Parents' perceptions of pediatric primary care quality: effects of race/ethnicity, language, and access

Comparing Outcomes Between Direct and ED Admissions for Neonatal Hyperbilirubinemia

OBJECTIVES

Pediatric direct admissions (DA) have multiple benefits including reduced emergency department (ED) volumes, greater patient and provider satisfaction, and decreased costs without compromising patient safety. We sought to compare resource utilization and outcomes between patients with a primary diagnosis of neonatal hyperbilirubinemia directly admitted with those admitted from the ED.

METHODS

Single-center, retrospective study at a large, academic, free-standing children's hospital (2017-2021). Patients were between 24 hours and 14 days old with a gestational age of ≥35 weeks, admitted with a primary diagnosis of neonatal hyperbilirubinemia. Outcomes included length of stay (LOS), time to clinical care, resource utilization, NICU transfer, and 7-day readmission for phototherapy.

RESULTS

A total of 1098 patients were included, with 276 (25.1%) ED admissions and 822 (74.9%) DAs. DAs experienced a shorter median time to bilirubin level collection (1.9 vs 2.1 hours, P = .003), received less intravenous fluids (8.9% vs 51.4%, P < .001), had less bilirubin levels collected (median of 3.0 vs 4.0, P < .001), received phototherapy sooner (median of 0.8 vs 4.2 hours, P < .001), and had a shorter LOS (median of 21 vs 23 hours, P = .002). One patient who was directly admitted required transfer to the NICU. No differences were observed in the 7-day readmission rates for phototherapy.

CONCLUSIONS

Directly admitting patients for the management of neonatal hyperbilirubinemia is a preferred alternative to ED admission as our study demonstrated that DAs had a shorter time to clinical care, shorter LOS, and less unnecessary resource utilization with no difference in 7-day readmissions for phototherapy.

Utilization and Patient-Reported Outcomes of Direct-to-Consumer Telemedicine During the First 6 Weeks of the COVID-19 Pandemic in the Largest Pediatric Ambulatory Network in New York State

Objective: We aimed to (1) describe telemedicine utilization and usability during the first 6 weeks of the pandemic and (2) determine if usability varied by individual- or visit-level characteristics. Methods: We conducted a retrospective cohort study of ambulatory pediatric telemedicine visits occurring between March 10, 2020, and April 18, 2020, across a large academic health system. We performed manual chart review to assess individual- and visit-level characteristics and invited caregivers to respond to an adapted Telehealth Usability Questionnaire (TUQ). We used multiple logistic regression to determine predictors of high usability. Results: There were 3,197 ambulatory pediatric telemedicine visits, representing 2,967 unique patients. Patients were racially/ethnically diverse (42.5% non-Hispanic White) and primarily English-speaking (89.2%). Surveys were completed by 441 (17%) of those invited. Every item of the TUQ had agreement or strong agreement from the majority of respondents. Compared with non-Hispanic White, non-Hispanic Asian identity was associated with lower usability in three domains and overall, and non-Hispanic Black identity was associated with higher satisfaction and future use. As compared with caregivers of infants younger than 1 year, caregivers of older patients reported lower usability in the three domains. Conclusions: Telemedicine was successfully implemented across 18 ambulatory pediatric specialties in the largest health system in New York State at the onset of COVID-19, and caregivers found it usable and acceptable. Usability scores did not vary by visit-level characteristics but did vary by race/ethnicity and age. Further research is necessary to identify modifiable drivers of the patient experience, particularly in non-Hispanic Asian communities and older adolescents.

Social Determinants of Health and Pediatric Emergency Department Outcomes: A Systematic Review and Meta-Analysis of Observational Studies

STUDY OBJECTIVE

Social determinants of health contribute to disparities in pediatric health and health care. Our objective was to synthesize and evaluate the evidence on the association between social determinants of health and emergency department (ED) outcomes in pediatric populations.

METHODS

This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity Extension guidelines. Observational epidemiological studies were included if they examined at least 1 social determinant of health from the PROGRESS-Plus framework in relation to ED outcomes among children <18 years old. Effect direction plots were used for narrative results and pooled odds ratios (pOR) with 95% confidence intervals (CI) for meta-analyses.

RESULTS

Fifty-eight studies were included, involving 17,275,090 children and 103,296,839 ED visits. Race/ethnicity and socioeconomic status were the most reported social determinants of health (71% each). Black children had 3 times the odds of utilizing the ED (pOR 3.16, 95% CI 2.46 to 4.08), whereas visits by Indigenous children increased the odds of departure prior to completion of care (pOR 1.58, 95% CI 1.39 to 1.80) compared to White children. Public insurance, low income, neighborhood deprivation, and proximity to an ED were also predictors of ED utilization. Children whose caregivers had a preferred language other than English had longer length of stay and increased hospital admission.

CONCLUSION

Social determinants of health, particularly race, socioeconomic deprivation, proximity to an ED, and language, play important roles in ED care-seeking patterns of children and families. Increased utilization of ED services by children from racial minority and lower socioeconomic status groups may reflect barriers to health insurance and access to health care, including primary and subspecialty care, and/or poorer overall health, necessitating ED care. An intersectional approach is needed to better understand the trajectories of disparities in pediatric ED outcomes and to develop, implement, and evaluate future policies.

Language Disparities in Caregiver Satisfaction with Physician Communication at Well Visits from 0-2 Years

OBJECTIVE

This study aimed to describe caregiver satisfaction with physician communication over the first two years of life and examine differences by preferred language and the relationship to physician continuity.

METHODS

Longitudinal data were collected at well visits (2 months to 2 years) from participants in a randomized controlled trial to prevent childhood obesity. Satisfaction with communication was assessed using the validated Communication Assessment Tool (CAT) questionnaire. Changes in the odds of optimal scores were estimated in mixed-effects logistic regression models to evaluate the associations between satisfaction over time and language, interpreter use, and physician continuity.

RESULTS

Of 865 caregivers, 35% were Spanish-speaking. Spanish-speaking caregivers without interpreters had lower odds of an optimal satisfaction score compared with English speakers during the first 2 years, beginning at 2 months [OR 0.64 (95% CI: 0.43, 0.95)]. There was no significant difference in satisfaction between English-speaking caregivers and Spanish-speaking caregivers with an interpreter. The odds of optimal satisfaction scores increased over time for both language groups. For both language groups, odds of an optimal satisfaction score decreased each time a new physician was seen for a visit [OR 0.82 (95% CI: 0.69, 0.97)].

CONCLUSION

Caregiver satisfaction with physician communication improves over the first two years of well-child visits for both English- and Spanish-speakers. A loss of physician continuity over time was also associated with lower satisfaction. Future interventions to ameliorate communication disparities should ensure adequate interpreter use for primarily Spanish-speaking patients and address continuity issues to improve communication satisfaction.

Racial and Ethnic Disparities for Unmet Needs by Mental Health Condition: 2016 to 2021

OBJECTIVES

Racial and ethnic minority children receive less care and inferior care in the United States, but less is known about how these disparities vary by mental health conditions. We examined unmet mental health needs by condition types to identify potentially hidden racial and ethnic inequities.

METHODS

We used data from the nationally representative National Survey of Children's Health, from 2016 to 2021 (n = 172 107). Logistic regression analyses were applied to mental health conditions in aggregate and individually and adjusted for individual and household characteristics.

