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Büschges JC, Schmidt-Trucksäss A, Neuhauser H. Association of blood pressure and heart rate with carotid markers of vascular remodeling in the young: a case for early prevention. J Hypertens 2024; 42:153-160. [PMID: 37796164 DOI: 10.1097/hjh.0000000000003578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
OBJECTIVE The association of childhood blood pressure (BP) and heart rate (HR) with intermediate markers of cardiovascular disease several decades later has been shown, but studies on more short-term outcomes are scarce. Using population-based data, this study investigates the association of four BP parameters and HR in childhood with three carotid markers for vascular remodeling one decade later. METHODS At the 11-year follow-up, 4607 participants of the nationwide KiGGS cohort aged 14 to 28 years had semi-automated sonographic carotid intima media thickness (CIMT) measurements. We investigated associations of baseline (age 3-17 years) and follow-up SBP, DBP, mean arterial pressure (MAP), pulse pressure (PP) and resting heart rate (RHR), with CIMT and lumen diameter at or above the 90th percentile and distensibility coefficient at or below the tenth percentile in logistic regressions. Analyses were further adjusted using a composite cardiovascular risk (CVR) score of BMI, triglycerides, total/HDL-cholesterol-ratio and HbA1c. RESULTS SBP, DBP, MAP and RHR were significantly and similarly associated with all carotid measures 11 years later, for example an odds ratio (OR) of 1.17 [confidence interval (CI) 1.06-1.29] for one standard deviation SBP increase with elevated CIMT when adjusting for sex, age and CVR score. Cross-sectionally, the strongest association was found for MAP with reduced distensibility coefficient (OR 1.76; CI 1.59-1.94). CONCLUSION This population-based cohort study shows robust and consistent associations between childhood BP and RHR and three carotid measures of vascular remodeling only one decade later, clearly underscoring the potential importance of preventing high BP already early in the life course.
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Affiliation(s)
- Julia C Büschges
- Robert Koch Institute, Department of Epidemiology and Health Monitoring
- DZHK (German Centre for Cardiovascular Research), partner site Berlin
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Arno Schmidt-Trucksäss
- Department of Sport, Exercise and Health, Division Sports and Exercise Medicine
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Hannelore Neuhauser
- Robert Koch Institute, Department of Epidemiology and Health Monitoring
- DZHK (German Centre for Cardiovascular Research), partner site Berlin
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Königstein K, Büschges JC, Schmidt-Trucksäss A, Neuhauser H. Cardiovascular Risk in Childhood is Associated With Carotid Intima-Media Thickness and Stiffness in Adolescents and Young Adults: The KiGGS Cohort. J Adolesc Health 2024; 74:123-129. [PMID: 37815767 DOI: 10.1016/j.jadohealth.2023.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/03/2023] [Accepted: 08/18/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE Cardiovascular risk factors are widespread among children and adolescents and may lead to accelerated vascular aging in middle adulthood. However, data are scarce on shorter-term consequences, for example, on associated distinctive vascular properties before age 30 years. This study analyzes the association of childhood exposure to cardiovascular risk factors with carotid properties in adolescents and young adults. METHODS Four thousand thirty one participants from the population-based German Health Interview and Examination Survey for Children and Adolescents cohort (aged 3-17 years) had carotid intima-media thickness (CIMT) and distensibility coefficient (DC) measurements at the second follow-up (aged 14-28 years). The assessment of cardiovascular risk factors at baseline included information about arterial hypertension, obesity, dyslipidemia, and passive smoking. RESULTS Single risk factors and the exposure to multiple cardiovascular risk factors were associated with elevated CIMT and decreased DC. Relative risks for CIMT ≥ 90th centile and/or DC ≤ 10th centile were increased in participants exposed to two (RRCIMT = 1.45 [95% confidence interval 1.11-1.91], p < .05; RRDC = 1.37 [1.02-1.84], p < .05) and ≥ three risk factors (RRCIMT = 1.66 [1.05-2.62], p < .05; RRDC = 1.25 [0.71-2.21], p > .05). DISCUSSION Exposure to multiple cardiovascular risk factors starting in childhood is associated with measurably increased CIMT and carotid stiffness in late adolescence and early adulthood. These findings underline the importance of population-wide preventive measures to promote optimal cardiovascular health.
