Relationship between presence of a reported medical home and emergency department use among children with asthma

How do plant demographic and ecological traits combined with social dynamics and human traits affect woody plant selection for medicinal uses in Benin (West Africa)?

BACKGROUND

Several hypotheses have been used in ethnobotany to explain the plant's selection criteria by people for their daily needs. Thus, it is important to assess synergy and complementarity among them, especially, those concerning the plant use value, social dynamics and human traits. The study aims to (i) highlight people's socio-economic factors, and plant ecological traits that affect the plant use-availability dynamic (PUD); and (ii) assess the available species diversity effect on ethno-medicinal knowledge diversity in Benin.

METHODS

Ethnobotanical interviews were carried out to quantify the importance of local species in different ecological zones of Benin with 590 traditional medicine actors. Vegetation surveys were done to assess species availability within 337 plots of 50 m x 40 m or 60 m x 30 m, depending on the climatic zone, for a total of 61.6 ha, established in 15 forests distributed within the 10 phytodistricts of Benin. The plant use availability hypothesis was quantified as a dynamic link between species use value and availability (PUD). A general and mixed linear models were used to assess the significance of each factor's effect on PUD. Pearson correlation test was applied on Shannon diversity index considering inventoried species in the field and those which were cited by people, for the available species diversity effect on ethno-medicinal knowledge diversity assessment.

RESULTS

A hundred and twenty woody medicinal plants, mostly trees (68.33%), were sampled. Growth form and its interaction with phytodistrict have a significant effect (p: 0.005) on PUD. The less available trees were the most used in the phytodistricts 3, 4, 8 and 10. PUD varies significantly according to social factors (p: 0.007). Ethnicity, age and main activity were the most quoted social factors which influenced the PUD. Ethnicity and age have various effects considering the phytodistricts. Moreover, the influence of age changes following the main activity. Plant selection did not solely link to the surrounding diversity (r: - 0.293; p: 0.403). Within some phytodistricts, especially those of 3, 4, 8 and 10, the less available tree species were the most requested.

CONCLUSION

It is urgent to reforest vegetation patches in some phytodistricts (3, 4, 8 and 10) of Benin with widely requested and no available species to avoid the extinction of their wild populations. This concerns Cassia sieberiana DC., Anonychium africanum (Guill. & Perr.) C. E.Hughes & G. P. Lewis, Pterocarpus erinaceus Poir., Cola millenii K. Schum., Azadirachta indica A. Juss., Khaya senegalensis (Desr.) A. Juss., Pseudocedrela kotschyi (Schweinf.) Harms, Treculia africana Decne. ex Trécul, Uapaca heudelotii Baill., Vitellaria paradoxa C. F. Gaertn., Kigelia africana (Lam.) Benth. and Newbouldia laevis (P. Beauv.) Seem. ex Bureau.

Social Risks and Health Care Utilization Among a National Sample of Children With Asthma

OBJECTIVES

Prior studies using single-center populations have established associations between social risks and health care utilization among children with asthma. We aimed to evaluate associations between social risks and health care utilization among a nationally representative sample of children with asthma.

STUDY DESIGN

In this cross-sectional study, we utilized the 2018-2019 National Survey of Children's Health to identify children 2 to 17 years old with asthma. Using the Healthy People (HP) 2030 social determinants of health (SDOH) framework, we identified 31 survey items assessing 18 caregiver-identified social risks as exposure variables and classified them into the 5 HP SDOH domains (Economy, Education, Health care, Community, and Environment). Primary outcome was caregiver-reported health care utilization. Associations between individual social risks and total number of SDOH domains experienced with health care utilization were assessed.

RESULTS

The weighted study population included 8.05 million children, 96% of whom reported ≥1 social risk. Fourteen social risks, spanning all 5 SDOH domains, were significantly associated with increased health care utilization. The 3 risks with the highest adjusted odds ratios (aOR) of health care utilization included: experiencing discrimination (aOR 3.26 [95% confidence interval (CI): 1.75, 6.08]); receiving free/reduced lunch (aOR 2.16, [95% CI 1.57, 2.98]); and being a victim of violence (aOR 2.11, [95% CI 1.11, 4]). Children with risks across more SDOH domains reported significantly higher health care utilization.

CONCLUSIONS

Among our national population of children with asthma, social risks are prevalent and associated with increased health care utilization, highlighting their potential contribution to pediatric asthma morbidity.

Autism Spectrum Disorder: The New Asthma?

While autism spectrum disorder (ASD) has traditionally been diagnosed in specialty care, rising prevalence rates have strained specialist capacity and created significant diagnostic bottlenecks. With long wait times for specialist evaluations, pediatricians are increasingly being asked to play a greater role in identifying, diagnosing, and managing ASD within the medical home. In this commentary we draw parallels between the challenges pediatricians faced two decades ago learning how to manage pediatric asthma in the medical home, to those faced today in the field of primary care ASD management. Reflecting on the lessons learnt in primary care asthma management may help us construct a roadmap towards a higher and more consistent standard of ASD primary care for patients and their families.