RESULTS

Relative to non-Hispanic white children with any mental health condition, non-Hispanic Black children had greater odds of unmet needs (adjusted odds ratio [aOR] = 1.56, 95% confidence interval [CI]: 1.18-2.05). Models disaggregated by specific mental health conditions revealed heterogeneous patterns. Specifically, relative to non-Hispanic white children, non-Hispanic Black children displayed elevated odds of unmet needs for behavioral problems (aOR = 1.41, 95% CI: 1.00-2.02), whereas Asian and Hispanic children displayed elevated odds for anxiety (aOR = 2.60, 95% CI: 1.20-4.29 and aOR = 1.41, 95% CI: 1.05-1.90, respectively).

CONCLUSIONS

Racial and ethnic minority children are disproportionately affected by unmet treatment needs. These disparities vary by individual mental health conditions and persist after controlling for socioeconomic characteristics. Results reveal clinically underserved racial and ethnic groups across different mental health conditions.

Shades of care: Understanding the needs of racially and ethnically diverse paediatric patients, their families, and health care providers in North America

While race and ethnicity have been acknowledged as determinants of health, there remain gaps regarding their effects on experiences of paediatric care. This scoping review examines empirical literature regarding the state and experience of paediatric care provided to racially and ethnically diverse families in North America. We seek to clarify the needs of care administrators and recipients, as well as to conceptualize what paediatric care must look like to enable equitable practices and optimal health outcomes. Utilizing Arksey and O'Malley's framework, we reviewed literature published between 2005 and 2020, most of which was written within an American context. The literature reviewed featured quantitative, qualitative and mixed methods studies. Paediatric care administrators and recipients collectively identified the following as domains requiring an increased focus: (1) knowledge (awareness or training), (2) alignment of views and values, (3) resources and (4) communication. Findings suggest overall that despite there being merit in the cultural competency efforts underway, more patient-centric approaches are vital. This review concludes by encouraging the sustained development of cultural safety initiatives in paediatric care to ultimately promote patient comfort and provider-patient collaboration.

Differences in End-of-Life Care between COVID-19 Inpatient Decedents with English Proficiency and Limited English Proficiency

Background: Patients with limited English proficiency (LEP) experience lower quality end-of-life (EOL) care. This inequity may have been exacerbated during the COVID-19 pandemic. Objective: Compare health care utilization, EOL, and palliative care outcomes between COVID-19 decedents with and without LEP during the pandemic's first wave in Massachusetts. Methods: Retrospective cohort study of adult inpatients who died from COVID-19 between February 18, 2020 and May 18, 2020 at two academic and four community hospitals within a greater Boston health care system. We performed multivariable regression adjusting for patient sociodemographic variables and hospital characteristics. Primary outcome was place of death (intensive care unit [ICU] vs. non-ICU). Secondary outcomes included hospital and ICU length of stay and time to initial palliative care consultation. Results: Among 337 patients, 89 (26.4%) had LEP and 248 (73.6%) were English proficient. Patients with LEP were less often white (24 [27.0%] vs. 193 [77.8%]; p < 0.001); were more often Hispanic or Latinx (40 [45.0%] vs. 13 [5.2%]; p < 0.001); and less often had a medical order for life-sustaining treatment (MOLST) on admission (15 [16.9%] vs. 120 [48.4%]; p < 0.001) versus patients with English proficiency. In the multivariable analyses, LEP was not independently associated with ICU death, ICU length of stay, or time to palliative care consultation, but was independently associated with increased hospital length of stay (mean difference 4.12 days; 95% CI, 1.72-6.53; p < 0.001). Conclusions: Inpatient COVID-19 decedents with LEP were not at increased risk of an ICU death, but were associated with an increased hospital length of stay versus inpatient COVID-19 decedents with English proficiency.

Differential Impact of Home Nurse Contact After Discharge by Financial Strain, Primary Care Access, and Medical Complexity

BACKGROUND

The Hospital to Home Outcomes (H2O) trials examined the effectiveness of postdischarge nurse support on reuse after pediatric discharge. Unexpectedly, children randomly assigned to a nurse visit had higher rates of reuse than those in the control group. Participants in randomized control trials are heterogeneous. Thus, it is possible that the effect of the intervention differed across subgroups (ie, heterogeneity of treatment effect [HTE]). We sought to determine if different subgroups responded differently to the interventions.

METHODS

The H2O trial is a randomized controlled trial comparing standard hospital discharge processes with a nurse home visit within 96 hours of discharge. The second trial, H2O II, was similar, except the tested intervention was a postdischarge nurse phone call. For the purposes of the HTE analyses, we examined our primary trial outcome measure: a composite of unplanned 30-day acute health care reuse (unplanned readmission or emergency department or urgent care visit). We identified subgroups of interest before the trials related to (1) financial strain, (2) primary care access, (3) insurance, and (4) medical complexity. We used logistic regression modeling with an interaction term between subgroup and treatment group (intervention or control).

RESULTS

For the phone call trial (H2O II), financial strain significantly modified the effect of the intervention such that the subgroup of children with high financial strain who received the intervention experienced more reuse than their control counterparts.

CONCLUSIONS

In HTE analyses of 2 randomized controlled trials, only financial strain significantly modified the nurse phone call. A family's financial resources may affect the utility of postdischarge support.

Surgical Patients' Hospital Experience Scores: Neighborhood Context Conceptual Framework

Objective

Through geocoding the physical residential address included in the electronic medical record to the census tract level, we present a novel model for concomitant examination of individual patient-related and residential context-related factors that are associated with patient-reported experience scores.

Summary Background Data

When assessing patient experience in the surgical setting, researchers need to examine the potential influence of neighborhood-level characteristics on patient experience-of-care ratings.

Methods

We geocoded the residential address included in the electronic medical record (EMR) from a tertiary care facility to the census tract level of Orange County, CA. We then linked each individual record to the matching census tract and use hierarchical regression analyses to test the impact of distinct neighborhood conditions on patient experience. This approach allows us to estimate how each neighborhood characteristic uniquely influences Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.

Results

Individuals residing in communities characterized by high levels of socioeconomic disadvantage have the highest experience ratings. Accounting for individual patient's characteristics such as age, gender, race/ethnicity, primary language spoken at home, length of stay, and average pain levels during their hospital stay, neighborhood-level characteristics such as proportions of people receiving public assistance influence the ratings of hospital experience (0.01, P < 0.05) independent of, and beyond, these individual-level factors.

Conclusions

This manuscript is an example of how geocoding could be used to analyze surgical patient experience scores. In this analysis, we have shown that neighborhood-level characteristics influence the ratings of hospital experience independent of, and beyond, individual-level factors.

Study of social disparities in pediatric laparoscopic appendectomy outcomes and cost

Purpose:

There is an increasing focus on racial and social disparities in health care. There have been several studies that have documented disparities in outcome between racial groups in the adult literature. Not much is known about disparities in outcomes after surgical procedures in children. The purpose of this study was to investigate the effect of race on complications (outcomes) and costs after laparoscopic appendectomy.

Methods:

This study is a single-center retrospective chart review of 248 pediatric patients who underwent appendectomies for uncomplicated acute appendicitis from 2015 to 2017. Patients were divided into minority (Africa American or Hispanic) and non-minority groups, and length of stay, preoperative and postoperative factors, and total costs were compared.

