Effectiveness of pentavalent rotavirus vaccine against severe disease

OBJECTIVE

To determine the vaccine effectiveness (VE) of complete and partial vaccination with the pentavalent rotavirus vaccine (RV5) in the prevention of rotavirus acute gastroenteritis (AGE) hospitalizations and emergency department visits during the first 3 rotavirus seasons after vaccine introduction.

METHODS

Active, prospective population-based surveillance for AGE and acute respiratory infection (ARIs) in inpatient and emergency department settings provided subjects for a case-control evaluation of VE in 3 US counties from January 2006 through June 2009. Children with laboratory-confirmed rotavirus AGE (cases) were matched according to date of birth and onset of illness to 2 sets of controls: children with rotavirus-negative AGE and children with ARI. The main outcome measure was VE with complete (3 doses) or partial (1 or 2 doses) RV5 vaccination.

RESULTS

Of age-eligible children enrolled, 18% of cases, 54% of AGE controls, and 54% of ARI controls received ≥1 dose of RV5. The VE of RV5 for 1, 2, and 3 doses against all rotavirus genotypes with the use of rotavirus-negative AGE controls was 74% (95% confidence interval [CI]: 37%-90%), 88% (95% CI: 66%-96%), and 87% (95% CI: 71%-94%), respectively, and with the use of ARI controls was 73% (95% CI: 43%-88%), 88% (95% CI: 68%-95%), and 85% (95% CI: 72%-91%), respectively. The overall VE estimates were comparable during the first and second years of life and against AGE caused by different rotavirus strains.

CONCLUSION

RV5 was highly effective in preventing severe rotavirus disease, even after a partial series, with protection persisting throughout the second year of life.

Reporting on continuity of coverage for children in Medicaid and CHIP: what states can learn from monitoring continuity and duration of coverage

OBJECTIVE

The Children's Health Insurance Program Reauthorization Act (CHIPRA) requires states to measure and report on coverage stability in Medicaid and the Children's Health Insurance Program (CHIP). States generally have not done this in the past. This study proposes strategies for both measuring stability and targeting policies to improve retention of Medicaid coverage, using Ohio as an example.

METHODS

A cohort of newly enrolled children was constructed for the 1-year time period between July 2007 and June 2008 and followed for 18 months. Hazard ratios were estimated after 18 months to predict the likelihood of maintaining continuous enrollment in Medicaid, adjusting for income eligibility group, age, race, gender, county type, and change in unemployment. Children dropping from the program at the renewal period (12-16 months) were followed for 12 months to determine their rate of return.

RESULTS

Approximately 26% of children aged <1 year and 35% of children aged 1 to 16 years dropped from Medicaid by 18 months, with the steepest drop occurring after 12 months, the point of renewal. Likelihood of dropping was associated with the higher income eligibility groups, older children, and Hispanic ethnicity. Approximately 40% of children who were dropped at renewal re-enrolled within 12 months. Children in the lowest income group returned sooner and in higher proportions than other children.

CONCLUSIONS

A substantial number of children lose Medicaid coverage only to re-enroll within a short time. Income eligibility group appears to be a strong indicator of stability. Effective monitoring of coverage stability is important for developing policies to increase retention of eligible children.

Clostridium difficile infection in hospitalized children in the United States

OBJECTIVES

To evaluate the trend in Clostridium difficile infection (CDI) among hospitalized children in the United States and to evaluate the severity of and risk factors associated with these cases of CDI.

DESIGN

A retrospective cohort study using the triennial Healthcare Cost and Utilization Project Kids' Inpatient Database for the years 1997, 2000, 2003, and 2006.

SETTING

Hospitalized children in the United States.

PARTICIPANTS

A nationally weighted number of patients (10 474 454) discharged from the hospital, 21 274 of whom had CDI.

MAIN EXPOSURE

Discharge diagnosis of CDI.

MAIN OUTCOME MEASURES

Trend in cases of CDI; effect and severity were measured by length of hospital stay, hospitalization charges, colectomy rate, and death rate.