Geographic proximity to primary care providers as a risk-assessment criterion for quality performance measures

IMPORTANCE

Previous studies have found a mixed association between Patient-Centered Medical Home (PCMH) designation and improvements in primary care quality indicators, including avoidable pediatric emergency department (ED) encounters. Whether these associations persist after accounting for the geographic locations of providers relative to where patients reside is unknown.

OBJECTIVE

To examine the association between geographic proximity to primary care providers versus hospitals and risk of avoidable and potentially avoidable ED visits among children with pre-existing diagnosis of attention-deficit/hyperactivity disorder or asthma.

METHODS

Retrospective cohort study of a panel of pediatric Medicaid claims data from the South Carolina from 2016-2018 for 2,959 beneficiaries having a pre-existing diagnosis of attention-deficit/hyperactivity disorder (ADD, ages 6-12) and 6,390 beneficiaries with asthma (MMA, ages 5-18), as defined using Healthcare Effectiveness Data and Information Set (HEDIS) performance measures. We calculated differences in avoidable and potentially avoidable ED visits by the beneficiary's PCMH attribution type and in relation to differences in proximity to their primary care providers versus hospitals. Outcomes were defined using the New York University Emergency Department Algorithm (NYU-EDA). Differences in ED visit risk were assessed using generalized estimation equations and compared using marginal effects models.

RESULTS

The 2.4 percentage point reduction in risk of avoidable ED visits among children in the ADD cohort who attended a PCMH versus those who did not increased to 3.9 to 7.2 percentage points as relative proximity to primary care providers versus hospitals improved (p < 0.01). Children in the ADD and MMA cohorts that were enrolled in a medical home, but did not attend one for primary care services exhibited a 5.4 and 3.0 percentage point increase in avoidable ED visit compared to children who were unenrolled and did not attend medical homes (p < 0.05), but these differences were only observed when geographic proximity to hospitals was more convenient than primary care providers. Mixed findings were observed for potentially avoidable visits.

CONCLUSIONS

In several health care performance evaluations, patient-centered medical homes have not been found to reduce differences in hospital utilization for conditions that are treatable in primary care settings among children with chronic illnesses. Analytical approaches that also consider geographic proximity to health care services can identify performance benefits of medical homes. Expanding risk-adjustment models to also include geographic data would benefit ongoing quality improvement initiatives.

The PUFFinCA scale: development of an instrument for evaluating the primary care functions of family physicians in childhood asthma

AimTo develop the Primary care fUnctions oF Family physicians in Childhood Asthma (PUFFinCA) scale for evaluating the cardinal process functions of primary care services (accessibility, comprehensiveness, continuity and coordination) provided by family physicians (FPs) in the management of childhood asthma. BACKGROUND: In the literature on the functions of primary care, there is no assessment tool focusing on children with asthma. Primary care assessment scales adapted to various languages are not suitable to adequately address the needs of special patient groups, such as children with asthma. METHODS: In this methodological study, the instrument development process was completed in four stages: establishing the pool of items, evaluating the content validity, applying the scale and statistical analysis. The scale was applied to 320 children who had asthma and received care in the clinic of the Department of Pediatrics, Division of Allergy and Pulmonology at Ege University School of Medicine, Turkey. The Cronbach's α and Spearman-Brown coefficient were calculated to determine the reliability of the scale. Principal component analysis was used to determine the construct validity of the scale.FindingsThe PUFFinCA scale was found to have four-factor structure and 25 items. Cronbach's α coefficient was 0.93. It has been determined that the reliability was excellent and the item-total correlation coefficients were >0.30 each. The factors were titled FP's 'functions of accessibility, first contact and continuity', 'functions of coordination and comprehensiveness of health services related to asthma management', 'provision of preventive care related to asthma' and 'provision of services for paid vaccinations'.

Association between Practice Participation in a Pediatric-focused Medical Home Learning Collaborative and Reduction of Preventable Emergency Department Visits by Publicly-insured Children in Massachusetts

Introduction:

This study evaluates the impact of practice participation in a pediatric patient-centered medical home learning collaborative on preventable emergency department (ED) visits among children in MassHealth (Massachusetts Medicaid/Children’s Health Insurance Program).

Methods:

Claims and enrollment data were extracted for child MassHealth members (aged 3–18) comprising 2 groups: members enrolled in a group of 13 child-serving practices that participated in an intensive, 29-month long patient-centered medical home learning collaborative (intervention group), and members enrolled in a group of 12 comparison practices with roughly similar panel size, type, and geographic location (comparison group). Preventable ED visits were identified using a modified version of the New York University ED algorithm. Two analyses were then conducted: (1) a repeat cross-sectional analysis among children enrolled in intervention or comparison group practices during baseline (first half of 2011) and follow-up (second half of 2013) periods; and (2) a longitudinal analysis among a subset of children enrolled for the full study period (2011–2013). Both analyses tested whether the effect of the intervention differed for children with versus without chronic conditions (effect modification).