Results:

Of 185 eligible patients, 45.9% (n = 85) were of Hispanic or African American ethnicity and 54.1% (n = 100) were Caucasian. About 11.8% of minority patients had comorbidities and 12% of majority patients had comorbidities (p = 1). Readmission rate for minority group patients was 3.5% (n = 3) and 2% (n = 2) for majority patients (p = 0.7). The average cost of hospital stay for minority patients was $30,900 and for majority patients was $31,111 (p = 0.59).

Conclusions:

Standardization of care protocols has reduced social/racial disparities in surgical outcomes. In the most common pediatric surgery emergency procedure, laparoscopic appendectomy, there were no differences in outcomes or costs between minority (Hispanic/Africa American) and Caucasian ethnic groups.

Level of evidence:

Level III

Type of study:

Clinical Study

THRIVE Conceptual Framework and Study Protocol: A Community-Partnered Longitudinal Multi-Cohort Study to Promote Child and Youth Thriving, Health Equity, and Community Strength

BACKGROUND

Given the profound inequities in maternal and child health along racial, ethnic, and socioeconomic lines, strength-based, community-partnered research is required to foster thriving children, families, and communities, where thriving is defined as optimal development across physical, mental, cognitive, and social domains. The Pittsburgh Study (TPS) is a community-partnered, multi-cohort study designed to understand and promote child and youth thriving, build health equity, and strengthen communities by integrating community partners in study design, implementation, and dissemination. TPS launched the Tracking Health, Relationships, Identity, EnVironment, and Equity (THRIVE) Study to evaluate children's developmental stages and contexts from birth through completion of high school and to inform a child health data hub accessible to advocates, community members, educators, health professionals, and policymakers.

METHODS AND ANALYSIS

TPS is rooted in community-partnered participatory research (CPPR), health equity, antiracism, and developmental science. Using our community-informed conceptual framework of child thriving, the THRIVE Study will assess cross-cutting measures of place, environment, health service use, and other social determinants of health to provide longitudinal associations with developmentally appropriate child and youth thriving outcomes across participants in six cohorts spanning from pregnancy through adolescence (child ages 0-18 years). Data from electronic health records, school records, and health and human services use are integrated to assess biological and social influences of thriving. We will examine changes over time using paired t-tests and adjusted linear regression models for continuous thriving scores and McNemar tests and adjusted logistic regression models for categorical outcomes (thriving/not thriving). Data analyses will include mixed models with a random intercept (in combination with the previously-specified types of regression models) to account for within-subject correlation.

DISCUSSION

By enhancing assessment of child and youth well-being, TPS will fill critical gaps in our understanding of the development of child and youth thriving over time and test strategies to support thriving in diverse communities and populations. Through CPPR and co-design, the study aims to improve child health inequities across multiple socioecological levels and developmental domains.

Social Disadvantage, Access to Care, and Disparities in Physical Functioning Among Children Hospitalized with Respiratory Illness

BACKGROUND AND OBJECTIVES

Understanding disparities in child health-related quality of life (HRQoL) may reveal opportunities for targeted improvement. This study examined associations between social disadvantage, access to care, and child physical functioning before and after hospitalization for acute respiratory illness.

METHODS

From July 1, 2014, to June 30, 2016, children ages 8-16 years and/or caregivers of children 2 weeks to 16 years admitted to five tertiary care children's hospitals for three common respiratory illnesses completed a survey on admission and within 2 to 8 weeks after discharge. Survey items assessed social disadvantage (minority race/ ethnicity, limited English proficiency, low education, and low income), difficulty/delays accessing care, and baseline and follow-up HRQoL physical functioning using the Pediatric Quality of Life Inventory (PedsQL, range 0-100). We examined associations between these three variables at baseline and follow-up using multivariable, mixed-effects linear regression models with multiple imputation sensitivity analyses for missing data.

RESULTS

A total of 1,325 patients and/or their caregivers completed both PedsQL assessments. Adjusted mean baseline PedsQL scores were significantly lower for patients with social disadvantage markers, compared with those of patients with none (78.7 for >3 markers versus 85.5 for no markers, difference -6.1 points (95% CI: -8.7, -3.5). The number of social disadvantage markers was not associated with mean follow-up PedsQL scores. Difficulty/delays accessing care were associated with lower PedsQL scores at both time points, but it was not a significant effect modifier between social disadvantage and PedsQL scores.

CONCLUSIONS

Having social disadvantage markers or difficulty/delays accessing care was associated with lower baseline physical functioning; however, differences were reduced after hospital discharge.

Insights in Public Health: Outpatient Care Gaps for Patients Hospitalized with Ambulatory Care Sensitive Conditions in Hawai'i: Beyond Access and Continuity of Care

Ambulatory care sensitive conditions (ACSCs) are conditions that can generally be managed in community-based healthcare settings, and, if managed well, should not require hospital admission. A 5-year, mixed methods study was recently concluded that (1) documented disparities in hospitalizations for ACSCs in Hawai'i through quantitative analysis of state-wide hospital discharge data; and (2) identified contributing factors for these hospitalizations through patient interviews. This Public Health Insights article provides deeper context for, and consideration of, a striking study finding: the differences between typical measures of access to care and the quality of patient/provider interactions as reported by study participants. The themes that emerged from the patients' stories of their own potentially preventable hospital admissions shed light on the importance of being heard, trust, communication, and health knowledge in their relationships with their providers. We conclude that improving the quality of the relationship and level of engagement between the patient and community/outpatient providers may help reduce hospitalizations for ACSCs in Hawai'i and beyond. These interpersonal-level goals should be supported by systems-level efforts to improve health care delivery and address health disparities.

Identifying Modifiable Health Care Barriers to Improve Health Equity for Hospitalized Children

BACKGROUND

Children from socially disadvantaged families experience worse hospital outcomes compared with other children. We sought to identify modifiable barriers to care to target for intervention.

METHODS

We conducted a prospective cohort study of hospitalized children over 15 months. Caregivers completed a survey within 3 days of admission and 2 to 8 weeks after discharge to assess 10 reported barriers to care related to their interactions within the health care system (eg, not feeling like they have sufficient skills to navigate the system and experiencing marginalization). Associations between barriers and outcomes (30-day readmissions and length of stay) were assessed by using multivariable regression. Barriers associated with worse outcomes were then tested for associations with a cumulative social disadvantage score based on 5 family sociodemographic characteristics (eg, low income).

RESULTS

Of eligible families, 61% (n = 3651) completed the admission survey; of those, 48% (n = 1734) completed follow-up. Nine of 10 barriers were associated with at least 1 worse hospital outcome. Of those, 4 were also positively associated with cumulative social disadvantage: perceiving the system as a barrier (adjusted β = 1.66; 95% confidence interval [CI] 1.02 to 2.30), skill barriers (β = 3.82; 95% CI 3.22 to 4.43), cultural distance (β = 1.75; 95% CI 1.36 to 2.15), and marginalization (β = .71; 95% CI 0.30 to 1.11). Low income had the most consistently strong association with reported barriers.

CONCLUSIONS

System barriers, skill barriers, cultural distance, and marginalization were significantly associated with both worse hospital outcomes and social disadvantage, suggesting these are promising targets for intervention to decrease disparities for hospitalized children.

