Children with special health care needs: Impact of health care expenditures on family financial burden

Exploring Psychosocial Distress in Caregivers of Children and Youth With Special Health Care Needs

PURPOSE

Caring for a child or youth with special health care needs (CYSHCN) can be overwhelming. Parents and caregivers may experience psychosocial distress, such as depression, frustration, and hopelessness. The purpose of the current study was to gain further insight into families' perspectives on the psychosocial impacts of caring for CYSHCN to identify gaps in health care systems and strengthen systems of support.

METHOD

A qualitative descriptive design was used in 16 parents and caregivers. Colaizzi's method of analysis and semi-structured interviews were used.

RESULTS

Six themes emerged from this study: (1) Stigma and Isolation, (2) Religion as a Coping Mechanism, (3) Financial Challenges, (4) Bearing the Burden, (5) Familial Denial, and (6) System-Related Concerns.

CONCLUSION

Psychiatric-mental health nurses (PMHNs) are in a pivotal position to use their knowledge, skills, and experiences to guide families. PMHNs can also engage communities and enhance mental health promotion to break the stigma associated with having a CYSHCN. [Journal of Psychosocial Nursing and Mental Health Services, 62(9), 37-46.].

Oral and dental health utilization determinants in special health care needs: a systematic review of reviews

BACKGROUND

Oral health is essential for overall well-being and can significantly improve quality of life. However, people with special health care needs (SHCN) often face challenges in accessing dental services. This study aimed to systematically review all available evidence on the oral and dental service utilization determinants among these individuals. Based on the findings, we also explore strategies to increase their access to dental care.

METHOD

This study is a systematic review of reviews based on the PRISMA 2020. Six databases were systematically searched including PubMed, Web of Science, Scopus, Embase, ProQuest, and Cochrane Library. Related keywords were applied up to 30 October 2023. This study includes all systematic, scoping, and rapid reviews written in English that examine the factors affecting dental service use among SHCNs. Microsoft Power BI was used for descriptive quantitative analysis, and MAXQDA version 10 was applied for qualitative thematic analysis.

RESULTS

The number of 2238 articles were retrieved based on the search strategy. After excluding duplications and appraising the eligibility, 7 articles were included. An examination of these 7 articles shows that they were all carried out from 2016 to 2022. Of these, 42% were systematic reviews, 42% used a scoping method, and one study (14%) was a rapid review. According to the thematic analysis, there were five main themes concerning determinants of oral and dental utilization of SHCN: "Financial considerations," "Patient-Provider Relationship," "Accessibility and Availability of Services," "Patient Factors," and "Quality of Care." Additionally, regarding strategies for improving utilization, three main themes emerged: "Education and Training," "Service Improvement," and "Policy Solutions.

CONCLUSION

This study delves into the intricate challenges SHCNs face in accessing dental services, highlighting the imperative for comprehensive interventions addressing supply and demand. Supply-oriented measures encompass dentist education, implementing financial policies for affordable services, and integrating dental care into primary healthcare systems. On the demand side, strategies revolve around empowering patients and caregivers and enhancing cultural inclusivity. Despite sustained efforts, current utilization rates fall short of optimal levels. Thus, effective strategic planning by policymakers and healthcare leaders is paramount to bolster dental service utilization among SHCNs, thereby enhancing their overall well-being.

Out-of-pocket expenses reported by families of children with medical complexity

Objectives

Due to their medical and technology dependence, families of children with medical complexity (CMC) have significant costs associated with care. Financial impact on families in general have been described, but detailed exploration of expenses in specific categories has not been systematically explored. Our objective was to describe out-of-pocket (OOP) expenses incurred by caregivers of CMC and to determine factors associated with increased expenditures.

Methods

This is a secondary observational analysis of data primary caregiver-reported OOP expenses as part of a randomized control trial conducted in Ontario, Canada. Caregivers completed questionnaires reporting OOP costs. Descriptive statistics were utilized to report OOP expenses and a linear regression model was conducted.

Results

107 primary caregivers of CMC were included. The median (IQR) age of participants was 34.5 years (30.5 to 40.5) and 83.2% identified as the mother. The majority were married or common-law (86.9%) and 50.5% were employed. The participant's children [median (IQR) age 4.5 (2.2 to 9.7); 57.9% male] most commonly had a neurological/neuromuscular primary diagnosis (46.1%) and 88% utilized medical technology. Total OOP expenses were $8,639 CDN annually (IQR = $4,661 to $31,326) with substantial expenses related to childcare/homemaking, travel to appointments, hospitalizations, and device costs. No factors associated with greater likelihood of OOP expenses were identified. A P-value of <0.05 was considered significant.

Conclusion

Caregivers of CMC incur significant OOP expenses related to the care of their children resulting in financial burden. Future exploration of the financial impact on caregiver productivity, employment, and identification of resources to mitigate OOP expenses will be important for this patient population.

Costs of Neonatal Medical Complexity: Impact on New Parent Stress and Decision-Making

OBJECTIVE

Parents of children with medical complexity experience substantial financial burdens. It is unclear how neonatal intensive care unit (NICU) clinicians prepare new parents of medically complex infants for this reality. This study explored new parent awareness of health care costs, desire to discuss costs with clinicians, and impact of costs on parents' medical decision-making.

STUDY DESIGN

The study design comprised semistructured interviews and surveys of parents of infants with medical complexity currently or previously in a NICU. Conventional content analysis was performed on interview transcripts, and descriptive analyses were applied to surveys.

RESULTS

Thematic saturation was reached with 27 families (15 NICU families and 12 post-NICU families) of diverse race/ethnicity/education/household income. Most were worried about their infants' current/future medical expenses and approximately half wanted to discuss finances with clinicians, only one parent had. While finances were not part of most parent's NICU decision-making, some later regretted this and wished cost had been incorporated into treatment choices. The family desire to discuss costs did not vary by family financial status. Parents described their infant's health care costs as: "We are drowning"; and "We'll never pay it off."

CONCLUSION

Most parents were worried about current and future medical expenses related to their infant's evolving medical complexity. Many wanted to discuss costs with clinicians; almost none had. NICU clinicians should prepare families for the future financial realities of pediatric medical complexity.

KEY POINTS

· Many families want to discuss costs with NICU clinicians.. · Some families want costs to be a part of medical decisions.. · Few families currently discuss costs with NICU providers..