Results:

Preventable ED visits declined from baseline to follow-up among children in both intervention and comparison practices. In the cross-sectional analysis, the decrease was the same in both practice groups, and for children with versus without chronic conditions. The longitudinal analysis shows a statistically significantly greater decrease among children with chronic conditions enrolled in the intervention practices (P = 0.02).

Conclusion:

Children with chronic conditions might receive the greatest benefit from receiving care in a medical home setting.

Current State of Child Health in Rural America: How Context Shapes Children's Health

PURPOSE

Children's health is influenced by the context in which they live. We provide a descriptive essay on the status of children in rural America to highlight features of the rural environment that may affect health.

DESCRIPTION

We compiled information concerning components of the rural environment that may contribute to health outcomes. Areas addressed include the economic characteristics, provider availability, uniquely rural health risks, health services use, and health outcomes among rural children.

ASSESSMENT

Nearly 12 million children live in the rural United States. Rural counties are economically disadvantaged, leading to higher rates of poverty among rural versus urban children. Rural and urban children are approximately equally likely to be insured, but Medicaid insures a higher proportion of children in rural areas. While generally similar in health, rural children are more likely to be overweight or obese than urban children. Rural parents are less likely to report that their children received preventive medical or oral health visits than urban parents. Rural children are more likely to die than their urban peers, largely due to unintentional injury.

CONCLUSION

Improving rural children's health will require both increased public health surveillance and research that creates solutions appropriate for rural environments, where health care professionals may be in short supply. Most importantly, solutions must be multisectoral, engaging education, economic development, and other community perspectives as well as health care.

The Medical Home Model and Pediatric Asthma Symptom Severity: Evidence from a National Health Survey

The objective was to investigate the association between receiving care under the medical home model and parental assessment of the severity of asthma symptoms. It was hypothesized that parents of children who received care under the medical home model reported less severe asthma symptoms compared with their counterparts, whose care did not meet the medical home criteria. Secondary analyses were conducted using cross-sectional data from the 2011-2012 National Survey of Children's Health. Children with asthma aged 0-17 years were included and classified as receiving care from the medical home if their care contained 5 components: a personal doctor, a usual source of sick care, family-centered care, no problems getting referrals, and effective care coordination. Ordinal logistic regression was used to examine the relationship between parent-rated severity of asthma symptoms (mild, moderate, and severe symptoms) and the medical home. Approximately 52% of 8229 children who reported having asthma received care from the medical home. Only 30.8% of children with severe asthma symptoms received care that met the medical home criteria, compared to 55.7% of children with mild symptoms. After accounting for confounding factors, obtaining care under the medical home model decreased the odds of parent-reported severe asthma symptoms by 31% (adjusted odds ratio 0.69; 95% CI, 0.56-0.85). Study results suggest that the medical home model can reduce parent-rated severity of asthma symptoms. The findings highlight the importance of providing medical home care to children with asthma to improve the outcomes that matter most to children and their families.

Evaluating the Impact of Parent-Reported Medical Home Status on Children's Health Care Utilization, Expenditures, and Quality: A Difference-in-Differences Analysis with Causal Inference Methods

OBJECTIVE

To evaluate the effects of the parent-reported medical home status on health care utilization, expenditures, and quality for children.

DATA SOURCES

Medical Expenditure Panel Survey (MEPS) during 2004-2012, including a total of 9,153 children who were followed up for 2 years in the survey.

STUDY DESIGN

We took a causal difference-in-differences approach using inverse probability weighting and doubly robust estimators to study how changes in medical home status over a 2-year period affected children's health care outcomes. Our analysis adjusted for children's sociodemographic, health, and insurance statuses. We conducted sensitivity analyses using alternative statistical methods, different approaches to outliers and missing data, and accounting for possible common-method biases.

PRINCIPAL FINDINGS

Compared with children whose parents reported having medical homes in both years 1 and 2, those who had medical homes in year 1 but lost them in year 2 had significantly lower parent-reported ratings of health care quality and higher utilization of emergency care. Compared with children whose parents reported having no medical homes in both years, those who did not have medical homes in year 1 but gained them in year 2 had significantly higher ratings of health care quality, but no significant differences in health care expenditures and utilization.

CONCLUSIONS

Having a medical home may help improve health care quality for children; losing a medical home may lead to higher utilization of emergency care.

Characteristics of Pediatric Emergency Revisits After an Asthma-Related Hospitalization

STUDY OBJECTIVE

We identify and characterize factors related to subsequent emergency revisits among children hospitalized for asthma.

METHODS

This population-based, prospective, observational cohort included children aged 2 to 16 years, hospitalized for asthma at an urban pediatric facility and followed for greater than or equal to 12 months. The primary outcome was asthma-related emergency revisit within 12 months of discharge. Revisits were identified by billing codes, respiratory chief complaints, and medications administered (eg, albuterol, systemic corticosteroids), dispensed, or prescribed. Predictors and covariates include demographic, socioeconomic, access, and environmental exposure variables collected during index admission. Multivariable logistic regression was used to evaluate the association between predictors and odds of asthma-related revisit.