Pediatric Primary Care Relationships With African American Families: A Critical Review

INTRODUCTION

High-quality primary care is critical to help African American families mitigate the effects of social determinants of health that negatively affect child health and well-being. At the core of primary care is a healthy relationship between the parent and provider. This critical review of the literature evaluates what is known about the parent-provider relationship for African Americans.

METHODS

We identified 277 studies in Ovid MEDLINE and screened them for inclusion. Data extraction and qualitative synthesis were used to describe what is known and identify themes.

RESULTS

Twelve cross-sectional analyses and one mixed cross-sectional and longitudinal design research studies were identified. Studies identified parent factors, provider factors, parent-provider interaction factors, and health care system factors that affected the parent-provider relationship.

DISCUSSION

The results identify best practices and future research directions for providers, which would improve pediatric primary care quality for African American children.

Perceived Access to Outpatient Care and Hospital Reutilization Following Acute Respiratory Illnesses

OBJECTIVE

Efforts to decrease hospital revisits often focus on improving access to outpatient follow-up. Our objective was to assess the relationship between perceived access to timely office-based care and subsequent 30-day revisits following hospital discharge for 4 common respiratory illnesses.

METHODS

This was a prospective cohort study of children 2 weeks to 16years admitted to 5 US children's hospitals for asthma, bronchiolitis, croup, or pneumonia between July 2014 and June 2016. Hospital and emergency department (ED) (in the case of croup) admission surveys administered to caregivers included the Consumer Assessments of Healthcare Providers and Systems Timely Access to Care. Access composite scores (range 0-100, with greater scores indicating better access) were linked with 30-day ED revisits and inpatient readmissions from the Pediatric Health Information System. The relationship between access to timely care and repeat utilization was assessed using multivariable logistic regression adjusting for demographics, hospitalization, and home/outpatient factors.

RESULTS

Of the 2438 children enrolled, 2179 (89%) reported an office visit in the previous 6 months. Average access composite score was 52.0 (standard deviation, 36.3). In adjusted analyses, greater access scores were associated with greater odds of 30-day ED revisits (odds ratio [OR] = 1.07; 95% confidence interval [CI], 1.02-1.13)-particularly for croup (OR = 1.17; 95% CI, 1.02-1.36)-but not inpatient readmissions (OR = 1.02; 95% CI, 0.96-1.09).

CONCLUSIONS

Perceived access to timely office-based care was associated with significantly greater odds of subsequent ED revisit. Focusing solely on enhancing timely access to care following discharge for common respiratory illnesses may be insufficient to prevent repeat utilization.

Health Care Access Barriers Bring Children to Emergency Rooms More Frequently: A Representative Survey

Children may visit the emergency department (ED) regularly in part because they and their caregivers may be experiencing barriers to appropriate and timely pediatric care. However, assessing the wide range of potential barriers to access to care that children and their caregivers may experience is often a challenge. The objective of this study was to assess the barriers to pediatric health care reported by caregivers and to examine the association between those reported barriers to care with the frequency of children's ED visits in the past 12 months. Assessment of ED utilization and access to care barriers was made through a telephone interview survey conducted as part of a broader Community Health Needs Assessment in 2015. A weighted community sample of adult caregivers (N = 1057) of children between the ages of 0-17 residing in Miami-Dade, Broward, and Palm Beach counties, Florida were contacted. This study found that multiple ED visits (≥2 vs. 0) in the past 12 months by a child were most strongly associated with access to care barriers attributed to language and culture (relative risk [RR] = 2.51), trouble finding a doctor (RR = 1.86), scheduling an appointment (RR = 1.68), and transportation access (RR = 1.73). These findings suggest that access to care barriers experienced by households may exacerbate the risk of a child experiencing repeated visits to the ED in a year. Findings are discussed further in the context of actionable population health management strategies to reduce risk of frequent ED utilization by children.

Influence of awareness and availability of medical alternatives on parents seeking paediatric emergency care

AIMS

Direct seeking of care at paediatric emergency departments may result from an inadequate awareness or a short supply of medical alternatives. We therefore evaluated the care-seeking patterns, availability of medical options and initial medical assessments - with overall reference to socioeconomic status - of parents at an urban paediatric emergency department in a Scandinavian country providing free paediatric healthcare.

METHODS

The parents of children assessed by paediatric emergency department physicians at a Swedish university hospital over a 25-day winter period completed a questionnaire on recent medical contacts and their reasons for attendance. Additional information was obtained from ledgers, patient records and population demographics.

RESULTS

In total, 657 of 713 eligible patients (92%) were included. Seventy-nine per cent of their parents either failed to or managed to establish medical contact before the emergency department visit, whereas 21% sought care with no attempt at recent medical contact. Visits with a failed telephone or primary care contact (18%) were more common outside office hours ( p=0.014) and were scored as less urgent ( p=0.014). A perceived emergency was the main reason for no attempt at medical contact before the visit. Direct emergency department care-seeking was more common from the city district with the lowest socioeconomic status ( p=0.027).

CONCLUSIONS

Although most parents in this Swedish study tried to seek medical advice before attending a paediatric emergency department, perceived emergency, a short supply of telephone health line or primary care facilities and lower socioeconomic status contributed to direct care-seeking by almost 40% of parents. Pre-hospital awareness and the availability of medical alternatives with an emphasis on major differences in socioeconomic status should therefore be considered to further optimize care-seeking in paediatric emergency departments.

The association between parent-reported provider communication quality and child obesity status: Variation by parent obesity and child race/ethnicity

OBJECTIVE

To examine the association between healthcare provider communication quality and child obesity status, and the role of parent obesity and child race/ethnicity regarding this association.

METHODS

We conducted a cross-sectional secondary data analysis with the 2011-2013 Medical Expenditures Panel Survey of parents with children ages 6-12 (n=5390). We used multivariable logistic regression to examine the association of parent-reported healthcare provider communication quality (explaining well, listening carefully, showing respect, and spending enough time) with child obesity status, and effect modification by parent obesity and child race/ethnicity.

RESULTS

Parents of obese children were more likely to report that their child's healthcare provider listened carefully (OR=1.41, p=0.002) and spent enough time (OR=1.33, p=0.022) than parents of non-obese children. Non-obese parents of obese children experienced better communication in the domains of listening carefully (p<0.001) and spending enough time (p=0.007). Parents of obese non-Hispanic Asian children and non-Hispanic Black children were more likely to report that providers explained things well (p=0.043) and listened carefully (p=0.012), respectively.

CONCLUSION

Parents of obese children experienced better communication if parents were non-obese or children were non-Hispanic Black or Asian.

PRACTICE IMPLICATIONS

Healthcare providers should ensure effective communication with obese parents of obese children.

Satisfaction With Communication in Primary Care for Spanish-Speaking and English-Speaking Parents

BACKGROUND AND OBJECTIVE

Effective communication with primary care physicians is important yet incompletely understood for Spanish-speaking parents. We predicted lower satisfaction among Spanish-speaking compared to English-speaking Latino and non-Latino parents.

METHODS

Cross-sectional analysis at 2-month well visits within the Greenlight study at 4 pediatric resident clinics. Parents reported satisfaction with 14 physician communication items using the validated Communication Assessment Tool (CAT). High satisfaction was defined as "excellent" on each CAT item. Mean estimations compared satisfaction for communication items among Spanish- and English-speaking Latinos and non-Latinos. We used generalized linear regression modeling, adjusted for parent age, education, income, and clinic site. Among Spanish-speaking parents, we compared visits conducted in Spanish with and without an interpreter, and in English.