Children With Special Health Care Needs: An Analysis of National Survey of Children's Health Database

Background Children with Special Health Care Needs (CSHCN) represent a diverse pediatric population requiring healthcare services beyond typical childhood needs. This study analyzes data from the 2016-2020 National Survey of Children's Health Database to elucidate demographic patterns, prevalence rates, and nuanced factors influencing the health and well-being of CSHCN. Methods This retrospective observational study focuses on children aged 0-17 who are identified as CSHCN based on Maternal and Child Health Bureau criteria. A comprehensive analysis of the National Survey of Children's Health (NSCH) database examines key variables, including health outcomes, healthcare utilization, parental-reported health status, and socio-demographic factors. Stratified random sampling ensures national representation. Results The study encompassed 40,335 patients, revealing that 14.6% (CI: 14.0-15.3, n=6,445) of CSHCN received care in a well-functioning system. Across age groups, 19.1% (CI: 14.0-15.3, n=6,445) of CSHCN aged 0-5 received ongoing treatment, contrasting with 5.7% (CI: 5.2-6.2, n=1,599) in the 12-17 years group. Males exhibited a prevalence of 15% (CI: 14.1-15.9, n=3,674), and females had 14.2% (CI: 13.2-15.2, n=2,771). Racial disparities were noted; non-Hispanic Native Hawaiian/Other Pacific Islander children had a 3% (CI: 1.1-8.1, n=6) prevalence. Across Federal Poverty Level categories, prevalence ranged from 12.5% (CI: 11.5-13.6, n=1,753) to 17.7% (CI: 16.6-18.9, n=2,856). Notably, 18.5% (CI: 17.4-19.7, n=3,515) of children without adverse experiences were CSHCN. Among CSHCN in two-parent currently married households, 15.9% (CI: 15.0-16.8, n=4,330) received treatment, while those in unmarried households had a prevalence of 12.9% (CI: 10.5-15.7, n=335). CSHCN with parents born in the United States showed a prevalence of 15.4% (CI: 14.7-16.1, n=5,257). Conclusion This study provides valuable insights into the prevalence and demographic patterns of CSHCN. Limitations include potential recall bias and the retrospective study design. Despite these constraints, the findings lay a foundation for future research and targeted interventions, fostering a deeper understanding of the evolving landscape of pediatric healthcare in the United States.

Material Hardship, Protective Factors, Children's Special Health Care Needs, and the Health of Mothers and Fathers

BACKGROUND

Parents of children with special health care needs (CSHCN) are at risk of poorer health outcomes. Material hardships also pose significant health risks to parents. Little is known about how protective factors may mitigate these risks and if effects are similar between mothers and fathers.

METHODS

This was a cross-sectional survey study conducted using the US 2018/2019 National Survey of Children's Health, including parents of children 0 to 17 with income <200% of the federal poverty level. Separately, for parents of children with and without special health care needs (N-CSHCN), weighted logistic regression measured associations between material hardship, protective factors (family resilience, neighborhood cohesion, and receipt of family-centered care), and 2 outcomes: mental and physical health of mothers and fathers. Interactions were assessed between special health care needs status, material hardship, and protective factors.

RESULTS

Sample consisted of parents of 16,777 children; 4440 were parents of CSHCN. Most outcomes showed similar associations for both mothers and fathers of CSHCN and N-CSHCN: material hardship was associated with poorer health outcomes, and family resilience and neighborhood cohesion associated with better parental health outcomes. Family-centered care was associated with better health of mothers but not fathers. Interaction testing showed that the protective effects of family resilience were lower among fathers of CSHCN experiencing material hardship.

CONCLUSIONS

Family resilience and neighborhood cohesion are associated with better health outcomes for all parents, though these effects may vary by experience of special health care needs, parent gender, and material hardship.

The financial burden experienced by families during NICU hospitalization and after discharge: A single center, survey-based study

To investigate a broad array of costs and perceived financial burden (FB) faced by families of NICU graduates both during hospitalization and after discharge. Cross-sectional survey-based study design. A survey measuring socio-demographics, direct non-medical costs, indirect costs, social support and perceived FB was developed. One-hundred-twenty-two pairs of parents of NICU graduates participated in the study. Most of the families (87.7%) experienced FB due to NICU hospitalization. The median cost of visiting infant during NICU admission was 615 euros (range: 42,7320). FB correlated with cost for drugs (ρ = .271, p < .05, 95%CI:[.020, .490]), dietary supplement (ρ = .385, p < .05, CI:[.010, .665]), behavioral disorders (ρ =  -.186, p < .05, 95%CI:[-.356, -.003]), language delay (ρ = .243, p < .01, CI:[-.408, -.063]) and comorbidities (ρ =  -.206, p < .05, 95% CI:[-.374, -.024]). Transportation costs due to medical visits (ρ = .415, p < .01, 95% CI:[.239, .564]) and therapy sessions (ρ = .517, p < .05, CI:[.121, .771]) correlated with higher FB. Grandparents of the infant were the most frequent source of help (86.1%). Families having infants with adverse outcome experienced more hospitalizations after NICU discharge (p < .05) and higher FB (p < .01) than families with typically developing infant. Lack of government financial help was associated with higher perceived FB (CI:[1.117,29.127], p < .05).    Conclusions: Our findings demonstrated that parents of NICU graduates experience high rates of FB, highlighting their sources (e.g., grandparents support) and difficulties (e.g., private therapy costs) through the lens of patient perspective. Our study promotes reflection on policies which should be adopted from the European health services that are similar to the Italian one to support NICU graduate families and reduce inequalities. What is Known: • Families of NICU graduates face several kinds of costs during hospitalization and after discharge. What is New: • NICU hospitalization is a multifaceted event that impact financial burden experienced by families. • NICU graduate families whose infant had adverse outcome and felt lack of financial help from local policy makers experience higher rates of financial burden.

Social prescribing for children and young people with neurodisability and their families initiated in a hospital setting: a systematic review

OBJECTIVES

Social prescribing (SP) is a non-medical intervention in which professionals refer patients to a link worker (LW), who connects them with appropriate support. Children and young people (CYP) with neurodisability often have unmet needs and may bypass community initiatives. We undertook a review of hospital-initiated SP for CYP with neurodisability.

DESIGN

Systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance and using Mixed Methods Appraisal Tool.

DATA SOURCES

Medline, PsycINFO, PsycARTICLES, Embase, CINAHL, Scopus, Web of Science and FutureNHS, searched from 1 January 2000 to 19 October 2023, with no language restrictions.

ELIGIBILITY CRITERIA

Studies describing SP interventions for CYP (ages 0-25 years) with neurodisability/neurodivergence.

EXCLUSIONS

interventions outside of secondary care; with no description; or no LW.

DATA EXTRACTION AND SYNTHESIS

Two researchers independently screened references. Data were charted, summarised, quality assessments performed and narratively reviewed.