RESULTS

There was an increasing trend in cases of CDI, from 3565 cases in 1997 to 7779 cases in 2006 (P < .001). Patients with CDI had an increased risk of death (adjusted odds ratio [OR], 1.20; 95% confidence interval [95% CI], 1.01-1.43), colectomy (adjusted OR, 1.36; 95% CI, 1.04-1.79), a longer length of hospital stay (adjusted OR, 4.34; 95% CI, 3.97-4.83), and higher hospitalization charges (adjusted OR, 2.12; 95% CI, 1.98-2.26). There was no trend in death, colectomy, length of hospital stay, or hospitalization charges during the 4 time periods (ie, 1997, 2000, 2003, and 2006). The risk of comorbid diagnoses associated with CDI included inflammatory bowel disease, with an OR of 11.42 (95% CI, 10.16-12.83), and other comorbid diagnoses associated with immunosuppression or antibiotic administration.

CONCLUSIONS

There is an increasing trend in CDI among hospitalized children, and this disease is having a significant effect on these children. In contrast to adults, there is no increasing trend in the severity of CDI in children. Children with medical conditions (including inflammatory bowel disease and immunosuppression) or conditions requiring antibiotic administration are at high risk of CDI.

Measuring and reporting quality of health care for children: CHIPRA and beyond

BACKGROUND AND PURPOSE

The coming years could be a watershed period for children and health care as the nation implements the most significant federal health care legislation in 50 years: the Accountable Care Act (ACA). A year earlier, the American Recovery and Reinvestment Act (ARRA) set up a framework and road map for the eventual universal adoption of health information technology in its Health Information Technology for Economic and Clinical Health (HITECH) provisions, and the Children's Health Insurance Program Reauthorization Act (CHIPRA) legislation articulated a new and compelling vision for quality measurement in child health services. Each of these landmark advances in federal health policy contains relevant provisions for the measurement and improvement of the performance of the health system. Less clear is the extent to which the child specific framework articulated in CHIPRA will be preserved and built upon. Here, we set forth recommendations for ensuring that measurement and reporting efforts under CHIPRA, ARRA, and ACA are aligned for children.

POLICY THEMES AND RECOMMENDATIONS

Our findings around problems and recommendations are grouped into 2 broad areas: those that deal with helping states report and use current measures, and those that deal with expanding the current measures. Recommendations include 5 aimed at focusing efforts on measure reporting and use: 1) help states build a measurement infrastructure; 2) provide specific technical assistance and support to states on how to collect, report, and use measures; 3) establish a national office for quality monitoring; 4) make available nationally data from states; and 5) ensure specific focus on child health in HITECH initiatives. Recommendations also include 3 aimed at extending what is being measured: 1) continue emphasis on insurance stability; 2) ensure that disparities can be measured and monitored; and 3) build measures that focus on system accountability and outcomes.

CONCLUSIONS

National health care reform provides the opportunity to extend coverage and dramatically restructure systems of care. It will be important to ensure that focus on health care quality for children be maintained and that the advances made under CHIPRA reinforce and are not diluted or overtaken by broader reform efforts.

Short pediatric Crohn's disease activity index for quality improvement and observational research

BACKGROUND

Practical and objective instruments to assess pediatric Crohn's disease (CD) activity are required for observational research and quality improvement. The objectives were: 1) to determine the feasibility of completing the Pediatric Crohn's Disease Activity Index (PCDAI) and the Abbreviated PCDAI (APCDAI); and 2) to create a Short PCDAI by retaining and reweighting the most practical and informative components.

METHODS

Physicians in the ImproveCareNow Collaborative for pediatric inflammatory bowel disease (IBD) were asked to record components of the PCDAI and assign a Physician Global Assessment (PGA) of disease severity at each patient encounter. We assessed the feasibility of the PCDAI, the APCDAI, and the individual index components by determining the proportion of visits in which data were recorded. We created a short index by retaining and reweighting components of the PCDAI completed in ≥80% of visits. The feasibility of the Short PCDAI and its ability to discriminate between PGA categories were evaluated using descriptive statistics.