RESULTS

Compared to English-speaking Latino (n = 127) and non-Latino parents (n = 432), fewer Spanish-speaking parents (n = 303) reported satisfaction with 14 communication items. No significant differences were found between English-speaking Latinos and non-Latinos. Greatest differences were found in the use of a greeting that made the parent comfortable (59.4% of Spanish-speaking Latinos endorsing "excellent" vs 77.5% English-speaking Latinos, P < .01) and discussing follow-up (62.5% of Spanish-speaking Latinos vs 79.8% English-speaking Latinos, P < .01). After adjusting for parent age, education, income, and study site, Spanish-speaking Latinos were still less likely to report high satisfaction with these communication items. Satisfaction was not different among Spanish-speaking parents when the physician spoke Spanish versus used an interpreter.

CONCLUSIONS

Satisfaction with physician communication was associated with language but not ethnicity. Spanish-speaking parents less frequently report satisfaction with communication, and innovative solutions to enhance communication quality are needed.

The Impact of Ethnic and Cultural Differences on Parental Satisfaction in the PICU

OBJECTIVES

This study examined satisfaction of parents whose children were admitted to the PICU to identify priority areas for improvement. We hypothesized that differences exist in satisfaction of parents of different ethnicities.

DESIGN

Prospective observational study.

SETTING

PICU in a tertiary care pediatric hospital.

PATIENTS

All English-literate parents whose child was admitted to our PICU between February 2014 and February 2015 were eligible after informed consent was obtained. Parents included in this study in previous admission(s) were excluded.

INTERVENTION

Nil.

MEASUREMENTS AND MAIN RESULTS

We adapted Empowerment of Parent in the Intensive Care Questionnaire, a validated questionnaire survey specific for measuring parental satisfaction in PICUs. This adapted survey consisted of 31 questions (based on a scale of 1-6) examining five domains as follows: information giving, care and cure, parental participation, organization, and professional attitude. Reliability of Empowerment of Parent in the Intensive Care Questionnaire in our population was analyzed using Cronbach's alpha. We used ordinal logistic regression, controlling for socioeconomic status and educational level, to examine differences in parental perceptions of various ethnicities. We obtained a total of 206 responses (36.5%) from 543 admissions. There were 116 (56%) emergency and 90 (44%) elective admissions. The proportion of respondents were Chinese (126 [61%]), Malay (32 [16%]), Indian (23 [11%]), and "Others" (25 [12%]). Cronbach's alpha for domains of information giving (α = 0.80), care and cure (α = 0.93), parental participation (α = 0.84), organization (α = 0.79), and professional attitude (α = 0.88) were good. In all five domains, our median PICU scores were 6 (interquartile range, 5-6). Compared to other ethnic groups, Malay parents did perceive that domains of "care and cure," "parental participation," and "professional attitude" were less satisfactory.

CONCLUSIONS

Significant differences were found in satisfaction ratings between parents of different ethnicities. Further studies are needed to explore and determine reasons for these differences.

Examining ethnic disparities in provider and parent in-session participation engagement

PURPOSE

Well-documented ethnic disparities exist in the identification and provision of quality services among children receiving community-based mental health services. These disparities extend to parent treatment engagement, an important component of effective mental health services. Currently, little is known about differences in how providers support parents' participation in treatment and the degree to which parents actively participate in it. The purpose of this paper is to examine potential differences in both provider and parent in-session participation behaviours.

DESIGN/METHODOLOGY/APPROACH

Participants included 17 providers providing standard community-based mental health treatment for 18 parent-child dyads, with 44 per cent of the dyads self-identifying as Hispanic/Latino. In-session participation was measured with the parent participation engagement in child psychotherapy and therapist alliance, collaboration, and empowerment strategies observational coding systems.

FINDINGS

Overall, results indicate significantly lower levels of parent participation behaviours among Hispanic/Latino families compared to their Non-Hispanic/Non-Latino counterparts. No significant differences were seen in providers' in-session behaviours to support parent participation across Hispanic/Latino and Non-Hispanic/Non-Latino families.

RESEARCH LIMITATIONS/IMPLICATIONS

These findings contribute to the literature on ethnic differences in parent treatment engagement by utilising measures of in-session provider and parent behaviours and suggest that further investigation is warranted to documenting and understanding ethnic disparities in parents' participation in community-based child mental health treatment.

ORIGINALITY/VALUE

This paper contributes to the evaluation of differences in parent treatment engagement through demonstrating the utility of an in-session observational coding system as a measure of treatment engagement.

Disparities in Quality of Healthcare of Children from Immigrant Families in the US

The objective of this study was to examine disparities in quality of pediatric primary care among children from immigrant families in the US. Drawing from a nationally representative sample of 83,528 children ages 0-17 years from the 2007 National Survey of Children's Health, weighted logistic regression was used to assess the effect of immigrant family type on five indicators of quality of healthcare across children's racial/ethnic groups. Analyses controlled for indicators of child's access to care, family socio-economic characteristics, and primary language spoken in the household. Unadjusted estimates revealed a pattern of decreasing disparities from immigrant children to second-generation children, native-born children of immigrant parents, and to third-generation children, native-born children of native-born parents. Controlling for confounders showed that the positive effect of generational status on the quality of healthcare of children from immigrant families varied across indicators and among racial/ethnic groups. Not even third-generation Hispanic and Black children reached parity with third-generation White children on reported amount of time that providers devoted to their care and on providers' sensitivity to their family's values and customs. In contrast, disparities in reports of providers listening carefully to caregivers disappeared after adjusting for confounders, and only families headed by immigrant parents reported receiving less specific health-related information than the families of native-born White children. Our study suggests that it is important to develop interventions that help healthcare professionals to learn how different types of immigrant families perceive the interactions with the healthcare system and how to deliver care that increases the satisfaction of children from different racial/ethnic groups.

Barriers to care and quality of primary care services in children with sickle cell disease

AIMS

The aims of this study were: to (1) identify barriers to care in children with sickle cell disease; (2) examine the quality of primary care services received by these children and (3) examine the relationship between barriers to care and quality of primary care services in children with sickle cell disease.

BACKGROUND

Effective management in children with sickle cell disease requires early access to a comprehensive range of preventive screenings, urgent care treatments for vaso-occlusive pain crisis and ongoing prophylactic treatments.

DESIGN

A cross-sectional survey of parents of children with sickle cell disease was conducted between April-September 2011.

METHODS

Parents of children with sickle cell disease completed the Barriers to Care Questionnaire and Parent's Perceptions of Primary Care.

RESULTS

Parents of children with sickle cell disease (n = 38) reported health system barriers such as inability to contact doctors or clinics, extended wait times and inconvenient clinic hours. Some barriers were reported more frequently among children with concurrent sickle cell disease and asthma, compared with those children without a concurrent asthma condition. Parents who reported more barriers were least likely to perceive their care as accessible, comprehensive and coordinated.

CONCLUSIONS

Minimizing healthcare barriers may improve the quality of primary care services received by children with sickle cell disease and consequently prevent complications associated with sickle cell disease.

IMPLICATIONS FOR NURSING PRACTICE

Nurses and other care providers need to identify healthcare barriers, so that access, coordination, comprehensiveness and overall quality of primary care services may be improved in children with sickle cell disease.