RESULTS

A total of 671 children were enrolled; the majority were boys (65%), aged 4 to 11 years (59%), black (59%), and publicly insured (73%). There were 274 patients (41%) who were treated for asthma-related emergency revisits within 12 months of the index admission. In adjusted models, younger children, black children, children with excellent reported access to primary care, and children with a history of inhaled steroids were more likely to experience emergency revisits. Low income, detectable cotinine levels, and traffic exposure did not independently predict revisit.

CONCLUSION

Asthma-related emergency revisit is common after hospitalization, with more than 40% of children returning within 12 months. Socioeconomic and exposure-related risk factors typically predictive of asthma morbidity were not independently associated with emergency revisit among children in this cohort.

Does receiving care in a medical home reduce racial/ethnic disparities in ED visits among children with asthma in the United States?

Evidence has shown the implementation of medical home model improves care quality and outcomes. However, it is not clear whether receiving care from a medical home has any impact on racial/ethnic disparities in emergency department (ED) use by children with asthma. This study using the US National Survey of Children with Special Health Care Needs, 2009-2010, estimated racial/ethnic disparities in ED use. Generalized liner models were used to examine factors associated with ED use. Racial/ethnic differences in ED use were attenuated after adjusting for socio-economic variables. Ratios of prevalence ratios were calculated to examine the effect modification of medical home on ED use associated with race/ethnicity. The adjusted prevalence ratio of ED use of the Black to non-Hispanic White was 1.51 (95% confidence interval (CI): 1.36-1.67) with medical home and 1.35 (95% CI: 1.24-1.47) without medical home. Among those with care from a medical home Latino children had higher ED use compared with White children. There is no evidence that the self-reported care from a medical home narrows the gaps in ED use between non-Hispanic White and Black or Latino children with asthma.

Training Residents to Work in a Patient-Centered Medical Home: What Are the Outcomes?

Background The patient-centered medical home (PCMH) provides a setting to enhance resident training in systems-based practice. Few studies have addressed the impact of PCMHs on resident knowledge and confidence. Objective The goal of this study was to evaluate resident knowledge, confidence, behavior, and patient outcomes in a PCMH. Methods Our curriculum emphasized patient panel report card interpretation, a telephone medicine curriculum, and interdisciplinary team-based care of chronic medical conditions. We measured resident satisfaction, knowledge, and confidence. Patient outcomes included hemoglobin A1c (HbA1c) and blood pressures. Prescores and postscores were compared using paired t tests for continuous measures and McNemar's test for binary measures. Results A total of 154 residents were eligible for the curriculum. All residents participated in the curriculum, though not all residents completed the evaluation. Completion rates for paired pre-post knowledge and confidence surveys were 38% and 37%, respectively. Nearly 80% (69 of 87) of residents indicated that the curriculum was above average or outstanding. Our evaluation revealed very small immediate improvements in knowledge and confidence. No significant improvement in patients' HbA1cs or blood pressures occurred after the curriculum. Conclusions Explicit training to work in a PCMH was feasible and resulted in high levels of resident satisfaction and immediate small improvements in knowledge and confidence.

The Patient-Centered Medical Home: How Is It Related to Quality and Equity Among the General Adult Population?

This study investigates whether patient-reported characteristics of the medical home are associated with improved quality and equity of preventive care, advice on health habits, and emergency department use. We used adjusted risk ratios to examine the association between medical home characteristics and care measures based on the 2010 Medical Expenditure Panel Survey. Medical home characteristics are associated with 6 of the 11 outcome measures, including flu shots, smoking advice, exercise advice, nutrition advice, all advice, and emergency department visits. Educational and income groups benefit relatively equally from medical home characteristics. However, compared with insurance and access to a provider, medical home characteristics have little influence on overall disparities in care. In sum, our findings support that medical home characteristics can improve quality and reduce emergency visits but we find no evidence that medical home characteristics alleviate disparities in care.

Access to patient-centered medical homes in children with sickle cell disease

To determine the proportion of children with sickle cell disease (SCD) followed in a subspecialty clinic with access to a primary care provider (PCP) exhibiting practice-level qualities of a patient-centered medical home (PCMH). We surveyed 200 parents/guardians of children with SCD using a 44-item tool addressing PCP access, caregiver attitudes toward PCPs, barriers to healthcare utilization, perceived disease severity, and satisfaction with care received in the PCP versus SCD clinic settings. Individual PCMH criteria measured were a personal provider relationship and medical care characterized as accessible, comprehensive and coordinated. Although 94 % of respondents reported a PCP for their child, there was greater variation in the proportion of PCPs who met other individual PCMH criteria. A higher proportion of PCPs met criteria for coordinated care when compared to accessible or comprehensive care. In multivariate models, transportation availability, lower ER visit frequency and greater PCP visit frequency were associated favorably with having a PCP meeting criteria for accessible and coordinated care. Child and respondent demographics and disease severity had no impact on PCMH designation. Average respondent satisfaction scores for the SCD clinic was higher, when compared to satisfaction scores for the PCP. For children with SCD, access to a PCP is not synonymous with access to a medical home. While specific factors associated with PCMH access may be identified in children with SCD, their cause and effect relationships need further study.