RESULTS

This study population included 1355 subjects with CD (6373 visits). The PCDAI and APCDAI were complete in 16.7% and 44.1% of visits, respectively. A Short PCDAI, including general well-being, abdominal pain, stools, weight, abdominal exam, and extraintestinal manifestations were completed in 66.5% of visits. The correlation between the Short PCDAI and PGA was similar to that of the PCDAI (r = 0.60, P < 0.001 versus 0.61, P < 0.001).

CONCLUSIONS

The Short PCDAI is a practical and valid tool to measure pediatric CD activity. Its use should facilitate quality improvement and observational research.

Practice and child characteristics associated with influenza vaccine uptake in young children

OBJECTIVES

The objective of this study was to determine both practice and child characteristics and practice strategies associated with receipt of influenza vaccine in young children during the 2004-2005 influenza season, the first season for the universal influenza vaccination recommendation for all children who are aged 6 to 23 months.

METHODS

Clinical and demographic data from randomly selected children who were aged 6 to 23 months were obtained by chart review from a community-based cohort study in 3 US counties. The proportion of children who were vaccinated by April 5, 2005, in each practice was obtained. For assessment of practice characteristics and strategies, sampled practices received a self-administered practice survey. Practice and child characteristics that predicted complete influenza vaccination were determined by using multinomial logistic regression.

RESULTS

Forty-six (88%) of 52 sampled practices completed the survey and permitted chart reviews. Of 2384 children who were aged 6 to 23 months and were studied, 27% were completely vaccinated. The proportion of children who were completely vaccinated varied widely among practices (0%-71%). Most (87%) practices implemented ≥1 vaccination strategy. Complete influenza vaccination was associated with 3 practice characteristics: suburban location, lower patient volume, and vaccination strategies of evening/weekend vaccine clinics; with child characteristics of younger age, existing high-risk conditions, ≥6 well visits to the practice by 3 years of age, and any practice visit from October through January.

CONCLUSIONS

Modifiable factors that were associated with increased influenza vaccination coverage included October to January practice visits and evening/weekend vaccine clinics.

High costs of influenza: Direct medical costs of influenza disease in young children

This study determined direct medical costs for influenza-associated hospitalizations and emergency department (ED) visits. For 3 influenza seasons, children <5 years of age with laboratory-confirmed influenza were identified through population-based surveillance. The mean direct cost per hospitalized child was $5402, with annual cost burden estimated at $44 to $163 million. Factors associated with high-cost hospitalizations included intensive care unit (ICU) admission and having an underlying high-risk condition. The mean medical cost per ED visit was $512, with annual ED cost burden estimated at $62 to $279 million. Implementation of the current vaccination policies will likely reduce the cost burden.

How health policy influences quality of care in pediatrics

The primary focus of child health policy for the last twenty years has been on improving health care coverage and access. More recently, the focus has shifted to include not only coverage, but also the quality of the care received. This article describes some "voltage drops" in health care that impede delivery of high quality health care. The growing emphasis on quality is reflected in provisions of the new Child Health Program Reauthorization Act of 2009 (CHIPRA) legislation. In addition to providing funding for health coverage for over four million more children, it also includes the most significant federal investment in pediatric quality to date.

Using and understanding consumer satisfaction to effect an improvement in mental health service delivery

Consumer satisfaction is today, widely accepted as a measure of the level and quality of service received by consumers. The aim of this survey-based study is to explore consumer satisfaction with quality of care, staff, environment and discharge in a south eastern Sydney adult acute inpatient mental health unit. A cross-sectional analysis is pursued in order to identify aspects of the patient stay, which form an associative relationship with an overall rating of consumer satisfaction on a 10-point scale. During the survey period, there were 182 discharges. Seventy questionnaires (38.5%) were returned from this group. The survey results highlight a number of areas of identified need, enabling the service to prioritize organizational systems around meeting these needs. Multiple regression analysis identified three items in the survey, which were independently significant associates of overall consumer satisfaction. They included being happy with the service provided by the consumer support worker, having support for services on discharge and feeling safe and secure on the ward. The model containing these three items accounted for 50% of the variation in overall satisfaction. Two primary interventions have been developed because survey administration which, it is hoped, will address issues raised in the survey. The interventions were the development of an admission and discharge pathway and a ward-based psychosocial intervention programme, which includes the involvement of consumer support workers.