Impact of Age and Comorbidity on Cervical and Breast Cancer Literacy of African Americans, Latina, and Arab Women

This study examines the relationship between age, comorbidity, and breast and cervical cancer literacy in a sample of African American, Latina, and Arab women (N = 371) from Detroit, Michigan. The Age-adjusted Charlson Comorbidity Index (ACC) was used characterize the impact of age and comorbidity on breast and cervical cancer literacy. The relationship between ACC and breast and cervical cancer screening, and group differences, were assessed. There was a statistically significant difference between breast cancer literacy scores. ACC had a greater impact on breast cancer literacy for African Americans.

Pediatric asthma readmission: asthma knowledge is not enough?

OBJECTIVE

To characterize factors associated with readmission for acute asthma exacerbation, particularly around caregiver asthma knowledge, beliefs, and reported adherence to prescribed medication regimens.

STUDY DESIGN

We enrolled 601 children (aged 1-16 years) who had been hospitalized for asthma. Caregivers completed a face-to-face survey regarding their asthma knowledge, beliefs, and medication adherence. Caregivers also reported demographic data, child's asthma severity, exposure to triggers, access to primary care, and financial strains. We prospectively identified asthma readmission events via billing data over a 1-year minimum follow-up period. We examined time to readmission with Cox proportional hazards.

RESULTS

The study cohort's median age was 5 years, 53% were African American, and 57% were covered by Medicaid. At 1 year, 22% had been readmitted for asthma. In the multivariate analysis, a caregiver's demonstration of increased asthma knowledge was associated with increased readmission risk. In addition, children whose caregivers reported less-than-perfect adherence to daily medication regimens had increased readmission risk. Likewise, having previously been admitted for asthma, decreased medical home access, and black race were associated with increased readmission risk.

CONCLUSION

In a multifactorial assessment of risk factors for asthma readmission, greater asthma knowledge and decreased medication adherence were associated with readmission. Inpatient efforts to prevent readmission might best target medication adherence rather than continuing to primarily provide asthma education.

Use of colocated multidisciplinary services to address family psychosocial needs at an urban pediatric primary care clinic

OBJECTIVE

To examine associations between use of on-site multidisciplinary services at a pediatric primary care clinic, perceptions of the clinic, and health care utilization.

STUDY DESIGN

Eighty caregivers were interviewed during clinic visits assessing on-site service use, satisfaction, and perception of the clinic as a medical home. Acute care, emergency department, and well-child visit data were abstracted from children's medical records. Student's t test and multivariate regression were used to examine associations between service use, satisfaction, and health care utilization.

RESULTS

Use of ≥3 clinic services was associated with improved satisfaction (Client Satisfaction Questionnaire-8 mean: 31.8 vs 31.0, P < .05), stronger perception of the clinic as a medical home (Parents' Perception of Primary Care mean: 97.6 vs 93.4, P < .01), and increased missed well-child care visits (mean: 0.49 vs 0.20, P < .05).

CONCLUSIONS

On-site service use was associated with improved caregiver satisfaction but decreased well-child visit adherence. Caregivers using support services may face barriers to accessing preventive care.

Satisfaction with care and decision making among parents/caregivers in the pediatric intensive care unit: a comparison between English-speaking whites and Latinos

PURPOSE

Because of previously documented health care disparities, we hypothesized that English-speaking Latino parents/caregivers would be less satisfied with care and decision making than English-speaking non-Latino white (NLW) parents/caregivers.

MATERIALS AND METHODS

An intensive care unit (ICU) family satisfaction survey, Family Satisfaction in the Intensive Care Unit Survey (pediatric, 24 question version), was completed by English-speaking parents/caregivers of children in a cardiothoracic ICU at a university-affiliated children's hospital in 2011. English-speaking NLW and Latino parents/caregivers of patients, younger than 18 years, admitted to the ICU were approached to participate on hospital day 3 or 4 if they were at the bedside for greater than or equal to 2 days. Analysis of variance, χ(2), and Student t tests were used. Cronbach αs were calculated.

RESULTS

Fifty parents/caregivers completed the survey in each group. Latino parents/caregivers were younger, more often mothers born outside the United States, more likely to have government insurance or no insurance, and had less education and income. There were no differences between the groups' mean overall satisfaction scores (92.6 ± 8.3 and 93.0 ± 7.1, respectively; P = .80). The Family Satisfaction in the Intensive Care Unit Survey (pediatric, 24 question version) showed high internal consistency reliability (α = .95 and .91 for NLW and Latino groups, respectively).

CONCLUSIONS

No disparities in ICU satisfaction with care and decision making between English-speaking NLW and Latino parents/caregivers were found.

Caregiver depression and perceptions of primary care predict clinic attendance in head start children with asthma

OBJECTIVE

The purpose of this study is to evaluate the mediating role of perceptions of primary care (PC) on the association between depression and PC clinic attendance among caregivers of children with asthma. In adults, depression is associated with lower PC clinic attendance and ∼25% of mothers presenting to a pediatric PC clinic will screen positive for depression. Adults' perceptions about their medical care mediate the depression-clinic attendance relation, but this has not been tested in children or in an asthma population.

METHODS

This is a secondary prospective data analysis of 141 caregivers of Head Start children diagnosed with asthma, offered an intervention to reduce barriers to PC. Caregivers rated their depressive symptoms and perceptions of PC (access, provider contextual knowledge, and continuity of care) at baseline. PC clinic attendance was tracked prospectively for 6-months.

RESULTS

At baseline, 26% of caregivers screened positive for depression. Within 6-months, 66% of children attended a PC appointment. A positive depression screen was not associated with PC attendance (p = 0.07) or continuity of care (p = 0.98) but was inversely associated with perceptions of both access (p = 0.03) and provider contextual knowledge (p = 0.02). Though the total indirect effect was not significant, the specific indirect effect of depression on PC attendance through access was significant (95% CI: 0.01, 0.68).

CONCLUSIONS

Providing tangible resources to reduce barriers to PC without addressing perceptions of access may not sufficiently improve PC clinic attendance in pediatric asthma. Screening caregivers for depression may identify families requiring targeted interventions to improve their perceptions of access.

Prevalence of and disparities in barriers to care experienced by youth with type 1 diabetes

OBJECTIVE

To describe the prevalence of access and process barriers to health care and to examine their relationship to sociodemographic and disease factors in a large and diverse cohort of US youth with type 1 diabetes.

STUDY DESIGN

A cross-sectional analysis of 780 youth who participated in the SEARCH for Diabetes in Youth Study and were diagnosed with type 1 diabetes in 2002-2005. Experience of barriers to care was collected from parent report on questionnaires. Analyses included multivariate regression models to predict the presence of specific barriers to care.

RESULTS

Overall, 81.7% of participants reported at least one barrier; the 3 most common were costs (47.5%), communication (43.0%), and getting needed information (48.4%). Problems with access to care, not having a regular provider, and receiving contextual care (care that takes into account personal and family context) were associated with poorer glycated hemoglobin levels. Adjusted multivariate models indicated that barriers related to access (regular provider, cost) were most likely for youth with low family income and those without public health insurance. Barriers associated with the processes of quality care (contextual care, communication) were more likely for Hispanic youth and those whose parents had less education.

