Medical home disparities between children with public and private insurance

Association Between Insurance Type and Fluoride Varnish Application During Well-Child Visits in Massachusetts

OBJECTIVE

To compare rates of fluoride varnish (FV) applications during well-child visits for children covered by Medicaid and private medical insurance in Massachusetts.

METHODS

This cross-sectional study analyzed well-child visits for children aged 1 to 5 years paid by Medicaid and private insurance during 2016.Çô18 in Massachusetts. Multivariate regression models, with all covariates interacting with insurance type, were used to calculate odds ratios and adjusted predicted probabilities of fluoride varnish during well-child visits by calendar year and age.

RESULTS

Across 957,551 well-child visits, 40.0% were paid by private insurers. Unadjusted rates of fluoride varnish were significantly lower among well-child visits paid by private insurers (6.6%) than visits paid by Medicaid (14.2%). In the fully interacted regression model, the odds of a visit including fluoride varnish were significantly lower for older children than for children aged 1 for visits paid by both insurance types. Adjusted rates of fluoride varnish increased significantly from 2016 to 2018 for both insurance types. Moreover, rates were higher among visits for children covered under Medicaid than privately insured children in all years, and the differences by insurance type declined over time (2016: 8.0% points, 95% confidence interval.á=.á.êÆ8.7 to .êÆ7.3, 2018: 5.3% points, 95% confidence interval.á=.á.êÆ6.6 to .êÆ3.9).

CONCLUSIONS

Rates of fluoride varnish applications during well-child visits were low for both Medicaid and private insurance despite growth from 2016 to 2018 in Massachusetts. Low rates are concerning because this is a recommended service with the potential to help address racial, geographic, and income-based disparities in access and oral health outcomes.

Disparities in Access to Pediatric Otolaryngology Care During the COVID-19 Pandemic

OBJECTIVE

Racial/ethnic minority pediatric otolaryngology patients experience health disparities, including barriers to accessing health care. Our hypothesis for this study is that Hispanic or economically disadvantaged patients would represent a larger percentage of missed appointments and report more barriers to receiving care during the COVID-19 pandemic.

METHODS

A cross-sectional survey utilizing a modified version of the Barriers to Care Questionnaire was administered via telephone to no-show patients, and median income by zip code was collected. Chi-squared, logistic regression, and Student's t-tests were used to investigate any differences in those who did and did not keep their appointments as well as any differences in mean questionnaire scores.

RESULTS

No-show patients were more likely to be Hispanic than not (OR 2.3, 95% CI: 1.3, 3.9, P = .002) and to live in a zip code that had a median income less than 200% of the federal poverty level (OR 1.7, 95% CI: 1.2, 2.4, P = .004). Respondents with a high school degree tended to report more barriers to care compared to those with less education.

CONCLUSION

In our study, we identified ethnic, financial, and logistic concerns that may contribute to patients failing to keep their appointments with the otolaryngology clinic. Future studies are needed to assess the efficacy of measures aimed to reduce these barriers to care such as preventive plans to assist new patients and expanding telehealth services.

Social Factors Predictive of Intensive Care Utilization in Technology-Dependent Children, a Retrospective Multicenter Cohort Study