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Affiliation(s)
- Karsten Königstein
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany; Division Sports and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Switzerland; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany.
| | - Julia Charlotte Büschges
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany; Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Germany
| | - Arno Schmidt-Trucksäss
- Division Sports and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Switzerland; Department of Clinical Research, University Hospital Basel, University of Basel, Switzerland
| | - Hannelore Neuhauser
- Department of Epidemiology and Health Monitoring, Robert Koch Institute, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Germany
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Quimby D, Conn BM, Ellis TT, Iverson E. The process of capacity-building for pediatric subspecialty providers to address the needs of adolescents and young adults with chronic illness. Int J Adolesc Med Health 2023; 35:89-99. [PMID: 33161385 DOI: 10.1515/ijamh-2020-0216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/18/2020] [Indexed: 11/15/2022]
Abstract
Approximately 12% of adolescents in the USA live with a chronic health condition. Although youth with chronic illness visit healthcare providers more than healthy peers, pediatric subspecialty providers are less likely to address developmentally relevant concerns (e.g., reproductive health) with adolescents and young adults (AYA), particularly youth of color and/or youth in low-income communities. Despite the documented need for increased training, there remains a general lack of knowledge about pediatric subspecialty providers' training needs related to building their capacity to provide developmentally appropriate care to their adolescent and young adult patients. The present study describes an overall process for capacity-building to address the needs of diverse AYA patients with chronic medical conditions, built upon data representing key stakeholders and staff from 14 specialty care departments collected via quantitative surveys and focus groups. We describe the development of trainings for pediatric subspecialty providers from a large, urban, pediatric tertiary care center to address the health and psychosocial-related concerns of AYA living with chronic illness. We highlight valuable lessons from the capacity-building process in terms of increasing the ability of providers in a major pediatric healthcare center to provide developmentally appropriate care for AYA living with chronic illness. Finally, based on the results of our study, we provide recommendations on how to employ such a process in similar pediatric hospital settings.
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Affiliation(s)
- Dakari Quimby
- Division of Adolescent and Young Adult Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Bridgid M Conn
- Division of Adolescent and Young Adult Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Tierra T Ellis
- Division of Adolescent and Young Adult Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Ellen Iverson
- Division of Adolescent and Young Adult Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Hoopes AJ, Brandzel SD, Luce C, Ferguson DM, Shulman L, Chavez B, Lozano P, Lapham GT. What Do Adolescents and Their Parents Need From Mental Health Integration in Primary Care? A Qualitative Exploration of Design Insights. J Pediatr Health Care 2022; 36:570-581. [PMID: 35953380 PMCID: PMC10544844 DOI: 10.1016/j.pedhc.2022.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/14/2022] [Accepted: 06/23/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The design of integrated adolescent mental health care should address needs and preferences of patients and parents/guardians. METHOD We conducted interviews and focus groups with adolescents aged 13-17 years who received care at Kaiser Permanente Washington in 2020 and interviews with parents of such adolescents. We sought to (1) understand the challenges of primary care-based mental health and substance use screening and care for adolescents and (2) identify program design solutions. Sessions were audio-recorded, transcribed, and coded. Thematic analysis was applied to identify key challenges and design solutions. RESULTS Emerging themes from interviews (n = 41) and focus groups (n = 10) were summarized in five overarching design principles: Engagement, Privacy, Communication, Choice, and Ease. Each design principle was expanded for operationalization within a new health system program. DISCUSSION Health systems serving adolescents in primary care may consider application of these design principles to the development of mental health integration programs.