CONCLUSIONS

This study indicates that a large proportion of youth with type 1 diabetes experience substantial barriers to care. Barriers to access and those associated with processes of quality care differed by sociodemographic characteristics. Future investigators should expand knowledge of the systemic processes that lead to disparate outcomes for some youth with diabetes and assess potential solutions.

The voices of limited English proficiency Latina mothers on pediatric primary care: lessons for the medical home

The objective of this study is to inform medical home implementation in practices serving limited English proficiency Latino families by exploring limited English proficiency Latina mothers' experiences with, and expectations for, pediatric primary care. In partnership with a federally-qualified community health center in an urban Latino neighborhood, we conducted semi-structured interviews with 38 low-income Latina mothers. Eligible participants identified a pediatric primary care provider for their child and had at least one child 3 years old or younger, to increase the probability of frequent recent interactions with health care providers. Interview transcripts were coded and analyzed through an iterative and collaborative process to identify participants' satisfaction with and expectations for pediatric primary care. About half of the mothers interviewed were satisfied with their primary care experiences. Mothers suggested many ways to improve the quality of pediatric primary care for their children to better meet the needs of their families. These included: encouraging providers to invest more in their relationship with families, providing reliable same-day sick care, expanding hours, improving access to language services, and improving care coordination services. Limited English proficiency Latina mothers expect high-quality pediatric primary care consistent with the medical home model. Current efforts to improve primary care quality through application of the medical home model are thus relevant to this population, but should focus on the parent-provider relationship and timely access to care. Promoting this model among practices that serve limited English proficiency Latino families could improve engagement and satisfaction with primary care.

Bereaved parents and siblings offer advice to health care providers and researchers

OBJECTIVE

To determine how to improve care for families by obtaining their advice to health care providers and researchers after a child's death from cancer.

DESIGN

Families with a surviving sibling (age, 8 to 17 y) were recruited from cancer registries at 3 hospitals in the United States and Canada 3 to 12 months (M=10.4, SD=3.5) after the child's death.

SETTING

Data were collected in the home.

PARTICIPANTS

Participants (N=99) included 36 mothers, 24 fathers, and 39 siblings from 40 families.

OUTCOME MEASURES

Each participant completed a qualitative interview that was audio recorded, transcribed, and coded for thematic content.

FINDINGS

Five major themes included the need for: (a) improved communication with the medical team, (b) more compassionate care, (c) increased access to resources, (d) ongoing research, and (e) offering praise. Interwoven within the 5 themes was a subtheme of continuity of care.

CONCLUSIONS

Many participants were pleased with the care the child with cancer received, but others noted areas in need of improvement, particularly medical communication and continuity of care. Additional research is needed to inform interventions to improve services for families of children with life-limiting conditions.

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.

Linguistic and ethnic disparities in breast and cervical cancer screening and health risk behaviors among Latina and Asian American women

PURPOSE

This study intends to (1) describe breast and cervical cancer screening patterns and health risk behaviors for Latina and Asian American women, with consideration for their language, and (2) investigate the impact of health risk behaviors on breast and cervical cancer screenings after controlling for demographic characteristics and language.

METHODS

Data derived from the California Health Interview Survey 2007, which was a random-digit-dial population-based survey, were used. Latina (n = 3513) and Asian American (n = 2538) women were included in this study. Breast and cervical cancer screenings were measured by recent mammography and Pap smear examinations, respectively. Physical activity, smoking habits, alcohol consumption, and body mass index (BMI) were measured to assess health risk behaviors.

RESULTS

This study demonstrated that Asian Americans have better outcomes in health risk behaviors in general. However, Latinas were more likely than Asian Americans to receive mammograms and Pap smears. English-speaking Latinas and Asian Americans showed better outcomes in cancer screening and health risk behaviors, but BMI patterns differed based on language. Unhealthy risk behaviors were related to low screening rates, except for BMI and drinking, among Latina women.

CONCLUSIONS

The findings reveal unique ethnic and linguistic patterns that are relevant to health risk behaviors and cancer screening and that influence overall health outcomes. These findings suggest that health risk behaviors and cancer screening for ethnic minority populations may be framed by cultural contexts. Intervention strategies designed to promote healthy lifestyles and cancer screening may have greater sustainable benefits.

Racial and ethnic disparities in quality of health care among children with autism and other developmental disabilities

We examined racial and ethnic disparities in quality of care for children with autism and other developmental disabilities and whether disparities varied for children with autism compared to children with other developmental disabilities. Analyzing data from the National Survey of Children with Special Health Care Needs (N  =  4,414), we compared Black and Latino children to White children. We found racial and ethnic disparities on 5 of 6 quality outcomes. The interaction between race and disability status indicated that disparities in quality indicators were exacerbated among families of children with autism. These analyses suggest that children with autism, particularly those who are Latino and Black, face greater challenges in receiving high-quality health care.

Medical home disparities for Latino children by parental language of interview

Examination of Latino children in aggregate ignores important subgroup differences due to the parents' English language ability. Previous reports of the pediatric medical home have not stratified Latino children by parental language differences to compare the two groups directly. We analyzed the 2007 National Survey of Children's Health to determine medical home prevalence among Latino children, stratified by language of parental interview. Most Latino children with a Spanish-language parental interview had a usual source of care, but only one-quarter had a medical home. Striking medical home disparities persisted for Latino children with a Spanish-language interview, even after adjustment for potential confounders. Lack of a medical home was associated with disparities in the quality of care, more so than access disparities. Addressing health care disparities for Latino children requires particular attention to the unique needs of Latino children with parents who may experience language barriers during health care encounters.

Association of family-centered care with improved anticipatory guidance delivery and reduced unmet needs in child health care

Little is known about the association of family-centered care (FCC) with the quality of pediatric primary care. The objectives were to assess (1) associations between family-centered care (FCC), receipt of anticipatory guidance, and unmet need for health care; and (2) whether these associations vary for children with special health care needs (CSHCN). The study, a secondary data analysis of the 2004 Medical Expenditure Panel Survey, used a nationally representative sample of family members of children 0-17 years. We measured receipt of FCC in the last 12 months with a composite score average>3.5 on a 4 point Likert scale from 4 Consumer Assessment of Healthcare Providers and Systems questions. Outcome measures were six anticipatory guidance and six unmet health care service needs items. FCC was reported by 69.6% of family members. One-fifth (22.1%) were CSHCN. Thirty percent of parents reported≥4 of 6 anticipatory guidance topics discussed and 32.5% reported≥1 unmet need. FCC was positively associated with anticipatory guidance for all children (OR=1.45; 95% CI 1.19, 1.76), but no relation was found for CSHCN in stratified analyses (OR=1.01; 95% CI .75, 1.37). FCC was associated with reduced unmet needs (OR=.38; 95% CI .31, .46), with consistent findings for both non-CSHCN and CSHCN subgroups. Family-centered care is associated with greater receipt of anticipatory guidance and reduced unmet needs. The association between FCC and anticipatory guidance did not persist for CSHCN, suggesting the need for enhanced understanding of appropriate anticipatory guidance for this population.

Association of experiences of medical home quality with health-related quality of life and school engagement among Latino children in low-income families

OBJECTIVE

This study examines whether patient-reported indicators of a quality medical home are associated with measures of health among Latino children in low-income families.