Objective: Technology-dependent children with medical complexity (CMC) are frequently admitted to the pediatric intensive care unit (PICU). The social risk factors for high PICU utilization in these children are not well described. The objective of this study was to describe the relationship between race, ethnicity, insurance status, estimated household income, and PICU admission following the placement of a tracheostomy and/or gastrostomy (GT) in CMC. Study Design: This was a retrospective multicenter study of children <19 years requiring tracheostomy and/or GT placement discharged from a hospital contributing to the Pediatric Health Information System (PHIS) database between January 2016 and March 2019. Primary predictors included estimated household income, insurance status, and race/ethnicity. Additional predictor variables collected included patient age, sex, number of chronic complex conditions (CCC), history of prematurity, and discharge disposition following index hospitalization. The primary outcome was need for PICU readmission within 30 days of hospital discharge. Secondary outcomes included repeated PICU admissions and total hospital costs within 1 year of tracheostomy and/or GT placement. Results: Patients requiring a PICU readmission within 30 days of index hospitalization for tracheostomy or GT placement accounted for 6% of the 20,085 included subjects. In multivariate analyses, public insurance [OR 1.28 (95% C.I. 1.12-1.47), p < 0.001] was associated with PICU readmission within 30 days of hospital discharge while living below the federal poverty threshold (FPT) was associated with a lower odds of 30-day PICU readmission [OR 0.7 (95% C.I. 0.51-0.95), p = 0.0267]. Over 20% (n = 4,197) of children required multiple (>1) PICU admissions within one year from index hospitalization. In multivariate analysis, Black children [OR 1.20 (95% C.I. 1.10-1.32), p < 0.001] and those with public insurance [OR 1.34 (95% C.I. 1.24-1.46), p < 0.001] had higher odds of multiple PICU admissions. Social risk factors were not associated with total hospital costs accrued within 1 year of tracheostomy and/or GT placement. Conclusions: In a multicenter cohort study, Black children and those with public insurance had higher PICU utilization following tracheostomy and/or GT placement. Future research should target improving healthcare outcomes in these high-risk populations.

Nationwide analysis of mortality and hospital readmissions in esophageal atresia

PURPOSE

The purpose of this study is to identify determinants of mortality and hospital readmission in infants born with esophageal atresia ± tracheoesophageal fistula.

METHODS

The Nationwide Readmissions Database (2010-2014) was queried for newborns with a diagnosis of esophageal atresia. Outcomes included mortality and readmissions at 30-day and 1-year.

RESULTS

3157 patients were identified, of which 54% were male. 81% had an additional congenital anomaly, and 35% had VACTERL association. Overall mortality at index hospitalization was 11% (n = 360) and was significantly higher with additional congenital anomalies (13%), VACTERL (19%), and Spitz classification II/III (18%) vs. isolated esophageal atresia/tracheoesophageal fistula (4%), all p < 0.001. After esophageal atresia repair (n = 2179), 10% (n = 212) were readmitted within 30 days and 26% (n = 563) within 1 year, with 17% admitted to different hospitals. Common diagnoses during readmission were GERD (54%), infections (42%), failure to thrive (17%), tracheomalacia (14%), and esophageal stricture (10%). Unplanned readmissions accounted for 85% of readmissions. A large number underwent operative procedures, most commonly esophageal dilation (17%) and fundoplication/gastrostomy (12%).

CONCLUSION

Our study has uncovered a high likelihood of complications and unplanned readmission within the first year of life for newborns with esophageal atresia. Coordinated multidisciplinary care may help to decrease unnecessary readmissions and improve outcomes in this vulnerable population.

TYPE OF STUDY

Retrospective comparative analysis.

LEVEL OF EVIDENCE

Level III.

Primary Care and Home Visiting Utilization Patterns among At-Risk Infants

OBJECTIVE

To describe well child care (WCC) utilization in the first year of life among at-risk infants, and the relationship to home visiting enrollment.

STUDY DESIGN

Retrospective cohort study using linked administrative data for infants ≥34 weeks' gestation from 2010 to 2014, within a regional, academic primary care system. Association between WCC visits and home visiting enrollment was evaluated using bivariate comparisons and multivariable Poisson regression. Latent class analysis further characterized longitudinal patterns of WCC attendance. Multivariable logistic regression tested the association between home visiting and pattern of timeliest adherence to recommended WCC.

RESULTS

Of 11 936 infants, mean number of WCC visits was 4.1 in the first 12 months of life. Of 3910 infants eligible for home visiting, 28.5% were enrolled. Among enrolled infants, mean WCC visits was 4.7 vs 4.4 among eligible, nonenrolled infants, P value < .001. After multivariable adjustment, there was no significant association between enrollment and WCC visit count (adjusted incident rate ratio 1.03, 95% CI 0.99, 1.07). Using latent class analysis, 3 WCC classes were identified: infants in class 1 (77.7%) were most adherent to recommended WCC, class 2 (12.5% of cohort) had progressively declining WCC attendance over the first year of life, and class 3 (9.8%) maintained moderate attendance. In multivariable regression, home visiting was associated with class 1 membership, aOR 1.27, 95% CI 1.04, 1.57.

