National Trends in Indicators of a Medical Home for Children

Importance of medical home domains on emergency visits using a cross-sectional national survey of US children

BACKGROUND AND OBJECTIVES

Receiving care at patient-centred medical homes (PCMH) is associated with reduced emergency department (ED) visits among children. Adverse social determinants of health (SDoH), such as lower socioeconomic status and household poverty, are associated with increased ED visits in children. The objective of this study is to use machine learning techniques to understand the relative importance of each PCMH component among different populations with adverse SDoH on the outcome of ED visits.

METHODS DESIGN, SETTING AND PARTICIPANTS

This study used the 2018-2019 pooled data from the National Survey of Children's Health (NSCH), an annual survey of parents and caregivers of US children from birth to 17 years. PCMH components were operationalised by classifying parent/caregiver responses into five domains: care coordination (CC), having a personal doctor or nurse, having a usual source of care, family-centred care and ease of getting referrals. SDoH included five categories: (1) social and community context, (2) economic stability, (3) education access and quality, (4) healthcare access and quality and (5) neighbourhood and built environment.

PRIMARY OUTCOME MEASURE

We used a split-improvement variable importance measure based on random forests to determine the importance of PCMH domains on ED visits overall and stratified by SDoH.

RESULTS

Overall, between 3% and 28% experienced one or more gaps in PCMH domains. Models show that problems with referrals (rank, 2; Gini, 83.5) and gaps in CC (rank, 3; Gini, 81.0) were the two most important domains of PCMH associated with ED visits in children. This result was consistent among black and Hispanic children and among children with lower socioeconomic status.

CONCLUSIONS

Our study findings underscore the importance of poor CC and referrals on ED visits for all children and those from disadvantaged populations. Initiatives for expanding the reach of PCMH should consider prioritising these two domains, especially in areas with significant minority populations.

The Pediatrician Workforce in the United States and China

From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country's child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China's Maternal Child Health system with broad community accessibility and health workers who provide preventive care.In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.

Barriers and strategies to integrate medical genetics and primary care in underserved populations: a scoping review

Despite clinical and technological advances, serious gaps remain in delivering genetic services due to disparities in workforce distribution and lack of coverage for genetic testing and counseling. Genetic services delivery, particularly in medically underserved populations, may rely heavily on primary care providers (PCPs). This study aims to identify barriers to integrating genetic services and primary care, and strategies to support integration, by conducting a scoping review. Literature synthesis found barriers most frequently cited by PCPs including insufficient knowledge about genetics and risk assessment, lack of access to geneticists, and insufficient time to address these challenges. Telegenetics, patient-centered care, and learning communities are strategies to overcome these barriers. Telegenetics supplements face-to-face clinics by providing remote access to genetic services. It may also be used for physician consultations and education. Patient-centered care allows providers, families, and patients to coordinate services and resources. Access to expert information provides a critical resource for PCPs. Learning communities may represent a mechanism that facilitates information exchange and knowledge sharing among different providers. As PCPs often play a crucial role caring for patients with genetic disorders in underserved areas, barriers to primary care-medical genetics integration must be addressed to improve access. Strategies, such as telegenetics, promotion of evidence-based guidelines, point-of-care risk assessment tools, tailored education in genetics-related topics, and other system-level strategies, will facilitate better genetics and primary care integration, which in turn, may improve genetic service delivery to patients residing in underserved communities.

Ambulatory quality, special health care needs, and emergency department or hospital use for US children

OBJECTIVE

This study examined family-reported ambulatory care quality and its association with emergency department and hospital utilization, and how these relationships differed across levels of medical complexity.

DATA SOURCES

The 2006-2013 Medical Expenditure Panel Survey (MEPS).

STUDY DESIGN

Secondary analysis of MEPS data. Variables fitting the National Quality Measures Clearinghouse clinical quality measures domain framework were selected. Exploratory factor analysis grouped ambulatory quality into 12 access, experience, or process measures. Weighted negative binomial regression stratified by health status identified associations between ambulatory quality and ED visits or hospitalizations.

DATA COLLECTION

41,497 children ≤18 years were included. The 5-item special health care needs (SHCN) screener categorized health status as complex, less complex, or no SHCN.

PRINCIPAL FINDINGS

Weighted SHCN proportions were 1.6 Percent complex, 18.2 Percent less complex, and 80.0 Percent no SHCN. Mean ED visits were 130 and 335 visits/1000 children/year for no/ complex SHCN, respectively. Mean hospitalizations were 20 and 175 hospitalizations/1000 children/year for no/complex SHCN, respectively. ED visits were associated with 8 of 12 quality measures for no/less complex SHCN. For example, usually/always receiving needed care right away was associated with 22 Percent lower ED visit rate (95% CI 0.64-0.96). Hospitalizations were associated with 4 of 12 quality measures for less complex SHCN. In complex SHCN, associations between ambulatory quality and ED/hospital use were weak and inconsistent.