Type of Insurance and Use of Preventive Health Services Among Older Adults in Mexico

OBJECTIVE

The main purpose of this article was to assess the differences between Seguro Popular (SP) and employer-based health insurance in the use of preventive services, including screening tests for diabetes, cholesterol, hypertension, cervical cancer, and prostate cancer among older adults at more than a decade of health care reform in Mexico.

METHOD

Logistic regression models were used with data from the Mexican Health and Nutrition Survey, 2012.

RESULTS

After adjusting for other factors influencing preventive service utilization, SP enrollees were more likely to use screening tests for diabetes, cholesterol, hypertension, and cervical cancer than the uninsured; however, those in employment-based and private insurances had higher odds of using preventive care for most of these services, except Pap smears.

DISCUSSION

Despite all the evidence that suggests that SP has increased access to health insurance for the poor, inequalities in health care access and utilization still exist in Mexico.

Evaluation of a statewide medical home program on children and young adults with asthma

OBJECTIVE

Asthma, the most common chronic condition among children, accounts for significant healthcare utilization and impact on quality of life. Care coordination in a medical home is considered standard practice, but has not been rigorously evaluated.

METHODS

We initiated this pilot study of children/young adults with asthma (n = 967), ages: birth to 24 years, receiving care from a subset of pediatric practices (n = 20) participating in the Pennsylvania Medical Home Initiative, Educating Practices in Community-Integrated Care (92 practices statewide). We hypothesized children and youth with asthma receiving care coordination in the context of a formal medical home program would experience favorable associations with healthcare utilization and quality of life measures.

RESULTS

A total of 9240 care coordination encounters for this cohort of children/youth occurred over 100 days. The average length of care coordination encounter was 20.7 minutes. The most common care coordination activity was referral management (21%) and the care coordinator in the practice most often contacted parent/family and specialists (75%). Children with more severe asthma had more hospitalizations and emergency department (ED) visits than children with less severe asthma. There was a significant decrease in school absences, ED visits and acute care visits for children/youth with asthma with increasing length of time in a medical home program (p < 0.05).

CONCLUSION

Care coordination for children/youth with asthma is feasible and may yield improvements in healthcare utilization, expenditures and quality of life. Larger-scale implementation of care coordination and medical home models for children/youth with asthma and other diagnoses are warranted.

The Value Adults Place on Child Health and Functional Status

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

CONCLUSIONS

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

Associations between practice-reported medical homeness and health care utilization among publicly insured children

BACKGROUND

The patient-centered medical home (PCMH) is widely promoted as a model to improve the quality of primary care and lead to more efficient use of health care services. Few studies have examined the relationship between PCMH implementation at the practice level and health care utilization by children. Existing studies show mixed results.

METHODS

Using practice-reported PCMH assessments and Medicaid claims from child-serving practices in 3 states participating in the Children's Health Insurance Program Reauthorization Act of 2009 Quality Demonstration Grant Program, this study estimates the association between medical homeness (tertiles) and receipt of well-child care and nonurgent, preventable, or avoidable emergency department (ED) use. Multilevel logistic regression models are estimated on data from 32 practices in Illinois (IL) completing the National Committee for Quality Assurance's (NCQA) medical home self-assessment and 32 practices in North Carolina (NC) and South Carolina (SC) completing the Medical Home Index (MHI) or Medical Home Index-Revised Short Form (MHI-RSF).

RESULTS

Medical homeness was not associated with receipt of age-appropriate well-child visits in either sample. Associations between nonurgent, preventable, or avoidable ED visits and medical homeness varied. No association was seen among practices in NC and SC that completed the MHI/MHI-RSF. Children in practices in IL with the highest tertile NCQA self-assessment scores were less likely to have a nonurgent, preventable, or avoidable ED visit than children in practices with low (odds ratio 0.65; 95% confidence interval 0.47-0.92; P < .05) and marginally less likely to have such a visit compared with children in practices with medium tertile scores (odds ratio 0.72, 95% confidence interval 0.52-1.01; P = .06).

CONCLUSIONS

Higher levels of medical homeness may be associated with lower nonurgent, preventable, or avoidable ED use by publicly insured children. Robust longitudinal studies using multiple measures of medical homeness are needed to confirm this observation.

Health care expenditures associated with pediatric pain-related conditions in the United States

The primary objective of this study was to assess the impact of pediatric pain-related conditions on health care expenditures. We analyzed data from a nationally representative sample of 6- to 17-year-old children captured in the 2007 National Health Interview Survey and 2008 Medical Expenditure Panel Survey. Health care expenditures of children with pain-related conditions were compared with those of children without pain-related conditions. Pain-related conditions were associated with incremental health care expenditures of $1339 (95% confidence interval [CI], $248-$2447) per capita. Extrapolated to the nation, pediatric pain-related conditions were associated with $11.8 billion (95% CI, $2.18-$21.5 billion) in total incremental health care expenditures. The incremental health care expenditures associated with pediatric pain-related conditions were similar to those of attention deficit and hyperactivity disorder ($9.23 billion; 95% CI, $1.89-$18.1 billion), but more than those associated with asthma ($5.35 billion; 95% CI, $0-$12.3 billion) and obesity ($0.73 billion; 95% CI, $6.28-$8.81 billion). Health care expenditures for pediatric pain-related conditions exert a considerable economic burden on society. Efforts to prevent and treat pediatric pain-related conditions are urgently needed.