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Affiliation(s)
- Andrea J Hoopes
- Acting Assistant Investigator, Kaiser Permanente Washington Health Research Institute, and Department of Pediatrics, University of Washington, Seattle, WA.
| | - Susan D Brandzel
- Manager, Research Project Management Office, Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Casey Luce
- Research Project Manager III, Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Dawn M Ferguson
- User-Centered Design Associate, Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Lisa Shulman
- Research Interventionist, Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Blanca Chavez
- Practice Facilitator, Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Paula Lozano
- Senior Investigator, Kaiser Permanente Washington Health Research Institute, and Department of Health Systems and Population Health, University of Washington, Seattle, WA
| | - Gwen T Lapham
- Assistant Investigator, Kaiser Permanente Washington Health Research Institute, and Department of Health Systems and Population Health, University of Washington, Seattle, WA
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Lu W, Todhunter-Reid A, Mitsdarffer ML, Muñoz-Laboy M, Yoon AS, Xu L. Barriers and Facilitators for Mental Health Service Use Among Racial/Ethnic Minority Adolescents: A Systematic Review of Literature. Front Public Health 2021; 9:641605. [PMID: 33763401 PMCID: PMC7982679 DOI: 10.3389/fpubh.2021.641605] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/15/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction: Mental disorders represent serious public health concerns in the U.S. Compared with Whites, racial/ethnic minority adolescents are more likely to be affected by mental disorders but less likely to use mental health services. This systematic review aimed to summarize factors related to mental health service use among minority adolescents in the U.S. as identified in previous research. Methodology: Following the PRISMA guideline, we systematically searched seven databases for peer reviewed articles related to barriers and facilitators of mental health service use among racial/ethnic minority adolescents. Results: Thirty-two quantitative studies met our inclusion criteria, among which 12 studies (37.5%) sampled mostly Blacks or African Americans, 6 studies (18.7%) focused primarily on Hispanics or Latin/a/x, including Mexican Americans and Puerto Ricans, and 4 studies (12.5%) were mostly Asian Americans (e.g., Chinese, Vietnamese). Based on the socio-ecological framework, 21 studies (65.6%) identified adolescent-related barriers and facilitators of mental health service use, including biological (e.g., age, gender), clinical (e.g., symptom severity), behavioral (e.g., drug/alcohol use), and psychological characteristics (e.g., internal asset) of minority youth. Ten studies (31.3%) identified parents-related factors that influenced minority adolescent mental health service use, including parental perceptions and beliefs, family and parenting issues, and demographic characteristics. Primary factors at the therapist level included ethnic match between patient and practitioner, relationship with healthcare practitioners, and patient-therapist co-endorsement of etiological beliefs. Fifteen studies (46.9%) identified factors influencing minority adolescent mental health service use at the contextual/structural level, including household income, insurance status, and family structure. Lastly, acculturation and school experiences were major factors at the social/cultural level that influence minority adolescent service use. Conclusion: More empirical studies are needed to understand the mechanism underlying minority adolescents' unmet mental health service needs. Culturally competent interventions are warranted to engage minority adolescents with mental disorders into treatment.
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Affiliation(s)
- Wenhua Lu
- Department of Community Health and Social Medicine, School of Medicine, City University of New York, New York, NY, United States
| | | | | | - Miguel Muñoz-Laboy
- School of Social Welfare, Stony Brook University, New York, NY, United States
| | | | - Lei Xu
- Department of Health Education and Promotion, College of Health and Human Performance, East Carolina University, Greenville, NC, United States
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Lu W. Treatment for Adolescent Depression: National Patterns, Temporal Trends, and Factors Related to Service Use Across Settings. J Adolesc Health 2020; 67:401-408. [PMID: 32331929 DOI: 10.1016/j.jadohealth.2020.02.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 02/04/2020] [Accepted: 02/08/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE Untreated major depression can lead to various negative health and social consequences among adolescents. This study aimed to examine national patterns, temporal trends, and factors related to U.S. adolescents' mental health service use for 12-month major depression across service settings. METHODS Data on adolescents aged 12-17 years who received treatment for their 12-month major depression were drawn from the National Survey on Drug Use and Health, 2011-2018. Patterns, trends, and factors related to adolescents' service use in specialty mental health, educational, and general medical settings and multiple settings were examined using bivariate and multivariate logistic regression. RESULTS Across the survey years, service use in specialty mental health settings was the most common, followed by educational and general medical settings. A significant increase was observed in adolescents' specialty mental health service use (p < .001) over time, whereas the rates of service use in educational and general medical settings remained stable. Approximately 40% of adolescents who were treated for 12-month depression received services in multiple settings each year, with no significant change over time. Among multisetting service users, combined service use in specialty mental health and educational settings was the most common. Adolescents' age, race, gender, insurance status, family income, and school experiences significantly influenced their service use across settings. CONCLUSIONS Continued efforts are needed to improve service provision for adolescents with depression, especially in educational and general medical settings. Strengthened funding and policy support are warranted to expand safety-net mental health services for uninsured, low-income, and racial/ethnic minority adolescents.