It is time! Accelerating the use of child health information systems to improve child health

Articles in this issue show clearly the enormous impact that the use of health information technology can have on the quality of health care for children. However, they also point out the challenges that need to be overcome to realize fully the potential of health information technology to improve the quality and efficiency of health care.

Active, population-based surveillance for severe rotavirus gastroenteritis in children in the United States

OBJECTIVES

Routine vaccination of US infants against rotavirus was implemented in 2006, prompting the Centers for Disease Control and Prevention New Vaccine Surveillance Network to begin population-based acute gastroenteritis surveillance among US children<3 years of age. This surveillance system establishes baseline estimates of rotavirus disease burden and allows for the prospective monitoring of rotavirus vaccination impact.

METHODS

Eligible children with acute gastroenteritis (>or=3 episodes of diarrhea and/or any vomiting in a 24-hour period) who were hospitalized, were seen in emergency departments, or visited selected outpatient clinics in 3 US counties during the period of January through June 2006 were enrolled. Epidemiological and clinical information was obtained through parental interview and medical chart review, and stool specimens were tested for rotavirus with enzyme immunoassays. Rotavirus-positive specimens were genotyped by using reverse transcription-polymerase chain reaction assays.

RESULTS

Stool specimens were collected from 516 of the 739 enrolled children with acute gastroenteritis (181 inpatient, 201 emergency department, and 134 outpatient) and 44% tested positive for rotavirus (227 of 516 specimens). The most common strain was P[8]G1 (84%), followed by P[4]G2 (5%) and P[6]G12 (4%). None of the 516 children had received rotavirus vaccine. The rotavirus detection rate was 50% for hospitalized acute gastroenteritis cases, 50% for emergency department visits, and 27% for outpatient visits. Rotavirus-related acute gastroenteritis cases were more likely than non-rotavirus-related acute gastroenteritis cases to present with vomiting, diarrhea, fever, and lethargy. Directly calculated, population-based rates for rotavirus hospitalizations and emergency department visits were 22.5 hospitalizations and 301.0 emergency department visits per 10 000 children<3 years of age, respectively. A sentinel outpatient clinic visit rate of 311.9 outpatient visits per 10,000 children<3 years of age was observed.

CONCLUSIONS

Population-based, laboratory-confirmed rotavirus surveillance in the final rotavirus season before implementation of the US rotavirus vaccine program indicated a considerable burden of disease on the US health care system.

Vaccine effectiveness against laboratory-confirmed influenza in children 6 to 59 months of age during the 2003-2004 and 2004-2005 influenza seasons

OBJECTIVE

The goal was to estimate the effectiveness of influenza vaccination against laboratory-confirmed influenza during the 2003-2004 and 2004-2005 influenza seasons in children 6 to 59 months of age.

METHODS

We conducted a case-control study with children with medically attended, acute respiratory infections who received care in an inpatient, emergency department, or outpatient clinic setting during 2 consecutive influenza seasons. All children residing in Monroe County, New York, Davidson County, Tennessee, or Hamilton County, Ohio, were enrolled prospectively at the time of acute illness and had nasal/throat swabs tested for influenza with cultures and/or polymerase chain reaction assays. Children with laboratory-confirmed influenza were case subjects and children who tested negative for influenza were control subjects. Child vaccination records from the parent and the child's physician were used to determine and to validate influenza vaccination status. Influenza vaccine effectiveness was calculated as (1 - adjusted odds ratio) x 100.