Access to disease treatment among patients presenting to the emergency department with asthma or hypertension

BACKGROUND

Asthma and hypertension are common among Emergency Department (ED) patients. Primary care providers are integral in managing these conditions, yet these patients are often in the ED.

OBJECTIVE

To determine access to care among ED patients with asthma or hypertension and the association with sociodemographic factors and disease acuity.

METHODS

This was a prospective, cross-sectional study of ED patients at an urban county hospital conducted between June 4 and August 31, 2008. Consenting patients were surveyed, and peak flow or blood pressure measured as appropriate. Access to disease treatment was defined as self-reported access to a primary care provider or current prescription for asthma or hypertension, or both. Descriptive statistics and multinomial logistic regression were used to analyze data.

RESULTS

There were 2303 patients enrolled; 283 had asthma, 543 had hypertension, and 187 had both. Seventy-one patients (25.1%) with asthma, 151 patients (27.8%) with hypertension, and 19 patients (10.2%) with both had poor access to disease treatment. Seeking ED medical attention was related to having poor access to treatment for patients with both asthma and hypertension. Females with asthma had poor access to treatment. In hypertension patients, good access to treatment was associated with excellent/good health status, housing status, and decreasing age. Poor access to treatment was associated with increasing blood pressure.

CONCLUSIONS

Poor access to disease treatment and aspects of socioeconomic status were associated with seeking care in the ED. Changes in access to treatment may affect the number of patients seeking ED care, but not the severity of the presenting illness.

Frequent pediatric emergency department use in infancy and early childhood

OBJECTIVE

To define the threshold and population factors associated with pediatric emergency department (PED) use above the norm during the first 36 months of life.

METHODS

We conducted a cross-sectional study of children born between 2003 and 2006, treated in a single PED within the first 36 months of life. Exclusion criteria included out-of-county residence or history of abuse or neglect. The primary outcome, frequent PED use, was defined by the 90th percentile for PED visits per patient. Multivariate analysis was used to identify factors associated with frequent PED use.

RESULTS

A total of 41,912 visits occurred for 16,664 patients during the study. Pediatric ED use skewed heavily toward less than 2 visits per patient (median, 2; range, 1-39; interquartile range, 2). The threshold for frequent PED use was 5 or more visits per patient and occurred for 14% (95% confidence interval [95% CI], 13%-15%) of patients. Most visits were coded with low acuity International Classifications of Diseases, 9th Revision, Clinical Modification codes. The following factors were strongly associated with frequent PED use: lack of primary care physician (odds ratio [OR], 6.03; 95% CI, 5.39%-6.80%; P < 0.0001), non private insurance (OR, 3.64; 95% CI, 2.99%-4.46%; P<0.0001), and history of inpatient admission (OR, 3.09; 95% CI, 1.66%-2.24%; P < 0.0001). Leaving without being seen, black race, Hispanic ethnicity, and residence in a poverty-associated zip code were also significantly associated, but less strongly predictive of, frequent PED use.

CONCLUSIONS

The threshold for frequent PED use was more than 5 visits per patient within the first 36 months of life. Further study is needed to better define this population and develop targeted interventions to ensure care provision occurs in the ideal setting.

The role of medical home in emergency department use for children with developmental disabilities in the United States

OBJECTIVE

Children with developmental disabilities (DDs) have higher rates of emergency department use (EDU) than their typically developing peers do. This study sought to elucidate the relationship between EDU frequency and access to a comprehensive medical home for children with DD.

METHODS

This study conducted multivariate logistic regression analysis on data from the 2005-2006 National Survey of Children with Special Health Care Needs to explore the association between EDU frequency among children with DD and medical home.

RESULTS

Compared with children with DD reporting zero EDU, children with 3 or more EDU were less likely to report access to usual health care source (adjusted odds ratio [AOR], 0.63; 95% confidence interval [CI], 0.45-0.88). Moreover, children with DD who had 3 or more EDU were less likely to have clinicians who listen to parental concerns (AOR, 0.58; 95% CI, 0.45-0.76), demonstrate sensitivity toward family values and customs (AOR = 0.60, 95% CI = 0.46, 0.78), and build meaningful family partnerships (AOR, 0.69; 95% CI, 0.53-0.89).

CONCLUSIONS

The study suggests that children with DD reporting 3 or more EDU per year would likely reduce their EDU by having access to usual source of primary care services and to clinicians with skills in building meaningful partnership with the parents. The inclusion of these medical home attributes in the adoption of patient-centered medical homes with the implementation of the Affordable Care Act presents a mechanism to improve care at lower cost as well as facilitate chronic disease management and coordination between emergency medicine and primary care physicians that may lead to reductions in EDU and unnecessary hospitalization.

