Children's Health Care in the First National Healthcare Quality Report and National Healthcare Disparities Report

Prevalence of Sleep Disorders Among Children 4 - 6 Years Old in Tehran Province, Iran

BACKGROUND

Sleep patterns may change over a person's lifetime; however, the quantity and quality of sleep always depend on individual factors such as age, sex, and psychological and environmental factors. In children, sleep is as important as development. Quantitative sleep problems related to sleep onset and qualitative sleep disorders such as frequent awakenings may lead to insufficient sleep.

OBJECTIVES

This study aimed to assess the prevalence of sleep disorders among children 4 - 6 years old attending the health centers of Shahid Beheshti University of Medical Sciences, Tehran, Iran, in 2013.

PATIENTS AND METHODS

This was a cross-sectional study on 400 children selected using a multistage sampling method. Data were collected by interviews. The questionnaire included two sections: a demographic section with questions about the demographic characteristics of the children and parents and a children's sleep habit questionnaire (CSHQ). Data were analyzed by SPSS 16 and different statistical tests were used (P < 0.05).

RESULTS

The mean age of the children was 64.27 ± 9.3 months. The prevalence of sleep disorders was 36.25%. Sleep disorders were significantly associated with age, height, body mass index, residence of children, father's occupation, mother's diseases, father's drug abuse, and parents' marital status (P < 0.05).

CONCLUSIONS

Sleep disorders in children threaten growth and development, and are dangerous for their health. Sleep disorders should be considered in the differential diagnosis of children's learning and behavioral problems.

Racial disparities at the point of care for urban children with persistent asthma

Little is known about disparities in preventive asthma care delivery at the time of an office visit. Our objective was to better understand what treatments are delivered at the point of care for urban children with asthma, and whether there are racial disparities. We enrolled 100 Black and 77 White children (2-12 years) with persistent asthma from 6 primary care practices. We evaluated how frequently providers delivered guideline-based asthma actions at the index visit. We also assessed asthma morbidity prior to the index visit and again at 2 month follow-up. Black children had greater symptom severity and were less likely to report having a preventive medication at baseline, but were no more likely to report a preventive medication action at the time of an office visit. Symptoms persisted for Black children at follow-up, suggesting additional preventive actions were needed. Further efforts to promote consistent guideline-based preventive asthma care are critical.

Impact of operative intervention delay on pediatric trauma outcomes

BACKGROUND

Establishing quality indicators is an essential step in improving mortality and disability among pediatric patients with trauma. We hypothesized that timing of craniotomy, intracranial pressure (ICP) monitoring for traumatic brain injury, and abdominal operation for solid organ injury correlates with a reduced risk of death, shorter stay, and reduced risk of requiring assistance at discharge.

METHODS

This was a retrospective cohort study of 99,513 pediatric patients with trauma, using the National Trauma Data Bank.

RESULTS

For patients who had an ICP monitor placed within 4 hours compared with those whose ICP monitor was delayed, there was no difference in mortality; however, there was a shorter stay in the hospital (relative risk [RR], 0.84; 95% confidence interval (CI), 0.72-0.97) and in the intensive care unit (ICU) (RR, 0.76; 95% CI, 0.66-0.86) in those that survived to discharge. Patients who had craniotomy within 4 hours had higher mortality (RR, 1.98; 95% CI, 1.11-3.51) compared with those that were delayed. After excluding those that died, there was a shorter overall stay (RR, 0.69; 95% CI, 0.59-0.81) and ICU stay (RR, 0.69; 95% CI, 0.57-0.83). Similar length of stay results were seen in pediatric patients with solid organ injuries. Excluding those that died, length of stay (RR, 0.58; 95% CI, 0.47-0.73) and ICU stay (RR, 0.52; 95% CI, 0.37-0.74) were shorter.

CONCLUSION

Early intervention in those who survive their initial operation is associated with shorter ICU and hospital stay for traumatic brain and solid organ injuries.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Pursuing perfection: an asthma quality improvement initiative in school-based health centers with community partners

This article describes an innovative asthma quality improvement initiative conducted in school-based health centers (SBHCs) with collaboration among multiple community partners including the children's hospital, a federally qualified health center, the health department, the public school, and parents of children with asthma. The aim was to improve the health of children with asthma in these schools, as measured by minimal asthma-related activity restriction and reduction in asthma-related emergency department (ED) visits. Process measures tracked included the percent of children with (1) asthma severity classified, (2) persistent asthma with controller medication prescribed, and (3) written care plans. Data supported a statistically significant decreasing trend for the percent of SBHC children reporting activity restriction due to asthma. In addition, trend analysis demonstrated a statistically significant difference in ED visits for asthma in the SBHC group compared with a non-SBHC group. Improvements were demonstrated for all process measures. Factors contributing to success included emphasis on community engagement, transparency in sharing ideas and results, benefits outweighing human resource costs of participating, readily available data to drive improvement, and the use of multiple intervention strategies.