RESULTS

After removal of duplicates, 518 references were identified. Following screening, eight articles (covering five SP schemes) were included. Rahi et al connected 68 families of CYP newly diagnosed with visual impairment to a community LW. Families needed information about social and educational services, and emotional support. Healthcare professionals had more time for clinical issues. Six papers described three different digital interventions supporting in total 86 CYP with traumatic brain injury and their families. Wade et al (2004, 2005a, 2005b) provided a website with core and individualised sessions, and weekly therapist support. Wade et al (2018) provided a smartphone application, website and weekly meetings with an online coach. These interventions boosted social behaviours. Wade et al (2014, 2015) found that online family problem-solving therapy improved overall child functioning compared with self-guided resources. Toutain et al (2009) provided non-medical support to 11 children with fetal alcohol syndrome and their mothers. No outcome data were provided. Studies reported benefits to health, well-being, healthcare usage, knowledge, skills, satisfaction and service delivery.

CONCLUSION

Literature describing hospital-initiated SP schemes for CYP with neurodisability, while sparse, suggests potential benefit.

PROSPERO REGISTRATION NUMBER

CRD42022384188.

Typologies of dependency, household characteristics, and disparity in formal and informal care use: analysis of community-dwelling long-term care insurance claimants in an urban municipality of China

BACKGROUND

A comprehensive understanding of subgroups of community-dwelling older adults and their long-term care (LTC) utilization can help to promote equality in the long-term services and support system. Dependency and household characteristics were found to affect the LTC utilization of homebound older adults. However, few studies considered the typologies of dependency of older populations according to co-occurring limitations, and little is known about differences in LTC use among elderly of typologies of dependency under distinct household conditions.

METHODS

We aimed to identify typologies of dependency of older adults living at home and explore the disparities in formal care and informal care use among typologies of dependency by income and living situation. In this cross-sectional study, we used the public long-term care insurance (LTCI) database of Yiwu, Zhejiang Province, China, and included 1675 individuals aged ≥ 60 years living at home. Cluster analysis was conducted to determine typologies of dependency among older adults. A two-step multilevel analysis was used to examine disparities in formal and informal care use related to household income and living status among typologies of dependency.

RESULTS

Seven dependency clusters were identified. Pro-wealthy inequalities in both formal and informal care use were found in the least dependent cluster and the limited-locomotion cluster. Pro-poor inequalities in formal care use were found in the fully dependent cluster without impaired vision and the cluster with intact continence and vision. Living with family members was positively associated with receiving formal care for the fully dependent cluster. Older adults in most clusters were more likely to use informal care when living with family members, except for the least dependent cluster and the limited-locomotion cluster.

CONCLUSIONS

Our findings suggest that household inequalities in LTC use varied among typologies of dependency of older adults, which may provide insights for researchers and policymakers to develop tailored LTC and targeted LTCI programs for older adults living at home and their family caregivers, considering both typologies of dependency and household characteristics.

Burden of care and a sense of loneliness in caregivers of children with type 1 diabetes. a cross-sectional study

BACKGROUND

Treatment of type 1 diabetes is a process involving not only sick children, but also their caregivers.

AIM

To assess the burden of care and sense of loneliness in caregivers of children with type 1 diabetes. Also, an analysis was conducted of the connection between sociodemographic factors characterizing caregivers and the clinical factors characterizing sick children and between the burden of care and the sense of loneliness.

MATERIALS AND METHODS

The study included 125 caregivers of children with type 1 diabetes. In order to collect the research data, the Caregiver Burden Scale and the Revised UCLA Loneliness Scale were used.

RESULTS

In the research group, the total result in the caregiving burden scale was 2.14, which remains within the average burden level. Caregivers showed the highest burden level in the General Strain Subscale. The analysis showed that mothers experience a greater burden of care than fathers in the General Strain Subscale and that caregivers of younger children are more burdened with care within the Isolation and Disappointment Subscales. Moderate high degree of loneliness was shown in 4.8% of caregivers. A higher burden of care for caregivers of children with type 1 diabetes is accompanied by a higher sense of loneliness.

CONCLUSIONS

The results of this study may help healthcare professionals plan a holistic, family-centered care program that will take into account factors that increase the burden of care: younger age of the affected child, motherhood, caregiver unemployment, feelings of loneliness, lower education, caregiver unemployment, blood glucose meter measurements, and frequent night-time blood glucose measurements.

TAX4U Pilot Trial: Addressing Material Needs in the Pediatric Hospital Setting

OBJECTIVE

Interventions to address poverty and food insecurity in pediatric hospital care have been scarce. Access to government support is based on the completion of taxes. Medical-financial partnerships are defined as novel cross-sector collaborations in which health care systems and financial service organizations work collaboratively to improve health by reducing financial stress. The objective of our pilot study was to assess the feasibility of implementing a "free tax service" within a pediatric academic hospital setting.

METHODS

A pilot randomized controlled trial "TAX4U" was conducted from November 2020 until April 2021 in the general inpatient setting of an academic pediatric hospital. Eligible families were randomly assigned to receive either "free tax services" according to the Canada Revenue Agency-funded Community Volunteer Income Tax Program (CVITP) or "care as usual."

RESULTS

A total of 140 caregivers filled in the 8-question recruitment survey. We found that 101 (72%) families were not eligible to participate in the study. Reasons for ineligibility were not meeting CVITP criteria (n = 59, 58%), already filed tax (n = 25, 25%), and families did not sign the consent form (n = 17, 17%). Thirty-nine families were randomly assigned, with 20 (51.3%) families assigned to the intervention and 19 (48.7%) families receiving care as usual. Ultimately, 7 (35%) families received the tax intervention.

CONCLUSIONS

Offering free tax services may be feasible and reached vulnerable families in a pediatric hospital setting; however, the inclusion criteria of the CVITP program did not meet the needs of caregivers. Further research should explore offering a full-scope medical-financial partnership that meets the needs of low-income families in a hospital setting.

Chronic Illness in Children and Foregone Care Among Household Adults in the United States: A National Study

BACKGROUND

Childhood chronic illness imposes financial burdens that may affect the entire family.

OBJECTIVE

The aim was to assess whether adults living with children with 2 childhood chronic illnesses-asthma and diabetes-are more likely to forego their own medical care, and experience financial strain, relative to those living with children without these illnesses.

RESEARCH DESIGN

2009-2018 National Health Interview Survey.

SUBJECTS

Adult-child dyads, consisting of one randomly sampled child and adult in each family.

MEASURES

The main exposure was a diagnosis of asthma or diabetes in the child. The outcomes were delayed/foregone medical care for the adult as well as family financial strain; the authors evaluated their association with the child's illness using multivariable logistic regressions adjusted for potential confounders.