CONCLUSIONS

A pattern of timely WCC attendance was more likely among infants in home visiting; however, most infants eligible for home visiting were not enrolled.

Outpatient Visits Before Ambulatory Care-Sensitive Hospitalization of Children Receiving Medicaid

OBJECTIVES

Hospitalizations for ambulatory care-sensitive conditions (ACSC) are measured to indicate health care system quality, with the premise that fewer hospitalizations would occur with better preceding outpatient care. Our objectives were to identify outpatient care received in the 7 days preceding acute pediatric hospitalizations and to compare receipt of outpatient care by hospitalization type (ACSC vs non-ACSC).

METHODS

This retrospective observational study used a 10-state database of Medicaid claims to identify outpatient visits within 7 days before acute unplanned hospitalization for children aged 0 to 17 years. We used logistic regression to assess the relationship between hospitalization type and occurrence of a preceding outpatient clinic visit, controlling for patient age, race/ethnicity, type of Medicaid, and complex chronic conditions.

RESULTS

Of 254,902 hospitalizations, 28.6% had a preceding outpatient visit. Thirty-five percent of hospitalizations were for ACSC. A greater percentage of ACSC versus non-ACSC hospitalizations had a preceding outpatient visit (31.1% vs 27.3%, P < .001). In multivariable analysis, characteristics associated with a preceding outpatient visit were age <1 versus 13 to 17 years (adjusted odds ratio [aOR] 2.4; 95% confidence interval [CI] 2.3-2.5), ≥2 vs 0 complex chronic conditions (aOR 1.9; 95% CI 1.8-2.0), Medicaid managed care versus fee for service (aOR 1.2; 95% CI 1.2-1.3), and ACSC versus non-ACSC hospitalization (aOR 1.2; 95% CI 1.1-1.2).

CONCLUSIONS

Although receipt of outpatient care was modestly higher in children hospitalized with an ACSC, most hospitalized children did not receive preceding outpatient care. Further investigation is needed to assess why such a large proportion of children do not receive outpatient care before acute unplanned hospitalization, especially for ACSC.

Coordinated Asthma Program Improves Asthma Outcomes in High-Risk Children

Innovative approaches within primary care are needed to reduce fragmented care, increase continuity of care, and improve asthma outcomes in children with asthma. Our objective was to assess the impact of coordinated team-based asthma care on unplanned asthma-related health care utilization. A multidisciplinary asthma team was developed to provide coordinated care to high-risk asthma patients. Patients received an in-depth diagnostic and family needs assessment, asthma education, and coordinated referral to social and community services. Over a 2-year period, 141 patients were followed. At both 1 and 2 years postintervention, there was a significant decrease from preintervention rates in urgent care visits (40%, P = .002; 50%, P < .0001), emergency department visits (63%, P < .0001; 70%, P < .0001), and inpatient hospitalization (69%, P = .002; 54%, P = .04). Our coordinated asthma care program was associated with a reduction in urgent care visits, emergency department visits, and inpatient hospitalizations among high-risk children with asthma.

Inhaled Corticosteroid Claims and Outpatient Visits After Hospitalization for Asthma Among Commercially Insured Children

OBJECTIVE

To determine rates of inhaled corticosteroid (ICS) claims and outpatient follow-up after asthma hospitalization among commercially insured children.

METHODS

We conducted a retrospective cohort analysis of children hospitalized for asthma using 2013 national Truven MarketScan data. Covariates included age, sex, region, length of stay, and having an ICS claim within 35 days before hospitalization. Outcome variables were a claim for any ICS-containing medication and outpatient visit within 30 days after discharge. Multivariable analysis used logistic regression.