Barriers to care questionnaire: reliability, validity, and responsiveness to change among parents of children with asthma

BACKGROUND

Although it is well known which groups of children are more vulnerable to poor health care access, quality, and outcomes, less is known about how and why this occurs. Barriers to care-sociobehavioral processes that interfere with successful interaction with the health care system--may be a link between vulnerability and access, experiences, and outcomes.

OBJECTIVE

The aim of this study was to examine the reliability, validity, and responsiveness to change of the Barriers to Care Questionnaire (BCQ) in a sample of children with persistent asthma recruited from federally qualified health centers.

METHOD

Children (N = 252; aged 2-14 years) with persistent asthma and their parents (93.7% mother, 83.3% Hispanic, 76.9% Spanish speaking; 72.6% less than a high school diploma), enrolled in a clinical trial, and completed the BCQ, questions relating to access to care, the Parent's Perceptions of Primary Care Measure, and the Pediatric Quality of Life Inventory 4.0 (PedsQL) at baseline and 3 months.

RESULTS

The BCQ demonstrated internal consistency reliability. Supporting construct validity, barriers to care were worse for children without health insurance or an identified provider and who had problems with care or foregone care. Higher barriers correlated with poorer primary care and lower patient health-related quality of life. The BCQ was responsive to change, showing within- and between-subject differences for subjects with improved realized access from baseline to 3 months.

CONCLUSION

The BCQ is a reliable, valid, and responsive measure of barriers to care for vulnerable children with asthma. Barriers to care were associated with poorer access, lower primary care quality, and worse health-related quality of life.

Barriers to care and primary care for vulnerable children with asthma

OBJECTIVE

I tested the hypothesis that, for vulnerable children with asthma, barriers to care (pragmatics, skills, knowledge and beliefs, expectations of care, and marginalization) affect primary care experiences, after accounting for financial, potential, and realized access to care, demographic features, and asthma severity.

METHODS

Patients, recruited primarily from urban, federally qualified health centers, were between 3 and 12 years of age and had been diagnosed as having asthma. Bilingual, bicultural interviewers administered surveys in participants' homes. Validated instruments were used to measure barriers to care (Barriers to Care Questionnaire) and primary care experiences (Parent's Perceptions of Primary Care measure).

RESULTS

Of 252 families recruited, 56.6% of parents were monolingual Spanish speakers, 73.6% of mothers had not graduated from high school, and 24.5% of children were uninsured. Asthma severity was 27% mild persistent, 40.5% moderate persistent, and 32.5% severe persistent. In bivariate analyses, better access to care (being insured and having a regular provider) was related to better primary care experiences. Consistent with the hypothesis, multivariate regression analyses showed that fewer barriers (Barriers to Care Questionnaire scores) predicted better primary care (Parent's Perceptions of Primary Care total and subscale scores), after controlling for access to care, demographic features, and asthma severity (a 1-point change in Barriers to Care Questionnaire scores was associated with a 0.59-point change in Parent's Perceptions of Primary Care total scale scores). Having a regular doctor and not having experienced foregone care were also significant predictors of Parent's Perceptions of Primary Care scores in the multivariate analysis.

CONCLUSION

For vulnerable children with asthma, barriers to care explain variance in primary care characteristics beyond that explained by access, demographic factors, and disease severity.

Infant mortality in the Lower Mississippi Delta: geography, poverty and race

OBJECTIVE

The objectives of this study were to explore regional, economic and racial disparities in infant mortality rates between geographic sub-regions within the eight states containing the Delta and to test hypotheses that regional disparities would decrease over time while county poverty level and racial composition would remain significant predictors of infant mortality rates.

STUDY DESIGN

The study used secondary data analysis of county level rates, including descriptive statistics, hierarchical multiple regression with interaction effects and linear multiple regression. Models testing the impact of sub-regional geographic differences, percent of poverty, percent of black population and interaction effects were conducted at three time periods, the late 1970s, late 1980s and late 1990s.