RESULTS

The authors identified 93,264 adult-child dyads; 8499 included a child with asthma, and 179 a child with diabetes. Families with children with either illness had more medical bill problems, food insecurity, and medical expenses. Adults living with children with each illness reported more health care access problems. For instance, relative to other adults, those living with a child with asthma were more likely to forego/delay care (14.7% vs. 10.2%, adjusted odds ratio: 1.27; 95% CI: 1.16-1.39) and were more likely to forego medications, specialist, mental health, and dental care. Adults living with a child with diabetes were also more likely to forego/delay care (adjusted odds ratio: 1.76; 95% CI: 1.18-2.64).

CONCLUSIONS

Adults living with children with chronic illnesses may sacrifice their own care because of cost concerns. Reducing out-of-pocket health care costs, improving health coverage, and expanding social supports for families with children with chronic conditions might mitigate such impacts.

Partnering with Family Advocates to Understand the Impact on Families Caring for a Child with a Serious Mental Health Challenge

Family-driven care is a key principle of the system of care framework, but little research has documented the impact caring for a child with a serious mental health challenge has on families. In partnership with family advocates, this prospective, descriptive study was conducted to understand the impact a child's mental health challenge has on families' time, finances, life events, and caregiver employment. Study results showed the average family spent over $250 a week in unreimbursed costs, even though 84% of the children in the study received Medicaid. Caregivers spent approximately 10 h per week attending to the child's mental health needs, not including direct care for the child. Caregivers also reported a substantial impact on their employment. The results of this study have implications for the system of care supports for families. Perhaps most importantly, systems must utilize two-generation strategies in systems of care to minimize the impact on caregiver employment.

Oral Care for Children with Special Healthcare Needs in Dentistry: A Literature Review

Oral health is a very important aspect of general health, especially for vulnerable groups such as children with special healthcare needs. It is important to provide appropriate oral care in order to promote quality of life and good health for everyone, especially for children with special healthcare needs. Method: We reviewed the recent literature to collect knowledge regarding the delivery of quality oral care to children with special healthcare needs. We also explored some of the treatment management options that could address the needs of these children when attending dental clinics. Result: Unfortunately, we noted significant inequalities with issues related to oral health among those children. This situation often results in limitations to the activities of daily living for these children. There is therefore a need for much-needed advancements and refinements in oral healthcare to address the needs of children who have special healthcare needs. Conclusions: Providing children with special healthcare needs with high-quality dental care may necessitate active liaisons with healthcare facilitators and will require work across professions to make certain that these children’s oral health is also prioritized. Coordinated efforts by dental professionals are needed to provide dental health education and preventive interventions for these children.

Full-Time or Working Caregiver? A Health Economics Perspective on the Supply of Care for Type 1 Diabetes Patients

Type 1 diabetes mellitus (T1DM) is a chronic disease requiring lifelong insulin treatment. T1DM patients require care given not only by themselves but also by their family members, particularly in childhood-onset cases. This study aims to identify the relationship between health expenditure, HbA1c and other health outcomes and the socio-economic status of patients and their families, with a focus on family employment status, i.e., whether the caregiver is employed or is a homemaker. To clarify the relationship between the level of health, such as expenditure on health care and HbA1c, and the socioeconomic status of patients and their families, we focus on whether they are “potential full-time caregivers”. Using this analysis, we estimated the hypothetical health care expenditure and HbA1c and showed that male patients have higher expenditure and lower HbA1c when their caregiver is a potential full-time caregiver, whereas younger female patients have higher health care expenditure and lower HbA1c when their caregiver is employed. This finding is not meant to serve as criticism of health care policy in this area; rather, the aim is to contribute to economic policy in Japan for T1DM patients 20 years and older.

Food insecurity during COVID-19 in a Canadian academic pediatric hospital: a cross-sectional survey

BACKGROUND

Hospital-based food insecurity is defined as the inability of caregivers to obtain adequate food during their child's hospital admission. We aimed to measure the prevalence of household and hospital-based food insecurity, and to explore the associations with caregiver distress in an academic pediatric hospital setting.

METHODS

We conducted a cross-sectional survey of caregivers of children admitted to the general pediatric ward of an academic pediatric hospital in Toronto, Ontario, from April to October 2020. We measured household food insecurity using the 18-item Household Food Security Survey Module, and included 3 adapted questions about hospital-based food insecurity. We measured caregiver distress with the Distress Thermometer for Parents. We used descriptive statistics to assess the proportion of respondents with food insecurity, and linear regression models to explore the relation of household (adult and child) and hospital-based food insecurity with caregiver distress. We used thematic analysis to explore caregivers' feedback.

RESULTS

We contacted 851 caregivers, and 775 (91.1%) provided consent to participate. Overall, 430 (50.5%) caregivers completed at least part of the survey. Caregivers described a high prevalence of household (34.2%) and hospital-based (38.1%) food insecurity. Adult (β = 0.21, 95% confidence interval [CI] 0.07-0.36), child (β = 0.38, 95% CI 0.10-0.66) and hospital-based (β = 0.56, 95% CI 0.30-0.83) food insecurity were significantly associated with caregiver distress, independent of covariates. We identified financial burden, emotional and practical barriers, stress obtaining food and advocacy for food as important themes in caregiver feedback.

INTERPRETATION

Both household and hospital-based food insecurity were highly prevalent among caregivers. To reduce caregiver distress, hospitals need to consider reducing barriers for caregivers in obtaining food for themselves during their child's admission.

Underinsurance Among Children in the United States

OBJECTIVES

We describe the change in the percentage of children lacking continuous and adequate health insurance (underinsurance) from 2016 to 2019. We also examine the relationships between child health complexity and insurance type with underinsurance.

METHODS

Secondary analysis of US children in the National Survey of Children's Health combined 2016-2019 dataset who had continuous and adequate health insurance. We calculated differences in point estimates, with 95% confidence intervals (CIs), to describe changes in our outcomes over the study period. We used multivariable logistic regression adjusted for sociodemographic characteristics and examined relationships between child health complexity and insurance type with underinsurance.

RESULTS

From 2016 to 2019, the proportion of US children experiencing underinsurance rose from 30.6% to 34.0% (+3.4%; 95% CI, +1.9% to +4.9%), an additional 2.4 million children. This trend was driven by rising insurance inadequacy (24.8% to 27.9% [+3.1%; 95% CI, +1.7% to +4.5%]), which was mainly experienced as unreasonable out-of-pocket medical expenses. Although the estimate of children lacking continuous insurance coverage rose from 8.1% to 8.7% (+0.6%), it was not significant at the 95% CI (-0.5% to +1.7%). We observed significant growth in underinsurance among White and multiracial children, children living in households with income ≥200% of the federal poverty limit, and those with private health insurance. Increased child health complexity and private insurance were significantly associated with experiencing underinsurance (adjusted odds ratio, 1.9 and 3.5, respectively).

CONCLUSIONS

Underinsurance is increasing among US children because of rising inadequacy. Reforms to the child health insurance system are necessary to curb this problem.

