.
Presented by: Constance Yancy, M.B.A., B.S.N., R.N.,
C.P.H.Q., Director, Quality/Accreditation,
Quality/Accreditation, Health Services for Children with
Special Needs, 1101 Vermont Avenue, NW, Suite 1201,
Washington, DC 20005 Phone: (202) 721-7163 Email:
cyancy@hscsn.org
Research Objective: Ensure appropriate homecare
services through utilization management.
Study Design: Sample of HSCSN, Medicaid Health
Plan enrollees 0-22 years of age receiving homecare
services greater than $24,000.00 annually during the
measurement period. Homecare services include, R.N.,
LPN, Personal Care Assistant, and Respite.
Population Studied: HSCSN, Medicaid Health Plan,
enrollees 0-22 years of age receiving homecare services
greater than $24,000.00 annually. Homecare services
include, R.N., LPN, Personal Care Assistant, and
Respite.
Principal Findings: Total Medical Expenditures vs.
Home Health Medical Expenditures: Home Health
Medical Expenditures total 14% of Total Medical
Expenditures. Of the 14% of Home Health Medical
Expenditures, 4% are enrollees utilizing < $24,000.00
annually and 10% are enrollees utilizing >$24,000.00
annually. Home Health Medical Expenditures: 27% of
the Home Health Medical Expenditures are enrollees
utilizing <$24,000.00 annually. 73% of the Home Health
Medical Expenditures are enrollees utilizing >$24,000.00
annually. PM/PM: 2005-$178.80; 2006-$211.35; 2007$231.67; 2008YTD-$238.11;
Conclusions: Through the implementation of the
following interventions/strategies: a) Care Management
system updated to include treating diagnosis on
authorizations b) Internal Home Health Care Guidelines
were developed c) Home Health Care Guidelines
distributed to participating providers d) Assigned a
dedicated Home Health Nurse Reviewer (RN) e)
Conducted a focused review of all home care cases with
annual costs >$24,000. Over 50 cases (1.5% of
membership) meet the inclusion criteria and were
reviewed f) Implemented the Homecare Assessment
Team Comprised of Home Health Nurse Reviewer,
Medical Director, Social Worker, Team Leaders, Director
of Care Management/Utilization Management, and
Assistant Director of Care Management/Utilization
Management g) Initiated LICSW home visit psychosocial
assessment h) Collaboration with Medical Director and
staff to develop a home care treatment plan for members
meeting inclusion criteria i) Identify alternatives, if
possible, to 24 hour skilled nursing visits j)
Communication with family and treating provider
regarding homecare treatment plan, changes in home
care services, social services, follow-up, etc. k)
Education and empowering of caregivers for selfmanagement of care l) Identification and linkage to
community resources and support agencies for
caregivers to supplement non-medical needs, and m)
Availability of a home-based enteral feeding specialty
company to provide re-education and retraining to
members/caregivers receiving g-tube feedings. Identified
barriers, such as, 1)Criteria/industry standards for
homecare services for special needs children are not
available 2) Process for review and authorization of
homecare services was not centralized to specialized
staff 3) Practitioner reluctance to develop or modify
treatment plans 4) Psychosocial needs assessments by
Home Health agencies to guide treatment decisions
were not available 5) Parent/caregiver fear of
participating in the clinical care of the child 6)
Mechanism to capture the treating diagnosis not
available in our proprietary care management system;
were addressed. All of which collectively will positively
impact key stakeholders including the health plan,
practitioners, enrollees and enrollee caregivers.
Implications for Policy, Delivery or Practice: The
implications for delivery or practice impact health plan
internal processes, such as the development of
specialized criteria, staff training and education as well
as practitioner practice and home health providers. And
lastly, open and ongoing communication between all key
stakeholders.
™ Prevalence of Children with Special Health Care
Needs over Time: Individual and Family Level
Variability in the CSHCN Status
Yuan You
Presented by: Yuan You, Doctoral Candidate, Gillings
School of Global Public Health, University of North
Carolina at Chapel Hill, 485 Summerwalk Circle, Chapel
Hill, NC 27517 Phone: (302) 339-2420 Email:
yuanyou@email.unc.edu
Research Objective: Knowledge of the prevalence and
stability of children with special health care needs
(CSHCN) classification is an essential first step to
understanding the epidemiology and potential impacts of
special health care needs. Implications of being
classified as CSHCN for both individuals and families
depend on whether a child’s special health care needs
status is a temporary or more permanent condition.
However, no studies to date have examined whether
having special health care needs is a consistent
condition over time. Using the CSHCN Screener, this
study examines the individual level variability in CSHCN
status and the within-family variability in the number of
CSHCN over time as well as the source of variability
(screening criteria) associated with changes in CSHCN
status.
Study Design: Data are from the 2004 to 2005 Medical
Expenditure Panel Survey (MEPS). Analyses are
conducted at both the individual and the family level. For
the individual level analyses, Chi-square tests are
performed to assess the statistical significance of
differences in changes in the CSHCN status between
individuals of different demographic characteristics.
Logistic regression analyses are conducted to predict
the probability of being identified as a CSHCN in year
2005, controlling for conditions in year 2004 and other
demographic characteristics. For the family level
analyses, special focus is placed on stable-size families
(families without a change in the number of children)
with at least one CSHCN in either year to examine the
extent to which changes in the number of CSHCN occur
and the source of variability.
Population Studied: The study sample was drawn from
children aged 0-17 years and families with at least one
child in the 2004-2005 MEPS household files.
Principal Findings: At the individual level, among the
1,116 children who were identified as CSHCN in either
year 2004 or 2005, 47% kept the CSHCN label, while
53% either gained or lost the CSHCN label over a two
year period. The biggest source of variability comes from
changes in the prescription medication use. Being
identified based on prescription medication use, and
having household income below 100% FPL were
significantly associated with being identified as a
CSHCN in the next year, while the Hispanic ethnicity
was significantly associated with being identified as a
non-CSHCN in the next year. At the family level, less
than 15% of within family changes in the number of
CSHCN are due to loss or gain in number of children
from year to year. Most of the changes come from
children of stable-sized families moving in and out of
CSHCN criteria over years. More than half of the stablesized families had changes in the number of CSHCN
over a two year period, and the rate of gaining one or
more CSHCN (30.7%) was only slightly higher than the
rate of losing CSHCN (28.2%).
Conclusions: Despite that CSHCN prevalence is
relatively stable at a national level, substantial and
significant variation on the CSHCN status occurs over
time both at the individual and the family level.
Implications for Policy, Delivery or Practice: It is
important to understand the level and sources of
variability when interpreting CSHCN prevalence.
Funding Source(s): UNC Graduate Assistanceship