RESULTS

We enrolled 288 case subjects and 744 control subjects during the 2003-2004 season and 197 case subjects and 1305 control subjects during the 2004-2005 season. Six percent and 19% of all study children were fully vaccinated according to immunization guidelines in the respective seasons. Full vaccination was associated with significantly fewer influenza-related inpatient, emergency department, or outpatient clinic visits in 2004-2005 (vaccine effectiveness: 57%) but not in 2003-2004 (vaccine effectiveness: 44%). Partial vaccination was not effective in either season.

CONCLUSIONS

Receipt of all recommended doses of influenza vaccine was associated with halving of laboratory-confirmed influenza-related medical visits among children 6 to 59 months of age in 1 of 2 study years, despite suboptimal matches between the vaccine and circulating influenza strains in both years.

Health professionals' attitudes towards suicide prevention initiatives

Preventing suicide can depend upon the ability of a range of different health professionals to make accurate suicide risk assessments and treatment plans. The attitudes that clinicians hold towards suicide prevention initiatives may influence their suicide risk assessment and management skills. This study measures a group of non-mental health professionals' attitude towards suicide prevention initiatives. Health professionals that had attended suicide prevention education showed significantly more positive attitudes towards suicide prevention initiatives. The findings in this study further support the effectiveness of educating non-mental health professionals in suicide risk awareness and management.

Influenza burden for children with asthma

OBJECTIVE

The goal was to estimate the influenza disease burden among children with asthma and among healthy children by using active, laboratory-confirmed, population-based surveillance.

METHODS

Children 6 to 59 months of age residing in 3 US counties who were hospitalized with acute respiratory illnesses or fever were enrolled prospectively from 2000 through 2004. Similar children who presented to clinics and emergency departments during 2 of the influenza seasons (2002-2004) were enrolled. Rates of influenza-attributable outpatient visits and hospitalizations for children with asthma and for healthy children were estimated. History of asthma and receipt of influenza vaccine for the study children were determined through parental report. The prevalence of asthma in the surveillance population was assumed to be 6.2% for children 6 to 23 months of age and 12.3% for children 24 to 59 months of age.

RESULTS

Of 81 children 6 to 59 months of age with influenza-confirmed hospitalizations in 2000 to 2004, 19 (23%) had asthma. Average annual influenza-attributable hospitalization rates were significantly higher among children with asthma than among healthy children 6 to 23 months of age (2.8 vs 0.6 cases per 1000 children) but not children 24 to 59 months of age (0.6 vs 0.2 case per 1000 children). Of 249 children 6 to 59 months of age with influenza-confirmed outpatient visits in 2002 to 2004, 38 (15%) had asthma. Estimated outpatient influenza-attributable visit rates were higher among children with asthma than among healthy children 6 to 23 months of age (316 vs 152 cases per 1000 children) and 24 to 59 months of age (188 vs 102 cases per 1000 children) in 2003 to 2004. Few parents reported that their children had been vaccinated, including <30% of children with asthma.

CONCLUSION

Influenza-attributable health care utilization is high among children with asthma and is generally higher than among healthy children.

Pediatricians' adherence to pneumococcal conjugate vaccine shortage recommendations in 2 national shortages

OBJECTIVES

The goals were (1) to compare pediatricians' heptavalent pneumococcal conjugate vaccine shortage experience and adherence to shortage recommendations during 2 heptavalent pneumococcal conjugate vaccine shortages, (2) to assess factors associated with nonadherence to second shortage recommendations, and (3) to assess opinions about national immunization policy during vaccine shortages.

METHODS

We mailed surveys to all pediatrician immunization providers in the greater Cincinnati, Ohio, metropolitan area. We assessed heptavalent pneumococcal conjugate vaccine supply and immunization practices during the shortages and provider attitudes regarding immunization shortage policy.