DATA SOURCES

Data on 3,258 children ages 2-18 years are from a cross-sectional survey of parents of children affiliated with California's Healthy Kids insurance.

STUDY DESIGN

Medical home quality was assessed using the Parents' Perception of Primary Care and was associated with health-related quality of life (HRQOL) overall and in four domains (physical, emotional, social, and school/daycare) and four measures of school engagement.

PRINCIPAL FINDINGS

A higher total medical home score was associated with a higher total Pediatric Quality of Life Inventory score and scores in four subdomains (total beta [B]=1.77, physical B=1.71, social B=1.36, emotional B=2.22, and school/daycare B=1.69, all p<0.001). It was also associated with missing fewer than three school days due to illness (odds ratio [OR]=1.12, 95 percent confidence intervals [CI]: 1.05, 1.19), excellent/above average school performance overall (OR=1.10, 95 percent CI: 1.03, 1.17) and performance in reading (OR=1.13, 95 percent CI: 1.06, 1.20) and math (OR=1.10, 95 percent CI: 1.03, 1.16).

CONCLUSIONS

Patient-reported medical home quality indicators are favorably associated with HRQOL and measures of school engagement among Latino children in low-income families.

Measuring patient and family experiences of health care for children

BACKGROUND

The Institute of Medicine considers patient centeredness a core dimension of quality. Several patient/family surveys exist to assess pediatric health care. The Children's Health Insurance Program Reauthorization Act mandates strengthening quality measurement for children, including for patient/family experience of care.

OBJECTIVES

The aim of this study was to determine what instruments exist for measuring patient/family experience of pediatric health care and which should be included in the core measurement set for assessing Medicaid and the Children's Health Insurance Program (CHIP) programs; to identify gaps in measurement; and to provide recommendations for measure development.

METHODS

We developed a conceptual framework for measuring patient/family experience of care. We conducted a review of national measure clearinghouses and of the literature to assess validity, reliability, and feasibility of existing measures, and how these measures address the conceptual framework.

RESULTS

We found valid and reliable instruments for measuring patient/family experience of care include the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) instruments, Promoting Healthy Development Survey (PHDS), Young Adult Health Care Survey (YAHCS), and the National Research Corporation Picker Pediatric Inpatient Survey (NRC Picker). We identified the need for matching patients with providers and groups as a barrier for widespread use of the CAHPS® pediatric clinician & group instrument.

CONCLUSIONS

We recommended to the National Advisory Council for Healthcare Research and Quality Subcommittee on Children's Healthcare Quality Measures for Medicaid and Child Health Insurance Programs (SNAC) the CAHPS® Child Medicaid 4.0 and pediatric Clinician & Group Survey for inclusion in the initial recommended list of core measures for voluntary use by Medicaid and CHIP. The Clinician and Group Survey was not included in the list posted for public comment due to concerns at that time (December 2009) about feasibility. We also recommended that development of a child version of the CAHPS® behavioral and mental health survey now used in the adult population and of a pediatric hospital CAHPS® measure be considered high priorities for development in the next phase of Children's Health Insurance Program Reauthorization Act measurement activity. This phase should also explore methods to increase response rates and lower costs of obtaining consumer feedback.

Acceptance rates in state-federal vocational rehabilitation of clients with brain injury: Is racial disparity an issue?

PRIMARY OBJECTIVE

To utilize Aday and Andersen's Framework for the Study of Access to examine racial disparity within the State-Federal vocational rehabilitation system, among clients with brain injury. Research questions included: Do pre-disposing characteristics such as age, race, ethnicity, gender, marital status and education influence vocational rehabilitation acceptance rates in the US? Do enabling characteristics such as referral source, insurance coverage and primary source of support at application influence vocational rehabilitation acceptance rates in the US? Is there a difference, based on race, in the reason for case closure for vocational rehabilitation services?

METHODS AND PROCEDURES

Exhaustive CHAID analysis was conducted with acceptance for rehabilitation as the criterion variable and pre-disposing characteristics as predictor variables. Chi-square analysis was calculated with regard to reason for closure.

MAIN OUTCOMES AND RESULTS

Descriptive findings are presented. Of the pre-disposing factors, the most significant predictor of acceptance rate was education level. Pearson Chi-square analyses revealed significant differences between White and non-White clients with brain injury with regard to reason for closure.

CONCLUSIONS

The data indicate that racial differences were only a small part of the overall equation and again that distinct disparity by race is not evidenced in the RSA-911 data for persons with a primary or secondary diagnosis of brain injury.

Actualizing a provider alliance to expand health services access to a low-income urban community

Social change to facilitate health care access for vulnerable populations sometimes involves model-driven innovative structures and innovative planning and implementation approaches. This paper described and analyzed the rationale, conceptual framework, program components, and implementation of the South Central Health Care Alliance (SCHCA) implemented in South Los Angeles from January 2002 to December 2004. The program development and implementation was guided by an integrated framework linking the Open Systems Theory, the Social Cognitive Theory, the Health Belief Model, and the Preventive Health Education and Medical Home Project. The performance of the SCHCA as a social system, partnership, and participatory implementation program is also presented. While the SCHCA was found to be a dynamic social system that responded well to contingencies, its performance as a partnership and participatory implementation program was wanting in many respects.

National disparities in the quality of a medical home for children

OBJECTIVES

To examine socio-demographic disparities associated with a quality medical home.

METHODS

A nationally representative sample of children ages 0-17 years (n = 102,353) from the 2003 National Survey of Children's Health. Risk factors including non-white race/ethnicity, income <200% of the federal poverty level (FPL), uninsured, parent education lesser than high school, and non-English primary household language, were examined in relation to a quality medical home separately and together as a "profile" of risk. Fourteen questions were used to measure five medical home features: access, continuity, comprehensiveness, family-centered care, and coordination. Quality was defined as a value greater than median for each feature and for an overall score.

RESULTS

Before and after adjustment for child demographics and health status, all studied risk factors were associated with poorer quality medical home features. Uninsured [odds ratio (OR) = 0.43, 95% confidence interval (CI): 0.40-0.47] and low-income children (OR = 0.65, CI: 0.62-0.69) had among the lowest odds of a quality medical home overall and across most features, except coordination that showed an opposite trend. Summarized through risk profiles, children experiencing all five risk factors had 93% lower odds of a quality medical home overall (OR = 0.07, CI: 0.04-0.25) compared to zero risk children.

CONCLUSION

This study demonstrates large national disparities in the quality of a medical home for children. That disparities were most prevalent for the uninsured and those in or near poverty, both modifiable risk factors, suggests that reforms to increase coverage and to lift families out of poverty are essential to assuring that children have access to the full complement of appropriate health care services including a quality medical home.

A review of the evidence for disparities in child vs adult health care: a disparity in disparities

Racial and ethnic health disparities in primary care have been well documented in the US healthcare system. However, very little attention has been directed toward inequities in child health. The aim of this review is to provide context for the scope of the challenges associated with addressing pediatric health disparities in primary care by comparing the weight of evidence regarding racial/ethnic health disparities for children vs adults. A multisystem health disparities conceptual model will frame the search strategy and analysis of the review. This paper will: (1) identify knowledge deficits in the understanding of existing disparities in pediatric primary care relative to adult primary care; (2) assess root causes of disparities for children vs adults; and (3) propose recommendations for a research agenda and policy implementation to eliminate disparities in pediatric primary care.