RESULTS

A total of 5471 children aged 2 to 17 were included; 61% were boys, and mean age was 6.8 years. Forty-one percent had a claim for an ICS and 76% had an outpatient visit within 30 days after hospital discharge. In multivariable analysis, children who had an ICS claim within 35 days before the hospitalization were more likely to have an ICS claim within 30 days after discharge (relative risk [RR] 1.3, 95% confidence interval [CI] 1.2-1.5). The strongest predictor of an ICS claim within 30 days after discharge was attendance at an outpatient appointment (RR 1.4, 95% CI 1.3-1.6). Children aged 2 to 6 were more likely to attend an outpatient appointment (RR 1.1, 95% CI 1.1-1.2). Children with an ICS claim before admission were also more likely to attend an outpatient appointment (RR 1.1, 95% CI 1.004-1.1).

CONCLUSIONS

In this national sample of commercially insured children with asthma, rates of ICS claims after hospitalization are low despite high rates of outpatient visits. Both inpatient and outpatient physicians must play a role in increasing ICS adherence in this high-risk population of children with asthma.

Disparities in Patient- and Family-Centered Care During US Children's Health Care Encounters: A Closer Examination

OBJECTIVE

Patient- and family-centered care (PFCC), which recognizes the family as an integral partner in high-quality clinical decision-making, is important to improving children's health care. Studies examining PFCC disparities in the general US pediatric population, however, are sparse, and use methodology that might mislead readers to overestimate effect sizes because of the high prevalence of high-quality PFCC. We address these issues using improved statistical modeling of conceptually-grounded disparity domains on more recent data.

METHODS

This study examined 22,942 children in the 2011 to 2013 Medical Expenditure Panel Surveys (pooled cross-section) with at least 1 health care visit in the previous year (eligible for PFCC questions). We used robust-adjusted multivariable Poisson regression to estimate prevalence rate ratios-closer estimates of true risk ratios of highly prevalent outcomes-of 4 measures of high-quality PFCC and a composite measure.

RESULTS

Overall, PFCC quality prevalences were high, ranging from 95% to 97% across the 4 PFCC measures with 92% of parents reporting the composite measure. In multivariable analyses, lower prevalence of high-quality PFCC was consistently observed among publicly insured children (relative to the privately insured, prevalence rate ratios ranging from 0.978 to 0.984 across the PFCC measures; 0.962 in the composite) and children living in families below the poverty line (children at ≥400% of the poverty line had 1.018-1.045 times the prevalence of high-quality PFCC across the PFCC measures; 1.056 in the composite).

CONCLUSIONS

Although prevalence rate ratio methodology revealed smaller and perhaps clinically insignificant disparities in US children's PFCC quality than previously portrayed, nonetheless, several statistically significant disparities remain. The most consistent disparities identify those most vulnerable to PFCC quality: publicly insured and impoverished children.

Socioeconomic and Racial Disparities in Parental Perception and Experience of Having a Medical Home, 2007 to 2011-2012

OBJECTIVE

To evaluate whether socioeconomic (SES) and racial disparities in the parental perception and experience of having a medical home decreased from 2007 to 2011-2012.

METHODS

We used nationally representative samples of children aged 1 to 17 from the 2007 (n = 83,293) and 2011-2012 (n = 87,774) National Surveys of Children's Health. Multivariable logistic regression was used to test associations between SES (income, employment, and education) and race/ethnicity to the medical home and its subcomponents (personal doctor or nurse, usual source of care, family-centered care, referrals, care coordination), controlling for a priori identified covariates.

RESULTS

From 2007 to 2011-2012, fewer children overall had access to a medical home (56.9% vs 54.0%, aOR = 0.91, 95% confidence interval 0.86-0.96). There were no significant changes in SES and racial trends in access to the medical home during this time period. For example, parents of children <100% federal poverty level (FPL) were significantly less likely to report having a medical home than parents of children ≥400% FPL in 2007 and 2011-2012; however, this disparity did not significantly change during the time period (aOR = 0.98, 95% confidence interval 0.75-1.27). There were also no significant changes in SES and racial/ethnic disparities over time for each medical home subcomponent.