RESULTS

In the first time period, regional differences, percent of poverty, percent of black population and the interaction of region and poverty were all predictive of infant mortality (R(2) = 0.31, P < 0.0001). In the subsequent time periods, only percent of poverty and percent of black population were significant predictors (R(2) = 0.20, P < 0.0001 and R(2) = 0.26, P < 0.0001).

CONCLUSIONS

During the late 1970s and early 1980s, region, poverty and racial composition of counties all played an important part in predicting life chances for infants born in these eight states. Furthermore, Central Delta infants in counties with poverty levels of 30% or greater were significantly more likely to die than infants in other areas with the same rates of poverty, even after controlling for racial composition. The impact of regional differences was no longer significant at the ends of the subsequent two decades. Both medical and policy changes during these decades may have contributed to the decreased impact of region. However, both poverty and racial composition continue as important factors, accounting for more variance in the late 1990s than a decade before.

The association between contextual socioeconomic factors and prevalent asthma in a cohort of Southern California school children

Spatial variation in childhood asthma and a recent increase in prevalence indicate that environmental factors play a significant role in the etiology of this important disease. Socioeconomic position (SEP) has been associated inversely and positively with childhood asthma. These contradictory results indicate a need for systematic research about SEP and asthma. Pathways have been suggested for effects of SEP on asthma at both the individual and community level. We examined the relationship of prevalent asthma to community-level indicators of SEP among 5762 children in 12 Southern California communities, using a multilevel random effects model. Estimates of community-level SEP were derived by summarizing census block group-level data using a novel method of weighting by the proportion of the block groups included in a community-specific bounding rectangle that contained 95% of local study subjects. Community characteristics included measures of male unemployment, household income, low education (i.e., no high school diploma) and poverty. There was a consistent inverse association between male unemployment and asthma across the inter-quartile range of community unemployment rates, indicating that asthma rates increase as community SEP increases. The results were robust to individual-level confounding, methods for summarizing census block group data to the community level, scale of analysis (i.e., community-level vs. neighborhood-level) and the modeling algorithm. The positive association between SEP and prevalent childhood asthma might be explained by differential access to medical care that remains unmeasured, by the hygiene hypothesis (e.g., lower SES may associate with higher protective exposures to endotoxin in early life), or by SEP acting as a proxy for unmeasured neighborhood characteristics.

Administrative barriers to the adoption of high-quality mental health services for children in foster care: a national study

While the need to provide appropriate mental health services to children in foster care is well recognized, there is little information on administrative barriers to assuring that such services are provided. This article presents results from a national survey of mental health agencies to profile their awareness of currently available practice standards, the roles these standards play in guiding practice of mental health agencies, common reimbursement strategies in use for mental health services, and collaborations between mental health and child welfare agencies that enhance children's access to appropriate mental health care. Implications and recommendations for mental health policymakers are discussed.

The widening black/white gap in asthma hospitalizations and mortality

BACKGROUND

Large racial differences in asthma morbidity and mortality have prompted research on new interventions, public awareness, and health policy efforts in the past decade.

OBJECTIVE

We sought to characterize recent trends in US asthma hospitalization and mortality for black and white children and adults during the period from 1980 through 2002.

METHODS

We conducted a successive representative national cohort study of US residents ages 5 to 34 years using data from the National Hospital Discharge Survey and the US vital statistics system. Outcome measures included black/white (B/W) asthma hospitalization and mortality rates, rate ratios, and rate differences.

RESULTS

For asthma hospitalizations from 1980 through 2002, children ages 5 to 18 years had a 50% increase in the B/W rate ratio, and the rate difference increased from 22.8 to 28.3 hospitalizations per 10,000 population. For young adults ages 19 to 34 years, the B/W rate ratio increased from 2.3 to 2.8, and the rate difference decreased from 9.6 to 7.9 hospitalizations per 10,000 population. For asthma mortality from 1980 through 2001, children ages 5 to 19 years had a large increase in the B/W rate ratio from 4.5 to 5.6 and in the rate difference from 5.6 to 8.1 deaths per 1,000,000 population. There did not appear to be a significant change in the B/W differences for adults ages 20 to 34 years.

CONCLUSIONS

For children, there have been notable increases in asthma B/W differences in hospitalizations and mortality since 1980, whereas for adults the increase has been smaller. National efforts to improve asthma care over the past decade do not appear to have reduced this B/W gap. When treating children with asthma, it is important to consider the racial-ethnic factors that might lead to avoidable hospitalizations and premature mortality.