A conceptual framework for understanding financial burden during serious illness

Life-threatening illness is associated with financial burden among families. During this time, care-related expenses often increase. The concept of financial burden has not fully been explored nor conceptually described in the literature. Our study coalesces the empirical literature on financial burden into a more comprehensive multidimensional theoretical framework to understand financial burden among patients and families dealing with serious illness. Using Jabareen's phased approach for building conceptual frameworks, we synthesized the existing scientific literature (including existing measures of financial burden) to construct an empirically derived model. Definitions of financial burden are overlapping with similarities, but also inconsistencies. Many studies have focused more on objective and operational definitions, than subjective and conceptual aspects. Regarding measures for financial burden, many studies have only used a few items. The financial burden is dependent on the illness trajectories and duration. By considering multidimensionality, we illustrate potential financial burden factors (objective, coping, and subjective). Although anticipation and expectations about future financial issues are important, patients and caregivers generally experience objective aspects of burden, followed by subjective impressions of burden. Coping skills likely reduce subjective burden. Based on the results, we redefine the financial burden among patients with life-threatening illness and caregivers.

Caregiver burden versus intensity of anxiety and depression symptoms in parents of children with cerebral palsy as well as factors potentially differentiating the level of burden: a cross-sectional study (Poland)

OBJECTIVES

To assess the relationship between caregiver burden and severity of symptoms of anxiety/depression in parents of children with cerebral palsy (CP), and to identify factors differentiating the level of caregiver burden.

SETTING

Regional rehabilitation centres in South-Eastern Poland.

PARTICIPANTS

The study involved 190 parents of children with CP, that is, 138 women and 52 men.

PRIMARY AND SECONDARY OUTCOME MEASURES

Caregiver burden was assessed using Caregiver Burden Scale (CBS), while the intensity of anxiety and depression symptoms was measured using Hospital Anxiety and Depression Scale (HADS). Potential predictors were examined using Gross Motor Function Classification System for Cerebral Palsy (GMFCS), Barthel Index (BI) as well as a questionnaire focusing on the characteristics of the child, the parent and the family. The analyses applied Pearson's linear correlation coefficient as well as multiple regression analysis.

RESULTS

All the CBS measures are significantly correlated to HADS-A (anxiety) and HADS-D (depression). Intensity of anxiety is most visibly linked to CBS measures of disappointment and environment (p<0.0001), while severity of depression is related to emotional involvement and general strain (p<0.0001). The factors differentiating caregiver burden measure in the subscales of general strain (p<0.0001) and social isolation (p<0.0001) include the child's age and BI, and the parent's health status; in the subscale of disappointment (p<0.0001)-the child's age, BI, GMFCS, as well as the parent's age and health status; in the subscale of emotional involvement (p=0.0007)-BI, and the parent's health status; in the subscale of environment (p=0.0002)-the child's age and BI.

CONCLUSIONS

There is a positive linear relationship between the caregiver burden measures and severity of anxiety and depression. Effort should be made to relieve caregiver burden in parents of children with CP.

Family-centered Outcomes that Matter Most to Parents: A Pediatric Feeding Disorders Qualitative Study

OBJECTIVE

The purpose of this study was to examine the perspectives of caregivers of children with feeding disorders. We sought to understand their child's feeding impairment through the lens of caregivers, including the impact impairments had on daily life and social participation, what outcomes matter most to caregivers, contextual determinants that affect achieving desired outcomes, and how treatment approaches can optimally support families.

METHODS

We interviewed caregivers of children, ages 2 to 5 years, who received care at the Center for Feeding and Nutrition at MassGeneral Hospital for Children in Boston, MA. All children had a feeding disorder diagnosis, defined as an impairment in oral intake. We analyzed interview transcripts using principles of immersion-crystallization.

RESULTS

We reached thematic saturation after interviewing 30 caregivers (25 female). 66.7% of the children were white, 13.3% Asian, 10.0% black, and 10.0% were more than 1 race. Thirty percent were Hispanic. We identified four themes: feeding impairments impact the daily life and social participation of children; improving their child's health and quality of life is most important to caregivers; child, caregiver, and community factors are facilitators of achieving desired outcomes; whereas time, financial, access, and knowledge factors are barriers; and caregivers prefer treatment approaches that incorporate principles of family-centered care.

CONCLUSIONS

Given the daily life and social participation impacts of pediatric feeding disorders, treatment approaches should be family-centered, focus on functional and meaningful outcomes to improve the health and quality of life of children and their families, and address modifiable sociocontextual determinants.

Employment Outcomes After a Birth of a Child with a Developmental Disability: A National Nested Case-Control Study

Using records from the National Insurance Institute of Israel, we recognized all children with autism spectrum disorders (ASD, N = 8072) or hearing loss (HL, N = 2231) born in Israel between 2005 and 2010. Typical developed children were taken from a random 20% sample of children born during the same years (N = 227,492). Analyses were adjusted for year of birth, population group, parental ages, parental education, child birth order and peripherality. Working women, who gave birth to children with either ASD or HL, were at increased risk of not maintaining their working status over the 5 years after birth. There is a decreased ratio between household wage after and before birth, in families with children with either ASD or HL.

Material Hardships and Health Care Utilization Among Low-Income Children with Special Health Care Needs

OBJECTIVE

Material hardships, defined as difficulty meeting basic needs, are associated with adverse child health outcomes, including suboptimal health care utilization. Children with special health care needs (CSHCN) may be more vulnerable to the effects of hardships. Our objective was to determine associations between material hardships and health care utilization among CSHCN.

METHODS

We conducted a cross-sectional study surveying caregivers of 2- to 12-year-old CSHCN in a low-income, urban area. Independent variables were parent-reported material hardships: difficulty paying bills, food insecurity, housing insecurity, and health care hardship. Dependent variables were parent-reported number of emergency department (ED) visits, any hospital admission, and any unmet health care need. We used negative binomial and logistic regression to assess for associations between each hardship and each outcome.

RESULTS

We surveyed 205 caregivers between July 2017 and May 2018 and analyzed the data in 2018. After adjustment, difficulty paying bills (incidence rate ratio [IRR], 1.51; 95% confidence interval [CI], 1.08-2.12) and health care hardship (IRR, 1.72; 95% CI, 1.08-2.75) were associated with higher rates of ED visits. There were no associations between hardships and hospital admission. Difficulty paying bills (adjusted odds ratio [AOR], 2.13; 95% CI, 1.14-3.98), food insecurity (AOR, 1.95; 95% CI, 1.02-3.71), and housing insecurity (AOR, 2.71; 95% CI, 1.36-5.40) were associated with higher odds of unmet health care need.

CONCLUSIONS

Material hardships were associated with higher rates of ED visits and greater unmet health care need among low-income CSHCN. Future examination of the mechanisms of these associations is needed to enhance support for families of CSHCN.