CONCLUSIONS

Despite widespread efforts to promote the medical home for all children, large SES and racial disparities in the parental perception and experience of having a medical home persisted from 2007 to 2011-2012.

Parental Perceptions of Family Centered Care in Medical Homes of Children with Neurodevelopmental Disabilities

Life course theory sets the framework for strong inclusion of family centered care (FCC) in quality medical homes of children with neurodevelopmental disabilities (CNDD). The purpose of this study was to explore the perceptions of families with their experiences of FCC in medical homes for CNDD. Using a structured questionnaire, the Family-Centered Care Self-Assessment Tool developed by Family Voices, this study surveyed 122 parents of CNDD in a large urban area during 2010-2012. Data collected information on FCC in the provision of primary health care services for CNDD and focused on family-provider partnerships, care setting practices and policies, and community services. Frequency analysis classified participants' responses as strengths in the "most of the time" range, and weaknesses in the "never" range. Only 31 % of parents were satisfied with the primary health care their CNDD received. Based on an accepted definition of medical home services, 16 % of parents reported their CNDD had most aspects of a medical home, 64 % had some, and 20 % had none. Strengths in FCC were primarily evident in the family-provider partnership and care settings when focused on meeting the medical care needs of the child. Weaknesses in FCC were noted in meeting the needs of families, coordination, follow-up, and support with community resources. Improvements in key pediatric health care strategies for CNDD are recommended. CNDD and their families have multifaceted needs that require strong partnerships among parents, providers, and communities. Quality medical homes must include FCC and valued partnerships with diverse families and community-based providers.

Using quality improvement to promote implementation and increase well child visits in home visiting

A key goal of home visiting is to connect children with medical homes through anticipatory guidance regarding recommended well child care (WCC). Substantial barriers to WCC among low socioeconomic families can limit achievement of this outcome. Quality improvement strategies have been widely adopted in healthcare but only recently implemented in home visiting to achieve program outcomes. The objective of this initiative was to increase the percentage of infants enrolled in home visiting who completed at least 3 recommended WCC visits in the first 6 months of life within a large, multi-model program comprised of 11 sites. A series of 33 quality improvement cycles were conducted at 3 sites involving 18 home visitors and 139 families with infants in the target age range. These were deployed sequentially, and changes within and across sites were monitored using trend charts over time. Adopted strategies were then implemented program-wide. Initiatives focused on staff training in WCC recommendations, data collection processes, monthly family tracking reports, and enhanced communication with primary care offices. Data were shared in iterative sessions to identify methods for improving adherence. Wide baseline variability across sites was observed, with the percentage of infants with recommended care ranging from 35% to 83%. Over the project timeline, the percentage of infants receiving at least 3 WCC visits in the first 6 months increased from 58% to 86%. Quality improvement within home visiting can be used to improve WCC adherence and provides an example of maximizing implementation of home visiting interventions.

Immigrant Families, Children With Special Health Care Needs, and the Medical Home

OBJECTIVE

Immigrant children in the United States historically experience lower-quality health care. Such disparities areconcerning for immigrant children with special health care needs (CSHCNs). Our study assesses the medical home presence for CSHCN by immigrant family type and evaluates which medical home components are associated with disparities.

METHODS

We used the 2011 National Survey of Children's Health, comparing the prevalence and odds of a parent-reported medical home and 5 specific medical home components by immigrant family types using bivariate and multivariate logistic regression.