Association between participation in a multipayer medical home intervention and changes in quality, utilization, and costs of care

IMPORTANCE

Interventions to transform primary care practices into medical homes are increasingly common, but their effectiveness in improving quality and containing costs is unclear.

OBJECTIVE

To measure associations between participation in the Southeastern Pennsylvania Chronic Care Initiative, one of the earliest and largest multipayer medical home pilots conducted in the United States, and changes in the quality, utilization, and costs of care.

DESIGN, SETTING, AND PARTICIPANTS

Thirty-two volunteering primary care practices participated in the pilot (conducted from June 1, 2008, to May 31, 2011). We surveyed pilot practices to compare their structural capabilities at the pilot's beginning and end. Using claims data from 4 participating health plans, we compared changes (in each year, relative to before the intervention) in the quality, utilization, and costs of care delivered to 64,243 patients who were attributed to pilot practices and 55,959 patients attributed to 29 comparison practices (selected for size, specialty, and location similar to pilot practices) using a difference-in-differences design.

EXPOSURES

Pilot practices received disease registries and technical assistance and could earn bonus payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance (NCQA).

MAIN OUTCOMES AND MEASURES

Practice structural capabilities; performance on 11 quality measures for diabetes, asthma, and preventive care; utilization of hospital, emergency department, and ambulatory care; standardized costs of care.

RESULTS

Pilot practices successfully achieved NCQA recognition and adopted new structural capabilities such as registries to identify patients overdue for chronic disease services. Pilot participation was associated with statistically significantly greater performance improvement, relative to comparison practices, on 1 of 11 investigated quality measures: nephropathy screening in diabetes (adjusted performance of 82.7% vs 71.7% by year 3, P < .001). Pilot participation was not associated with statistically significant changes in utilization or costs of care. Pilot practices accumulated average bonuses of $92,000 per primary care physician during the 3-year intervention.

CONCLUSIONS AND RELEVANCE

A multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years. These findings suggest that medical home interventions may need further refinement.

Medical home characteristics and asthma control: a prospective, observational cohort study protocol

Background:

This paper describes the methods for an observational comparative effectiveness research study designed to test the association between practice-level medical home characteristics and asthma control in children and adults receiving care in safety-net primary care practices.

Methods:

This is a prospective, longitudinal cohort study, utilizing survey methodologies and secondary analysis of existing structured clinical, administrative, and claims data. The Scalable Architecture for Federated Translational Inquiries Network (SAFTINet) is a safety net-oriented, primary care practice-based research network, with federated databases containing electronic health record (EHR) and Medicaid claims data. Data from approximately 20,000 patients from 50 practices in four healthcare organizations will be included. Practice-level medical home characteristics will be correlated with patient-level asthma outcomes, controlling for potential confounding variables, using a clustered design. Linear and non-linear mixed models will be used for analysis. Study inception was July 1, 2012. A causal graph theory approach was used to guide covariate selection to control for bias and confounding.

Discussion:

Strengths of this design include a priori specification of hypotheses and methods, a large sample of patients with asthma cared for in safety-net practices, the study of real-world variations in the implementation of the medical home concept, and the innovative use of a combination of claims data, patient-reported data, clinical data from EHRs, and practice-level surveys. We address limitations in causal inference using theory, design and analysis.

Use of emergency departments among working age adults with disabilities: a problem of access and service needs

OBJECTIVE

To examine the relationship between emergency department (ED) use and access to medical care and prescription medications among working age Americans with disabilities.

DATA SOURCE

Pooled data from the 2006-2008 Medical Expenditure Panel Survey (MEPS), a U.S. health survey representative of community-dwelling civilians.

STUDY DESIGN

We compared the health and service utilization of two groups of people with disabilities to a contrast group without disability. We modeled ED visits on the basis of disability status, measures of health and health conditions, access to care, and sociodemographics.

DATA EXTRACTION

These variables were aggregated from the household component, the medical condition, and event files to provide average annual estimates for the period spanning 2006-2008.

PRINCIPAL FINDINGS

People with disabilities accounted for almost 40 percent of the annual visits made to U.S. EDs each year. Three key factors affect their ED use: access to regular medical care (including prescription medications), disability status, and the complexity of individuals' health profiles.

CONCLUSIONS

Given the volume of health conditions among people with disabilities, the ED will always play a role in their care. However, some ED visits could potentially be avoided if ongoing care were optimized.

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.

Patient-Centered Care and Emergency Department Utilization

Increased emergency department (ED) overcrowding has renewed interest in identifying remedies for unnecessary ED utilization. One potential remedy receiving more attention is patient-centered care. Relatively little is known, however, about how patient-centered care might decrease ED utilizatiosn. This study examined two mediating processes by which four dimensions of patient-centered care may affect patients’ reported ED visits. Cross-sectional path analysis of 8,140 chronically ill patients found that patients reporting higher levels of patient-centered care were less likely to have experienced problems of care coordination, and in turn were associated with decreased likelihood of having delayed care and fewer ED visits. These findings suggest that understanding how care is delivered, and not simply whether it is available or provided, is an important consideration in understanding ED utilization. Our findings suggest that fostering more fair and respectful relationships between patients and providers may be a particularly important way of reducing ED utilization.