Health care utilization and spending among privately insured children with medical complexity

Children with medical complexity have high health service utilization and health expenditures that can impose significant financial burdens. This study examined these issues for families with children enrolled in US private health plans. Using IBM Watson/Truven Analytics℠ MarketScan® commercial claims and encounters data (2012-2014), we analyzed through regression models, the differences in health care utilization and spending of disaggregated health care services by health plan types and children's medical complexity levels. Children in consumer-driven and high-deductible plans had much higher out-of-pocket spending and cost shares than those in health maintenance organizations and preferred provider organizations (PPOs). Children with complex chronic conditions had higher service utilization and out-of-pocket expenditures while having lower cost shares on various categories of services than those without any chronic condition. Compared to families covered by PPOs, those with high-deductible or consumer-driven plans were 2.7 and 1.7 times more likely to spend over US$1000 out of pocket on their children's medical care, respectively. Families with higher complexity levels were more likely to experience financial burdens from expenditures on children's medical services. In conclusion, policymakers and families with children need to be cognizant of the significant financial burdens that can arise from children's complex medical needs and health plan demand-side cost sharing.

Food insufficiency and children with special healthcare needs

OBJECTIVES

The purpose of this study was to examine the prevalence of food insufficiency, a more severe form of food insecurity, across levels of special healthcare needs among a nationally representative sample of children in the United States. The study also investigates whether medical home access serves as a possible protective mechanism against food hardship.

STUDY DESIGN

The study involves analysis of nationally representative cross-sectional data.

METHODS

The data used are the 2016 National Survey of Children's Health, a cross-sectional nationally representative sample of the US children (N = 48,709). Descriptive analyses and logistic regression analysis are used to estimate food insufficiency and its correlates by complexity of children's special healthcare needs.

RESULTS

Analysis showed that children with more complex special healthcare needs experienced roughly twice the rate of food insufficiency compared with children with no special healthcare needs or children with less complex healthcare needs. Multivariate analysis indicated that children with more complex healthcare needs face an increased risk of food insufficiency net of demographic and economic characteristics. Interaction models revealed that medical home access protects children with medical complexity from food insufficiency.

CONCLUSIONS

These findings document significantly elevated risk of food insufficiency among families with a child facing more complex special healthcare needs. Interventions in healthcare settings could include referrals to resources already in place to combat hunger such as food bank agencies and other resources that might help at-risk families obtain assistance through programs such as the Supplemental Nutrition Assistance Program and Women, Infants, and Children.

The Effect of Comprehensive Medical Care on the Long-Term Outcomes of Children Discharged from the NICU with Tracheostomy

Background:

Survival of infants with complex care has led to a growing population of technology-dependent children. Medical technology introduces additional complexity to patient care. Outcomes after NICU discharge comparing Usual Care (UC) with Comprehensive Care (CC) remain elusive.

Objective:

To compare the outcomes of technology-dependent infants discharged from NICU with tracheostomy following UC versus CC.

Methods:

A single site retrospective study evaluated forty-three (N=43) technology-dependent infants discharged from NICU with tracheostomy over 5½ years (2011-2017). CC provided 24-hour accessible healthcare-providers using an enhanced medical home. Mortality, total hospital admissions, 30-days readmission rate, time-to-mechanical ventilation liberation, and time-to-decannulation were compared between groups.

Results:

CC group showed significantly lower mortality (3.4%) versus UC (35.7%), RR, 0.09 [95%CI, 0.12-0.75], P=0.025. CC reduced total hospital admissions to 78 per 100 child-years versus 162 for UC; RR, 0.48 [95% CI, 0.25-0.93], P=0.03. The 30-day readmission rate was 21% compared to 36% in UC; RR, 0.58 [95% CI, 0.21-1.58], P=0.29). In competing-risk regression analysis (treating death as a competing-risk), hazard of having mechanical ventilation removal in CC was two times higher than UC; SHR, 2.19 [95% CI, 0.70-6.84]. There was no difference in time-to-decannulation between groups; SHR, 1.09 [95% CI, 0.37-3.15].

Conclusion:

CC significantly decreased mortality, total number of hospital admissions and length of time-to-mechanical ventilation liberation.

Impact of Non-medical Out-of-pocket Expenses on Families of Children With Cerebral Palsy Following Orthopaedic Surgery

PURPOSE

Limited research has been conducted on the non-medical out-of-pocket expenses (NOOPEs) incurred by families of children with chronic health conditions. The study objectives were to: 1) calculate the estimated NOOPEs incurred by families during hospitalization of their child, 2) identify predictors of high NOOPEs, and 3) assess the impact of the child's chronic health condition on the family's finances.

DESIGN AND METHODS

Prospective observational study. Parents were included if their child was 3-20years old, had severe, non-ambulatory cerebral palsy (CP), and scheduled for hip or spine surgery. Parents reported all NOOPEs incurred during their child's hospitalization using the Family Expense Diary. Families completed the subscales of the Impact on Family Scale and the Assessment of Caregivers Experience with Neuromuscular Disease. Descriptive and univariate and multiple hierarchical regression models were used in the analysis.

RESULTS

Fifty two parents participated. The total NOOPEs ranged from $193.00 to $7192.71 (M=$2001.92) per hospitalization representing an average of 4% of the family's annual earned income. Caregiver age (F=8.393, p<0.001), income (F=7.535, p<0.001), and distance traveled to the hospital (F=4.497, p=0.039) were significant predictors of high NOOPEs. The subscale scores indicated that a child's chronic health condition had a significant impact on family finances.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Hospitalization is associated with numerous NOOPEs that create additional financial demands for families caring for a child with severe CP. NOOPEs should be addressed when preparing families for their children's planned hospital admissions, especially those families of CSHCN who experience significant financial impacts secondary to their children's care.

Complex families, the social determinants of health and psychosocial interventions: Deconstruction of a day in the life of hospital social workers

The roles of hospital social workers are delineated in the literature; however, their daily interventions have only been described anecdotally. This study analyzes the daily work of social workers in a pediatric hospital through a survey completed which examined factors related to interventions utilized and time spent per case over a 1-day period. Length and types of interventions were associated with the social determinants of health, time since diagnosis, biopsychosocial issues, and perception of complexity. The study offers a snapshot of the personalized expertise, provided by social workers that addresses complex contextual and biopsychosocial concerns of patient and families.

A prospective study on the characteristics and subjects of pediatric palliative care case management provided by a hospital based palliative care team

Background

Case management is a subject of interest within pediatric palliative care. Detailed descriptions of the content of this type of case management are lacking. We aim to describe the contents of care provided, utilization of different disciplines, and times of usage of a pediatric palliative care case management program compared for patients with malignant disease (MD) and non-malignant disease (NMD).