RESULTS

The response rate was 61% (171 of 282 providers). Most pediatricians experienced heptavalent pneumococcal conjugate vaccine shortages (first shortage: 86%; second shortage: 84%). The rate of adherence to recommendations to defer the fourth heptavalent pneumococcal conjugate vaccine dose for healthy children was significantly higher during the second shortage, compared with the first shortage (first shortage: 62%; second shortage: 89%). Adherence to recommendations to administer the fourth dose to high-risk children remained unchanged (first shortage: 43%; second shortage: 45%). Controlling for other factors, pediatricians who reported a severe second shortage had greater odds of not fully vaccinating high-risk children, compared with those who reported no shortage. Contrary to recommendations, many pediatricians did not maintain tracking systems during the heptavalent pneumococcal conjugate vaccine shortages (first shortage: 37%; second shortage: 46%). Most pediatricians (91%) thought that national vaccine shortage recommendations were needed to protect them from liability.

CONCLUSIONS

The rate of adherence to recommendations to defer heptavalent pneumococcal conjugate vaccine doses for healthy children increased significantly from the first shortage to the second shortage. The nonadherent practice of deferring the fourth dose for high-risk children was associated with more severe shortages and, potentially, an inability to vaccinate.

Congruent satisfaction: is there geographic correlation between patient and physician satisfaction?

CONTEXT

Satisfaction among both physicians and patients is optimal for the delivery of high-quality healthcare. Although some links have been drawn between physician and patient satisfaction, little is known about the degree of satisfaction congruence among physicians and patients living and working in geographic proximity to each other.

OBJECTIVE

We sought to identify patients and physicians from similar geographic sites and to examine how closely patients' satisfaction with their overall healthcare correlates with physicians' overall career satisfaction in each selected site.

METHODS

We undertook a cross-sectional analysis of data from 3 rounds of the Community Tracking Study (CTS) Household and Physician Surveys (1996-1997, 1998-1999, 2000-2001), a nationally representative telephone survey of patients and physicians. We studied randomly selected participants in the 60 CTS communities for a total household population of 179,127 patients and a total physician population of 37,238. Both physicians and patients were asked a variety of questions pertaining to satisfaction.

RESULTS

Satisfaction varied by region but was closely correlated between physicians and patients living in the same CTS sites. Physician career satisfaction was more strongly correlated with patient overall healthcare satisfaction than any of the other aspects of the healthcare system (Spearman's rank correlation coefficient 0.628, P<0.001). Patient trust in the physician was also highly correlated with physician career satisfaction (0.566, P<0.001).

CONCLUSIONS

Despite geographic variation, there is a strong correlation between physician and patient satisfaction living in similar geographic locations. Further analysis of this congruence and examination of areas of incongruence between patient and physician satisfaction may aid in improving the healthcare system.

Panic reactions to terrorist attacks and probable posttraumatic stress disorder in adolescents

A number of factors, including subjective reactions and appraisal of danger, influence one's reaction to a traumatic event. This study used telephone survey methodology to examine adolescent and parent reactions to the 2001 World Trade Center attacks 6 to 9 months after they occurred. The prevalence of probable posttraumatic stress disorder (PTSD) in adolescents was 12.6%; 26.2% met study criteria for probable subthreshold PTSD. A probable peri-event panic attack in adolescents was strongly associated with subsequent probable PTSD and probable subthreshold PTSD. This study suggests that the early identification of peri-event panic attacks following mass traumatic events may provide an important gateway to intervention in the subsequent development of PTSD. Future studies should use longitudinal designs to examine the course and pathogenic pathways for the development of panic, PTSD, and other anxiety disorders after exposure to disasters.

Factors that influence adolescent reports of counseling by physicians on risky behavior

PURPOSE

To determine factors that affect whether low-income adolescents report that their doctor talked with them about risky behavior.

METHODS

Random digit-dial survey of low-income adolescents in New York City asking about depression, smoking, alcohol use, and sexual activity and the screening and counseling they received on these risk factors and risks during health visits.