RESULTS

Foreign-born CSHCNs were less likely than CSHCNs with US-born parents to have a medical home (adjusted odds ratio = 0.40, 95% confidence interval 0.19-0.85). The adjusted prevalence of having a medical home was 28% among foreign-born CSHCNs (P < .05) and 37% among CSHCNs with a foreign-born parent (P < .001), compared with 49% among CSHCNs with US-born parents. Foreign-born children without special needs also had a lower odds of a medical home, compared with children with US-born parents (adjusted odds ratio = 0.62, 0.46-0.83). The medical home component most frequently absent for immigrant children without special needs and CSHCNs with a foreign-born parent was family-centered care. In contrast, foreign-born CSHCNs most often lacked care coordination (adjusted prevalence = 37% versus 56% for CSHCNs with US-born parents; P < .05).

CONCLUSIONS

Disparities in medical home presence for CSHCNs appear to be exacerbated by immigrant family type. Efforts focused on improving family-centered care and care coordination may provide the greatest benefit for immigrant CSHCNs.

Emergency Hospital Admissions for Initial Febrile Urinary Tract Infection: Do Patient Demographics Matter?

BACKGROUND

In 2011, the American Academy of Pediatrics revised practice parameters regarding febrile urinary tract infection (fUTI) in children aged 2-24 months. The Section on Urology opposed the omission of voiding cystourethrogram (VCUG), and expressed concern that potential untoward consequences of deferring VCUG may be most felt by children on Medicaid.

OBJECTIVE

We ascertained imaging and characteristics of children presenting to the Emergency Department (ED) with initial fUTI to determine the impact of patient demographics on admissions for pyelonephritis.

METHODS

Children aged 2-24 months presenting to the ED with initial fUTI were identified. Demographics, insurance status, laboratory studies, renal-bladder ultrasound (RBUS), VCUG, and hospital admission status were evaluated.

RESULTS

Three-hundred fifty patients met inclusion criteria; 88 (25.1%) were admitted. Admitted patients were significantly (p < 0.001) younger (mean 0.31 ± 0.33 years) than those managed as outpatients (mean 0.91 ± 0.7 years). On univariate analysis, male gender (p < 0.001), Medicaid insurance (p < 0.05), and non-Hispanic race (p < 0.05) were associated with admission. Race retained significance on multivariate analysis; Caucasian children were 2.35 times (95% confidence interval [CI] 0.79-7.23) and African-American children 3.8 times more likely to be admitted than Hispanic patients (95% CI 1.88-7.63). Children with abnormal RBUS were 12.8 times more likely to require admission (95% CI 4.44-37.0). Medicaid was also independently predictive of admission; such patients were 2.6 times more likely to be admitted than those with private insurance (95% CI 1.15-5.88).

CONCLUSIONS

Abnormal ultrasound, non-Hispanic race, and public insurance were strongly associated with hospital admission in children presenting to the ED with initial febrile urinary tract infection.

Emergency room visits and readmissions after pediatric urologic surgery

OBJECTIVE

Reducing readmissions has become a focal point to increase quality of care while reducing costs. We report all-cause unplanned return visits following urologic surgery in children at our institution.

MATERIALS AND METHODS

Children undergoing urology procedures with returns within 30 days of surgery were identified. Patient demographics, insurance status, type of surgery, and reason for return were assessed.

RESULTS

Four thousand and ninety-seven pediatric urology surgeries were performed at our institution during 2012, with 106 documented unplanned returns (2.59%). Mean time from discharge to return was 5.9 ± 4.9 days (range, 0.3-24.8 days). Returns were classified by chief complaint, including pain (32), infection (30), volume status (14), bleeding (11), catheter concern (8), and other (11). Circumcision, hypospadias repair, and inguinal/scrotal procedures led to the majority of return visits, accounting for 21.7%, 20.7%, and 18.9% of returns, respectively. Twenty-two returns (20.75%) resulted in hospital readmission and five (4.72%) required a secondary procedure. Overall readmission rate was 0.54%, with a reoperation rate of 0.12%.

CONCLUSIONS

The rate of unplanned postoperative returns in the pediatric population undergoing urologic surgery is low, further strengthening the argument that readmission rates in children are not necessarily a productive focal point for financial savings or quality control.

Community health centers: medical homes for children?

OBJECTIVE

To explore medical home attributes of community health centers (CHCs) that provide care to low-income children nationwide compared to other providers for the poor.