CONCLUSIONS

Ambulatory quality may best predict ED and hospital use for children with no or less complex SHCN. Whether and how ambulatory care predicts emergency and hospital care in complex SHCN remains an important question.

Youth Access to Medical Homes and Medical Home Components by Race and Ethnicity

OBJECTIVES

Medical homes are an effective model of primary care. Historically, however, racial and ethnic minorities have not had equal access to medical homes. The present study estimated the national prevalence of youth's access to a medical home and its components by race and ethnicity.

METHODS

We conducted secondary data analysis using the 2016-2017 National Survey of Children's Health, a nationally representative, cross-sectional survey of U.S. youth age 0-17 years (N = 62,308). We obtained weighted and unweighted descriptive statistics and conducted multivariate logit regression models.

RESULTS

Although 49% of the total sample had access to a medical home, 57.1% of white youth had access compared to 37% of Hispanic youth and 39.7% of black youth. Among youth without a medical home, black youth had less access than white youth to a usual place for care (64.7% vs. 55.3%, adjusted odds ratio [aOR] = 0.82, 95% confidence interval [CI] 0.69-0.97) and family-centered care (78.1% vs. 66.7%, aOR = 0.64, 95% CI 0.52-0.79). Hispanic youth (68.2%) also had less access to family-centered care than white youth (aOR = 0.73, 95% CI 0.60-0.89). White youth were less likely to have access to effective care coordination, when needed, than Hispanic youth (46.2% vs. 53.5%, aOR = 1.35, 95% CI 1.09-1.66).

CONCLUSIONS FOR PRACTICE

Our findings suggest racial/ethnic disparities exist in youth's access to a medical home and its components. We posit the need for continued efforts to enhance access to medical homes for all youth. Future studies need to examine systemic barriers to youth's access to medical homes.

Impact of Social Capital on the Availability of Health Care Services

Children with special health care needs (CSHCN) and their families experience many structural, financial, psychosocial, and physical obstacles to accessing and fully utilizing a continuum of health care services, including a myriad of contextual barriers that are unique to their local communities. Social capital is one contextual barrier hypothesized in the literature to reduce access to health care services. To better understand the role of social capital in accessing health care services for this vulnerable population, a study was constructed using data from a large representative sample of CSHCNs. The analysis was conducted on data collected through the National Survey of Children's Health, a cross-sectional study of child health that includes information on physical and mental health; access to health care; and neighborhood, school, and social context. Logistic regression analyses were performed on a reduced, complete data set containing only CSHCN (n = 32,496) using 5 medical home variables and an investigator-constructed social capital composite score. Social capital was not found to be a complete mediator of individual medical home characteristics; however, each increase in the social capital scale reduced the odds of experiencing a delay in care of overall health care services by 12.5% (P = .006). The effects of social capital on the accessibility of health care services is significant and focusing on strengthening social capital within communities will improve overall health outcomes for this vulnerable group of children.

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.

Geographic Access to Cancer Care and Mortality Among Adolescents

PURPOSE

Adolescents with cancer have had less improvement in survival than other populations in the United States. This may be due, in part, to adolescents not receiving treatment at Children's Oncology Group (COG) institutions, which have been shown to increase survival for some cancers. The objective of this ecologic study was to examine geographic distance to COG institutions and adolescent cancer mortality.

METHODS

We calculated cancer mortality among adolescents and sociodemographic and healthcare access factors in four geographic zones at selected distances surrounding COG facilities: Zone A (area within 10 miles of any COG institution), Zones B and C (concentric rings with distances from a COG institution of >10-25 miles and >25-50 miles, respectively), and Zone D (area outside of 50 miles).

RESULTS

The adolescent cancer death rate was highest in Zone A at 3.21 deaths/100,000, followed by Zone B at 3.05 deaths/100,000, Zone C at 2.94 deaths/100,000, and Zone D at 2.88 deaths/100,000. The United States-wide death rate for whites without Hispanic ethnicity, blacks without Hispanic ethnicity, and persons with Hispanic ethnicity was 2.96 deaths/100,000, 3.10 deaths/100,000, and 3.26 deaths/100,000, respectively. Zone A had high levels of poverty (15%), no health insurance coverage (16%), and no vehicle access (16%).

CONCLUSIONS

Geographic access to COG institutions, as measured by distance alone, played no evident role in death rate differences across zones. Among adolescents, socioeconomic factors, such as poverty and health insurance coverage, may have a greater impact on cancer mortality than geographic distance to COG institution.