A novel approach to identifying targets for cost reduction in the emergency department

This article introduces a novel framework that classifies emergency department (ED) visits according to broad categories of severity, identifying those categories of visits that present the most potential for reducing costs associated with the ED. Although cost savings directly attributable to the ED are apt to be an important emphasis of organizations operating under reformed payment systems, our framework suggests that a focus on diverting low-acuity visits away from the ED would result in far less savings compared with strategies aimed at reducing admissions and to a lesser extent improving the efficiency of ED care for intermediate or complex conditions. We conclude that targeting these categories, rather than minor injuries/illnesses, should be the primary focus of cost-reduction strategies from the ED. Given this understanding, we then discuss the implications of these findings on the financing of an emergency care system that needs to account for the required fixed costs of "stand-by capacity" of the ED and explore ways in which the ED can be better integrated into a patient-centered health care system.

The patient-centered medical home: a review of recent research

The patient-centered medical home is an important innovation in health care delivery. There is a need to assess the scope and substance of published research on medical homes. This article reviews published evaluations of medical home care for the period 2007 to 2010. Chief findings from these evaluations as a whole include associations between the provision of medical home care and improved quality, in addition to decreased utilization associated with medical home care in high-cost areas such as emergency department use. However, fewer associations were found across evaluations between medical home care and enhanced patient or family experiences. The early medical home research appears to reflect both the wide variation in how medical homes are being designed and implemented in practice and in how researchers are choosing to evaluate patient-centered medical home design and implementation. While some aspects of medical home care show promise, continued evolution of medical home evaluative research is needed.

Health care use and expenditures associated with access to the medical home for children and youth

BACKGROUND

The pediatric medical home is an approach to the delivery of family-centered health care. Policy-makers and payers are interested in potential changes to health care utilization and expenditures under this model.

OBJECTIVE

To test associations between having a medical home and health service use and expenditures among US children and youth.

RESEARCH DESIGN

Observational cross-sectional study.

SUBJECTS

A total of 26,221 children aged 0 to 17 years surveyed in the 2005 to 2007 Medical Expenditure Panel Surveys.

MEASURES

Parent report of a child's access to a medical home was developed from multiple survey items in the Medical Expenditure Panel Surveys. Negative binomial regression examined the association between the medical home and parent-reported counts of annual outpatient, inpatient, emergency department, and dental visits. Two-part models examined associations between the medical home and parent-reported annual total, outpatient, inpatient, emergency department, and other health care expenditures. Models accounted for potential self-selection into a medical home using propensity scores.

RESULTS

Children with a medical home had a greater incidence of preventive visits [incidence rate ratio (IRR)=1.11; (95% confidence intervals (CI), 1.03-1.20)] and dental visits [IRR=1.09 (95% CI, 1.02-1.17)] and a lower incidence of emergency department visits [IRR=0.87 (95% CI, 0.79-0.97)] compared with children without a medical home. Children with a medical home also had greater odds of incurring total, outpatient, prescription medication, and dental expenditures, OR's ranging from 1.09 to 1.38. Despite greater odds of incurring certain expenditures, expenditures were no different for children with and without a medical home.

CONCLUSIONS

The medical home is associated with several domains of health service use, yet there is no evidence for its association with health care expenditures for children and youth.

Adolescent asthma: a developmental approach

PURPOSE OF REVIEW

The purpose of this review is to update providers on how best to address asthma in adolescents.

RECENT FINDINGS

Asthma is a common chronic disease, with increased prevalence in minority populations, especially those living in poverty. Published treatment guidelines form the basis of modern asthma treatment, based on disease severity, frequency of symptoms, and lung function measured by spirometry. Written asthma action plans are recommended for patients with persistent asthma. Treating teens with asthma can be challenging, as they may deny disease, underreport symptoms, abandon medication regimens, and engage in risk-taking behaviors. Psychiatric comorbidities such as depression, anxiety, and even posttraumatic stress disorder can have profound effects on the adolescent with asthma, making the treatment much more challenging.

SUMMARY

Pediatricians should utilize a developmental approach, incorporating guideline-based therapies when developing treatment plans for teens with asthma. Resources such as school-based health centers, community health workers, mental health professionals, and possibly asthma specialists are all valuable aids to the physician in the medical home in providing care coordination for their teens with asthma.

How can we remodel practices into medical homes without a blueprint or a bank account?

Medical homes are widely viewed as a solution to the problems with American medical care, despite lack of answers to many important questions. Review of articles from issues of 5 journals devoted to the medical home in 2010 provides few answers to those questions. However, with some exceptions, those answers seem more likely to come from real-life efforts to implement medical homes than from the research literature. In any other industry, that would be the case, especially the key questions about the financial viability of both the transformation of traditional practices and sustainability of the new care model.