METHODS

Cross-sectional study of children aged 0 to 17 years in the Medical Expenditure Panel Survey (MEPS; 2003 to 2009) who resided in families living at <200% of the federal poverty level (FPL) and had visits to a primary care setting. CHC visits were defined as a visit to a neighborhood/family health center, rural health clinic, or community health center. Independent measures included provider type, age, gender, race/ethnicity, insurance, FPL, number of parents at home, language, maternal education, health status, and special health care need. Dependent measures included 4 medical home attributes: accessibility, and family-centered, comprehensive, and compassionate care.

RESULTS

CHCs typically serve low-income children who are publicly insured or uninsured, come from racial/ethnic minority groups, and have poorer health status. Eighty percent to 90% of parents visiting both CHCs and other primary care providers rated high levels of family-centered, comprehensive, and compassionate care. However, CHCs had a 10% to 18% lower rating of accessibility (after-hours care, telephone access) even after controlling for sociodemographic characteristics. Racial/ethnic disparities existed at both settings, but these patterns did not differ between CHCs and other settings.

CONCLUSIONS

On the basis of parental reports, CHCs received similar ratings to other primary care providers for family-centered, comprehensive, and compassionate care, but lower ratings for accessibility. Further studies should examine strategies for practice transformation in CHCs to improve patient satisfaction and accessibility to optimize child health outcomes.

Medical home disparities are not created equal: differences in the medical home for children from different vulnerable groups

OBJECTIVE

To identify components of the medical home that contribute to medical home disparities for vulnerable children.

METHODS

Cross-sectional analysis of 2007 National Survey of Children's Health. Prevalence of components of the medical home were estimated by special health care needs (SHCN), race/ethnicity, primary language, and health insurance.

RESULTS

Medical home disparities for children with SHCN were driven by differences in getting help with care coordination, when needed (71% vs. 91% children without SHCN, p<.001). Medical home disparities for other groups were largely attributable to less family-centered care (Hispanic 49% and African American 55% vs. White 77%, p<.001; non-English primary language 37% vs. English 72%, p<.001; uninsured 45% and publicly insured 57% vs. privately insured 75%, p<.001).

CONCLUSIONS

The components of the medical home that contribute to medical home disparities differ between groups of vulnerable children. Medical home implementation may benefit from focusing on the specific needs of target populations.

Pediatric readmission prevalence and variability across hospitals

IMPORTANCE

Readmission rates are used as an indicator of the quality of care that patients receive during a hospital admission and after discharge.

OBJECTIVE

To determine the prevalence of pediatric readmissions and the magnitude of variation in pediatric readmission rates across hospitals.

DESIGN, SETTING, AND PATIENTS

We analyzed 568,845 admissions at 72 children's hospitals between July 1, 2009, and June 30, 2010, in the National Association of Children's Hospitals and Related Institutions Case Mix Comparative data set. We estimated hierarchical regression models for 30-day readmission rates by hospital, accounting for age and Chronic Condition Indicators. Hospitals with adjusted readmission rates that were 1 SD above and below the mean were defined as having "high" and "low" rates, respectively.

MAIN OUTCOME MEASURES

Thirty-day unplanned readmissions following admission for any diagnosis and for the 10 admission diagnoses with the highest readmission prevalence. Planned readmissions were identified with procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification.

RESULTS

The 30-day unadjusted readmission rate for all hospitalized children was 6.5% (n = 36,734). Adjusted rates were 28.6% greater in hospitals with high vs low readmission rates (7.2% [95% CI, 7.1%-7.2%] vs 5.6% [95% CI, 5.6%-5.6%]). For the 10 admission diagnoses with the highest readmission prevalence, the adjusted rates were 17.0% to 66.0% greater in hospitals with high vs low readmission rates. For example, sickle cell rates were 20.1% (95% CI, 20.0%-20.3%) vs 12.7% (95% CI, 12.6%-12.8%) in high vs low hospitals, respectively.