Methods

A three-month prospective study, with questionnaires filled in by members of a pediatric palliative care team (PPCT) for each contact with parents.

Results

Four hundred fifty-five contacts took place with parents of 70 patients (27MD, 43NMD). Sixty-two percent of all contacts were with the specialized nurse. The child life specialists, psychologist and social worker were also regularly consulted, the chaplain was not consulted. Ninety-five percent of all contacts took place between 8 am and 6 pm during weekdays, a limited number between 6 pm and 9 pm. Twenty-five percent of all contacts were proactively initiated by the PPCT, 25 % were initiated by parents. In these care characteristics, no differences were seen for MD and NMD patients. Psychosocial topics were addressed most frequently. MD patients consulted the PPCT more often about school and NMD patients about socio-economic issues.

Conclusions

All different disciplines of the PPCT were regularly consulted, except for the chaplain. With an easy accessible team with a highly pro-active approach, availability from 8 am to 9 pm seems sufficient to accommodate patient’s and parent’s needs. More anticipation seems required for socio-economic topics. This insight in pediatric palliative case management can provide guidance in the development of a new PPCT.

Mental Health of Parents as Caregivers of Children with Disabilities: Based on Japanese Nationwide Survey

The number of children with disability is increasing gradually in Japan. Previous researches in other countries have reported that parents as caregivers (CGs) of children with disability have mental health problems, but the actual situation has not been examined nationwide in Japan so far. The aim of this study was to evaluate the association between mental health of CGs who had children with disability and characteristics of children, CGs, and household based on the nation-wide survey. This study utilized data from 2010 Comprehensive Survey of the Living Conditions, and defined children with disability aged 6 to 17. Individual data of children and CGs were linked, and 549 pairs of them were extracted. The Japanese version of Kessler 6 (K6) was used to assess mental health status of caregiver, scored 5 and over represented to general psychological distress. Logistic regression was used to evaluate the associations of interest. The almost half (44.4%) of CGs had psychological distress (k6 score; 5 +) in nationwide, and 8.9% of CGs might have serious mental illness (K6 score; 13 +). After adjusting covariates of child, CG, and household factors, CG having a current symptom (OR, 95% CI: 3.26, 1.97-5.39), CG's activity restriction (OR, 95% CI: 2.95, 1.38-6.32), low social support (OR, 95%CI: 9.31, 1.85-46.8), three generation family (OR, 95% CI: 0.49, 0.26-0.92), and lower 25% tile group of monthly household expenditure (OR, 95% CI:1.92, 1.05-3.54), were significantly associated with psychological distress of CGs. This study encourages health care providers to pay more attentions toward parent's mental health, especially for in case of having low social support, and lower income family. Further research should examine the detailed information of child's disease and disability, medical service use, and quality and quantity of social support in nationwide to straighten the system for supporting services of both children with disabilities and their CGs.

The Value Adults Place on Child Health and Functional Status

OBJECTIVES

To summarize the value adults place on child health and functional status and provide a new quantitative tool that enhances our understanding of the benefits of new health technologies and illustrates the potential contributions of existing data sets for comparative effectiveness research in pediatrics.

METHODS

Respondents, ages 18 years and older, were recruited from a nationally representative panel between August 2012 and February 2013 to complete an online survey. The survey included a series of paired comparisons that asked respondents to choose between child health and functional status outcomes, which were described using the National Survey of Children with Special Health Care Needs, a 14-item descriptive system of child health outcomes. Using respondent choices regarding an unnamed 7- or 10-year-old child, generalized linear model analyses estimated the value of child health and functional status on a quality-adjusted life-year scale.

RESULTS

Across the domains of health and functional status, repeated or chronic physical pain, feeling anxious or depressed, and behavioral problems (such as acting out, fighting, bullying, or arguing) were most valuable, as indicated by adult respondents' preference of other health problems to avoid outcomes along these domains.

DISCUSSION

These findings may inform comparative effectiveness research, health technology assessments, clinical practice guidelines, and public resource allocation decisions by enhancing understanding of the value adults place on the health and functional status of children.

CONCLUSIONS

Improved measurement of public priorities can promote national child health by drawing attention to what adults value most and complementing conventional measures of public health surveillance.

Correlates of wellness among youth with functional disabilities

BACKGROUND

The literature is more informative on the impediments to wellness among youth with functional limitations and less instructive on the state of wellness for this population.

OBJECTIVE

To explore overall wellness, and each sub-dimension of wellness, in a national sample of youth with functional limitations and to determine how demographic characteristics are associated with wellness.

METHODS

Using a previously validated screening instrument, we identify youth with functional limitations aged 12 to 17 represented in the 2011/12 National Survey of Children's Health. Survey items were coded to operationalize an overall wellness score comprised of four sub-dimensions of wellness (i.e., physical, intellectual, emotional, and social).

RESULTS

The mean overall wellness score was 26.7 (out of 40) and had an approximate normal distribution. Mean raw scores for each sub-dimension were as follows: social = 2.79 (out of 4; 69.7%); emotional = 4.09 (out of 6; 68.2%); intellectual = 3.79 (out of 8; 47.4%); and physical = 6.30 (out of 8; 78.7%). Lower wellness scores were associated with older age among youth, increasing number of chronic health conditions, lower income, single mother homes, and youth whose mother reported fair or poor mental health status (all p < 0.05). Higher wellness scores were positively associated with mother's education (p < 0.001).

CONCLUSIONS

Program planners should consider interventions that target youth with functional limitations shown to be at particular risk for lower overall wellness and promote family involvement and comprehensive supports, including maternal educational attainment, mental health screening, and referral.

Endoscopic third ventriculostomy has no higher costs than ventriculoperitoneal shunt

OBJECTIVE

To evaluate the cost of endoscopic third ventriculostomy (ETV) compared to ventriculoperitoneal shunt (VPS) in the treatment of hydrocephalus in children.

METHOD

We studied 103 children with hydrocephalus, 52 of which were treated with ETV and 51 with VPS in a prospective cohort. Treatment costs were compared within the first year after surgery, including subsequent surgery or hospitalization.

RESULTS

Twenty (38.4%) of the 52 children treated with VPS needed another procedure due to shunt failure, compared to 11 (21.5%) of 51 children in the ETV group. The average costs per patient in the group treated with ETV was USD$ 2,177,66±517.73 compared to USD$ 2,890.68±2,835.02 for the VPS group.

CONCLUSIONS

In this series there was no significant difference in costs between the ETV and VPS groups.