RESULTS

Prevalence of counseling by physicians was low, according to adolescent reports, ranging from 17% of adolescents counseled about depression to 52% about sexually transmitted diseases. Older adolescents were more likely than younger to receive counseling about all topics. In bivariate and multivariate models, having the risk factor was strongly associated with physicians counseling for depression (adjusted [adj.] OR = 4.42; p < 0.001); for sexual activity and counseling about condom use (adj. OR = 4.06; p < 0.01), and birth control (adj. OR = 2.76; p < 0.03). Still, many adolescents at risk had not received counseling. Many adolescents have not had a private and confidential visit with their provider. Having a private and confidential visit was also associated with receipt of counseling.

CONCLUSIONS

Adolescents are not receiving sufficient counseling about risks and risky behavior, according to their own reports. There is need to improve delivery of counseling and ensure that private and confidential visits are provided to youth.

How do stressful family environments relate to reported access and use of health care by low-income children?

This study examines the effect of stressful family environments on children's access to and use of health care, using a sample of 9,854 low-income children from the 1999 National Survey of America's Families. Indicators of stress included aspects of family structure, economic hardship, family turbulence, and parental ill health; these were combined into a composite family stress indicator. Having health insurance was the strongest predictor of health care access and use, but stressful family environments were significantly and inversely associated with parents' having confidence in the ability of family members to obtain health care, children having health care needs met, and children having any dental care in the previous year. The authors concluded that while enrollment in health insurance may be necessary to access and use health care, it is not sufficient. Stressful family environments also appear to influence the ability of parents to obtain care for their children.

Behavior problems in New York City's children after the September 11, 2001, terrorist attacks

Children's behavior was assessed with 3 cross-sectional random-digit-dial telephone surveys conducted 11 months before, 4 months after, and 6 months after September 11, 2001. Parents reported fewer behavior problems in children 4 months after the attacks compared with the pre-September 11 baseline. However, 6 months after the attacks, parents' reporting of behavior problems was comparable to pre-September 11 levels. In the 1st few months after a disaster, the identification of children who need mental health treatment may be complicated by a dampened behavioral response or by a decreased sensitivity of parental assessment to behavioral problems.

Costs of enrolling children in Medicaid and SCHIP

As a way of saving Medicaid dollars, many states are reintroducing administrative hurdles into the enrollment process to deter people from enrolling. This study finds that administrative tasks associated with enrollment absorb sizable amounts of funds. We estimate that it costs approximately dollars 280 to enroll a child in Medicaid or the State Children's Health Insurance Program (SCHIP) in the New York City area. This amount could be reduced by approximately 40 percent if documentation requirements were simplified. In an era of scarce resources, the case for simplification is more compelling than ever.

Periods of Unmanaged Care in Medicaid Managed Care

Churning in Medicaid has been long recognized as a problem leading to breaks in coverage. Tenure in Medicaid managed care has received less attention. Recent reports indicate that children's tenures in health plans are far shorter than tenures in Medicaid itself, but explanations for the difference are not given. In the research reported here, we conducted case studies in five states to determine difference in tenure and reasons for the difference. Our investigation showed that children were enrolled in Medicaid two to four months longer than in specific Medicaid health plans. The major reasons for the gap were retroactive enrollment in Medicaid and delays in selecting a health plan. Frequent and burdensome Medicaid renewal processes exacerbate the problem, resulting in breaks in enrollment and the need to reenroll. The task of managing the care of Medicaid children is difficult without adequate tenures in health plans.

Churning in Medicaid managed care and its effect on accountability

There is concern that churning in Medicaid excludes children from the accountability system for managed care because they may not meet the one-year continuous enrollment requirement. This study explores the effect of churning in measuring childhood immunization coverage rates under the current accountability system. Data were collected from administrative databases at the Centers for Medicaid and Medicare Services and 12 states with high Medicaid managed care penetration. On average in the 12 states only 39% of the children enrolled in one specific managed care plan met the continuous enrollment requirement. However, Centers for Medicaid and Medicare Services data showed that 78% of children were enrolled in Medicaid (but not the same plan) continuously for 12 months. Both plan-specific rates and overall Medicaid rates varied greatly across the states. Policies that result in churning mean that many vulnerable children fall outside of the accountability structure intended to assure that they receive necessary services.