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Affiliation(s)
- Wenhua Lu
- Department of Childhood Studies, Rutgers, The State University of New Jersey, Camden, New Jersey.
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Schraeder K, Dimitropoulos G, McBrien K, Li JY, Samuel S. Perspectives from primary health care providers on their roles for supporting adolescents and young adults transitioning from pediatric services. BMC FAMILY PRACTICE 2020; 21:140. [PMID: 32660598 PMCID: PMC7359255 DOI: 10.1186/s12875-020-01189-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 06/12/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Transitioning from pediatric care to adult-oriented care at age 18 (the age of transfer in most countries and jurisdictions) is a complex process for adolescents and young adults affected by chronic physical health and/or mental health conditions. The role of primary health care (PHC) providers for this population is poorly understood. Perspectives from these providers, such as family physicians and other members of the primary care team, have not been explored in depth. METHODS A total of 18 participants (e.g., family physicians, social workers, nurses) were recruited from 6 Primary Care Networks in Calgary, Alberta, Canada. Semi-structured individual interviews were conducted, and transcribed verbatim. A qualitative description approach was used to analyze the data, and included thematic analysis. RESULTS Five distinct, yet overlapping, roles of primary health care providers for adolescents and young adults transitioning to adult care resulted from our analysis: (1) being the "common thread" (continuous accessible care); (2) caring for the "whole patient" (comprehensive care); (3) "knowing families" (family-partnered care); (4) "empowering" adolescents and young adults to develop "personal responsibility" (developmentally-appropriate care); and (5) "quarterbacking" care (coordination of specialist and/or community-based care). Participants identified potential benefits of these roles for adolescents and young adults transitioning to adult care, and barriers in practice (e.g., lack of time, having minimal involvement in pediatric care). CONCLUSIONS Input from family physicians, who follow their patients across the lifespan and provide the majority of primary care in Canada, are critical for informing and refining recommended transition practices. Our findings provide insights, from PHC providers themselves, to bolster the rationale for primary care involvement during transitions from pediatric specialty and community-based care for AYAs. Solutions to overcome barriers for integrating primary care and specialty care for adolescents and young adults need to be identified, and tested, with input from key stakeholders.
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Affiliation(s)
- Kyleigh Schraeder
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 28 Oki Drive, Calgary, Alberta, Canada.