CONCLUSIONS AND RELEVANCE

Among patients admitted to acute care pediatric hospitals, the rate of unplanned readmissions at 30 days was 6.5%. There was significant variability in readmission rates across conditions and hospitals. These data may be useful for hospitals' quality improvement efforts.

Medical home quality and readmission risk for children hospitalized with asthma exacerbations

OBJECTIVE

The medical home likely has a positive effect on outpatient outcomes for children with asthma. However, no information is available regarding the impact of medical home quality on health care utilization after hospitalizations. We sought to explore the relationship between medical home quality and readmission risk in children hospitalized for asthma exacerbations.

METHODS

We enrolled 601 children, aged 1 to 16 years, hospitalized for an acute asthma exacerbation at a single pediatric facility that captures >85% of all asthma admissions in an 8-county area. Caregivers completed the Parent's Perception of Primary Care (P3C), a Likert-based, validated survey. The P3C yields a total score of medical home quality and 6 subscale scores assessing continuity, access, contextual knowledge, comprehensiveness, communication, and coordination. Asthma readmission events were prospectively collected via billing data. Hazards of readmission were calculated by using Cox proportional hazards adjusting for chronic asthma severity and key measures of socioeconomic status.

RESULTS

Overall P3C score was not associated with readmission. Among the subscale comparisons, only children with lowest access had a statistically increased readmission risk compared with children with the best access. Subgroup analysis revealed that children with private insurance and good access had the lowest rates of readmission within a year compared with other combinations of insurance and access.

CONCLUSIONS

Among measured aspects of medical home in a cohort of hospitalized children with asthma, having poor access to a medical home was the only measure associated with increased readmission. Improving physician access for children with asthma may lower hospital readmission.

Does the patient-centred medical home work? A critical synthesis of research on patient-centred medical homes and patient-related outcomes

Health-care systems in the USA and most of western Europe face challenges in the coordination and integration of care for patients, particularly those with chronic conditions. In response to these problems, interest in the patient-centred medical home (PCMH) model has increased significantly in recent years in the USA, with PCMH implementation underway in a wide variety of practice settings across the country. Despite this enthusiasm, there have been relatively few attempts to examine the empirical evidence on the effects of PCMH on quality and access-related outcomes for patients. This article reviews findings from empirical evaluations of the effects of PCMH on patient-related outcomes and critically examines methodological and conceptual issues in the growing body of PCMH literature. The results of this review suggest that published evaluations are predominantly weighted towards findings that indicate that PCMH is associated with a wide range of positive patient outcomes. However, methodological and measurement issues present in much of this research should be considered when evaluating these findings. The article concludes with recommendations for future PCMH evaluation.

Medical home disparities for children by insurance type and state of residence

The objectives of this study are (1) to compare the prevalence of a medical home between children with public and private insurance across states, (2) to investigate the association between a medical home and state health care characteristics for children with public and private insurance. We performed a cross-sectional analysis of the 2007 National Survey of Children's Health, estimating the prevalence of parents' report of a medical home and its components for publicly- and privately-insured children in all 50 states and the District of Columbia. We then performed a series of random-effects multilevel logistic regression models to assess the associations between a medical home and insurance type, individual sociodemographic characteristics, and state level characteristics/policies. The prevalence of a medical home varied significantly across states for both publicly- and privately-insured children (ranges: 33-63 % and 57-76 %, respectively). Compared to privately-insured children, publicly-insured children had a lower prevalence of a medical home in all states (public-private difference: 5-34 %). Low prevalence of a medical home was driven primarily by less family-centered care. Variation across states and differences by insurance type were largely attributable to lower reports of a medical home among traditionally vulnerable groups of children, including racial/ethnic minorities and non-English primary language speakers. The prevalence of a medical home was not associated with state level characteristics/policies. There are significant disparities between states in parents' report of a medical home for their children, especially for publicly-insured children. Interventions seeking to address these disparities will need to target family-centered care for traditionally vulnerable populations of children.