Families with special needs children: family health, functioning, and care burden

There are 11.2 million children with special health care needs in the United States or one in five households caring for a special needs child. A small group of children who need continuous medical, nursing, therapeutic services that enable them to survive is growing in numbers. This study examined physical health (physical functioning), mental health (emotional, social, and cognitive functioning; communication; and worry), family functioning (daily activities, family relationships), and care burden (caregiver employment, caregiving time, travel time, health-related out-of-pocket expenditures) of parent caregivers for medically complex, medical technology-dependent children. Data were collected once a month for 5 months on 84 parents recruited in South Florida using the Pediatric Quality of Life Family Impact Module. Physically, parents were tired when they woke up: too tired to do the things they liked to do and with little energy for chores or social activities. Mentally, they were frustrated, anxious, and angry; felt helpless and hopeless; had cognitive problems remembering and focusing on tasks; were worried about the child's medications, treatments, side effects; and were anxious about child's future and effect of the child's condition on other family members. Socially, they felt isolated and that people did not understand their family situation; they found it hard to talk with others including physicians and nurses. Average weekly hours of direct care was 33.0 (SD = 30.4 hours); average monthly out-of-pocket expenditures was $348.78 (SD = $623.34). It is essential to assess parents' physical and mental health and functioning and to provide interventions to improve health and functioning for both the parents and the children for whom they are caring.

Psychosocial support for children and families requiring renal replacement therapy

Chronic kidney disease (CKD) and the need for renal replacement therapy (RRT) can place a great strain on the child and family. As well as the medical and nutritional prescription, each child and family requires an individual psychosocial prescription that requires input from multiprofessional team members. The information needs of each child and family need to be constantly evaluated as well as the choice of therapy in relation to social, psychological and economic factors. Many tertiary units lack adequate "time" to deliver such assessments and coordinate the support and respite care for those on long-term dialysis, especially when significant numbers of children are now accepted onto RRT programmes with co-morbidities. National and international standards are needed for the staffing of comprehensive tertiary paediatric renal units as well as studies evaluating supportive care to families.

Access to care for children with autism in the context of state Medicaid reimbursement

This paper examines the role of state residence and Medicaid reimbursement rates in explaining the relationship between having autism and access to care for children. Three questions are addressed: (1) Is there variation across states in the relationship between having autism and access to care? (2) Does taking account of state residence explain a significant amount of the variation in this relationship? (3) Does accounting for Medicaid reimbursement rates enhance our understanding of this relationship? Data from the 2005 National Survey of Children with Special Health Care Needs were combined with state characteristics to estimate a hierarchical generalized linear model of the association between state residence, Medicaid reimbursement rate and problems accessing care for children with special health care needs with and without autism. Findings indicate there is significant variation between states in the relationship between having autism and problems accessing care, and accounting for state residence explains a significant amount of variation in the model. Medicaid reimbursement rates have an independent effect on access to care for children with autism: when families raising children with autism live in states with higher reimbursement rates, they have lower odds of experiencing problems accessing care. The state context in which families live impacts access to care for children with autism. Moreover, when families live in states with higher Medicaid reimbursement rates, they are less likely to experience problems getting care. The value of this analysis is that it helps identify where to look for strategies to improve access.

The employment and financial effects on families raising children with special health care needs: an examination of the evidence

INTRODUCTION

Over 10 million children in the United States have special health care needs (U.S. Department of Health & Human Services, 2008). Parents struggle to afford needed health care and wrestle with the dual responsibilities of caregiving and employment. Researchers from a variety of disciplines, health care, and social science, in particular, are analyzing what variables affect a family's ability to access needed health care while balancing work and caregiving.

METHODS

A systematic literature review was conducted on the past 11 years of research that examined insurance status, insurance type, family out-of-pocket expenses, employment outcomes (reductions in hours or stopping work all together), and the role of receiving care in a medical home.

RESULTS

It was found that private health insurance, more severe conditions, and specific diagnoses are related to increased expenses and employment changes. It was also found that receiving care in a medical home reduces both.

DISCUSSION

It is vital that clinicians and policy makers move forward in expanding the concept of the medical home model as a means to improving the well-being of families raising children with special health care needs.

A national profile of health care and family impacts of children with muscular dystrophy and special health care needs in the United States

We used the 2005-2006 National Survey of Children with Special Health Care Needs to compare 3 types of outcomes between children with and those without parental reported muscular dystrophy: (1) functional limitations; (2) health care experiences in terms of the 5 components of a medical home; and (3) family impacts, including financial or out-of-pocket costs and parental employment and time use. We used weighted logistic regression to examine their associations with muscular dystrophy after adjustment for socio-demographic characteristics. Among children with special health care needs, children with reported muscular dystrophy were much more likely to have difficulties with ambulation and self-care. They were more likely to have family members who reported financial problems, reduced or stopped employment, and spent more than 10 hours weekly providing or coordinating care. Muscular dystrophy was not associated with the likelihood of having a medical home after adjustment for socioeconomic status and other socio-demographic characteristics.

State-level income inequality and family burden of U.S. families raising children with special health care needs

Growing evidence supports the hypothesis that income inequality within a nation influences health outcomes net of the effect of any given household's absolute income. We tested the hypothesis that state-level income inequality in the United States is associated with increased family burden for care and health-related expenditures for low-income families of children with special health care needs. We analyzed the 2005-06 wave of the National Survey of Children with Special Health Care Needs, a probability sample of approximately 750 children with special health care needs in each state and the District of Columbia in the US Our measure of state-level income inequality was the Gini coefficient. Dependent measures of family caregiving burden included whether the parent received help arranging or coordinating the child's care and whether the parent stopped working due to the child's health. Dependent measures of family financial burden included absolute burden (spending in past 12 months for child's health care needs) and relative burden (spending as a proportion of total family income). After controlling for a host of child, family, and state factors, including family income and measures of the severity of a child's impairments, state-level income inequality has a significant and independent association with family burden related to the health care of their children with special health care needs. Families of children with special health care needs living in states with greater levels of income inequality report higher rates of absolute and relative financial burden.

Health Care Reform and Concurrent Curative Care for Terminally Ill Children: A Policy Analysis

Within the Patient Protection and Affordable Care Act of 2010 or health care reform, is a relatively small provision about concurrent curative care that significantly affects terminally ill children. Effective on March 23, 2010, terminally ill children, who are enrolled in a Medicaid or state Children's Health Insurance Plans (CHIP) hospice benefit, may concurrently receive curative care related to their terminal health condition. The purpose of this article was to conduct a policy analysis of the concurrent curative care legislation by examining the intended goals of the policy to improve access to care and enhance quality of end of life care for terminally ill children. In addition, the policy analysis explored the political feasibility of implementing concurrent curative care at the state-level. Based on this policy analysis, the federal policy of concurrent curative care for children would generally achieve its intended goals. However, important policy omissions focus attention on the need for further federal end of life care legislation for children. These findings have implications nurses.