| | - Gina Dimitropoulos
- Faculty of Social Work, University of Calgary, Calgary, Alberta, Canada
- Mathison Centre for Mental Health Research & Education, University of Calgary, Calgary, Alberta, Canada
| | - Kerry McBrien
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jessica Yijia Li
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 28 Oki Drive, Calgary, Alberta, Canada
| | - Susan Samuel
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, 28 Oki Drive, Calgary, Alberta, Canada
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Sanzari CM, Liu RT. Temporal Trends in Treatment Utilization for Disordered Eating in U.S. Adolescents From 2004 Through 2017: A Nationally Representative Study. J Adolesc Health 2019; 65:564-566. [PMID: 31279723 PMCID: PMC6755044 DOI: 10.1016/j.jadohealth.2019.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/03/2019] [Accepted: 05/04/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of the article was to assess temporal changes in adolescent treatment utilization for disordered eating. METHODS Data were drawn from adolescents (unweighted N = 236,752), aged 12-17 years, in the National Survey on Drug Use and Health for 2004-2017. Joinpoint regression assessed temporal trends in overall treatment utilization for disordered eating and broken down by inpatient and outpatient services. RESULTS Overall treatment utilization ranged from 840 to 1,734 per 100,000 across the 14-year study period. An increase in overall treatment utilization was observed starting in 2010. A similar pattern was observed for outpatient care, with an increase starting in 2010. For inpatient care, an increase in service use was observed across the entire 14-year period. CONCLUSIONS Treatment utilization for eating problems has increased over time. However, a substantial proportion of teens with eating problems remains without treatment. These findings highlight the need for increased efforts to develop strategies addressing this unmet need.
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Affiliation(s)
- Christina M Sanzari
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, East Providence, Rhode Island
| | - Richard T Liu
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, East Providence, Rhode Island.
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Allende-Richter SH, Johnson ST, Maloyan M, Glidden P, Rice K, Epee-Bounya A. A Previsit Screening Checklist Improves Teamwork and Access to Preventive Services in a Medical Home Serving Low-Income Adolescent and Young Adult Patients. Clin Pediatr (Phila) 2018; 57:835-843. [PMID: 29027477 DOI: 10.1177/0009922817733698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Publicly insured adolescents and young adults experience significant obstacles in accessing primary care services. As a result, they often present to their medical appointments with multiple unmet needs, adding time and complexity to the visit. The goal of this project was to optimize team work and access to primary care services among publicly insured adolescents and young adults attending an urban primary care clinic, using a previsit screening checklist to identify patient needs and delegate tasks within a care team to coordinate access to health services at the time of the visit. We conducted an interventional quality improvement initiative in a PDSA (Plan-Do-Study-Act) cycle format; 291 patients, 13 to 25 years old were included in the study over an 8-months period. The majority of patients were receptive to the previsit screening checklist; 85% of services requested were provided; nonclinician staff felt more involved in patient care; and providers' satisfaction increased.
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Affiliation(s)
- Sophie H Allende-Richter
- 1 Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Sydney T Johnson
- 1 Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,3 Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Mariam Maloyan
- 1 Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Patricia Glidden
- 1 Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Kerrilynn Rice
- 1 Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Alexandra Epee-Bounya
- 1 Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
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Abstract
It might seem strange to ask whether increasing access to medical care can improve children's health. Yet Lindsey Leininger and Helen Levy begin by pointing out that access to care plays a smaller role than we might think, and that many other factors, such as those discussed elsewhere in this issue, strongly influence children's health. Nonetheless, they find that, on the whole, policies to improve access indeed improve children's health, with the caveat that context plays a big role-medical care "matters more at some times, or for some children, than others." Focusing on studies that can plausibly show a causal effect between policies to increase access and better health for children, and starting from an economic framework, they consider both the demand for and the supply of health care. On the demand side, they examine what happens when the government expands public insurance programs (such as Medicaid), or when parents are offered financial incentives to take their children to preventive appointments. On the supply side, they look at what happens when public insurance programs increase the payments that they offer to health-care providers, or when health-care providers are placed directly in schools where children spend their days. They also examine how the Affordable Care Act is likely to affect children's access to medical care. Leininger and Levy reach three main conclusions. First, despite tremendous progress in recent decades, not all children have insurance coverage, and immigrant children are especially vulnerable. Second, insurance coverage alone doesn't guarantee access to care, and insured children may still face barriers to getting the care they need. Finally, as this issue of Future of Children demonstrates, access to care is only one of the factors that policy makers should consider as they seek to make the nation's children healthier.
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Affiliation(s)
| | - Helen Levy
- Institute for Social Research, the Ford School of Public Policy, and the Department of Health Management and Policy of the School of Public Health at the University of Michigan
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