Access to care, unmet health needs, and poverty status among children with and without chronic conditions

Access to Specialty Care for Commercially Insured Youths With Type 1 and Type 2 Diabetes

Importance

Youths with type 2 diabetes are at higher risk for complications compared with peers with type 1 diabetes, though few studies have evaluated differences in access to specialty care.

Objective

To compare claims with diabetes specialists for youths with type 1 vs type 2 diabetes and the association between specialist claims with multidisciplinary and acute care utilization.

Design, Setting, and Participants

This cross-sectional study used Optum Clinformatics Data Mart commercial claims. Individuals included in the study were youths younger than 19 years with type 1 or 2 diabetes as determined by a validated algorithm and prescription claims. Data were collected for youths with at least 80% enrollment in a commercial health plan from December 1, 2018, to December 31, 2019. Statistical analysis was performed from September 2022 to January 2024.

Main Outcomes and Measures

The primary outcome was the number of ambulatory claims from an endocrine and/or diabetes physician or advanced practice clinician associated with a diabetes diagnosis code; secondary outcomes included multidisciplinary and acute care claims.

Results

Claims were analyzed for 4772 youths (mean [SD] age, 13.6 [3.7] years; 4300 [90.1%] type 1 diabetes; 472 [9.9%] type 2 diabetes; 2465 [51.7%] male; 128 [2.7%] Asian, 303 [6.4] Black or African American, 429 [9.0%] Hispanic or Latino, 3366 [70.5%] non-Hispanic White, and 546 [11.4%] unknown race and ethnicity). Specialist claims were lower in type 2 compared with type 1 diabetes (incidence rate ratio [IRR], 0.61 [95% CI, 0.52-0.72]; P < .001) in propensity score-weighted analyses. The presence of a comorbidity was associated with increased specialist claims for type 1 diabetes (IRR, 1.07 [95% CI, 1.03-1.10]) and decreased claims for type 2 diabetes (IRR, 0.77 [95% CI, 0.67-0.87]). Pooling diagnosis groups and adjusted for covariates, each additional specialist claim was associated with increased odds of a claim with a diabetes care and education specialist (odds ratio [OR], 1.31 [95% CI, 1.25-1.36]), dietitian (OR, 1.14 [95% CI, 1.09-1.19]), and behavioral health clinician (OR, 1.16 [95% CI, 1.12-1.20]). For acute care claims, each additional specialist claim was associated with increased odds of admission (OR, 1.17 [95% CI, 1.11-1.24]) but not for emergency claims (OR, 1.03 [95% CI, 0.98-1.82]).

Conclusions and Relevance

This cross-sectional study found that youths with type 2 diabetes were significantly less likely to have specialist claims despite insurance coverage, indicating other barriers to care, which may include medical complexity. Access to diabetes specialists influences engagement with multidisciplinary services. The association between increasing ambulatory clinician services and admissions suggests high utilization by a subgroup of patients at greater risk for poor outcomes.

Preventive dental care utilization and dental caries for Medicaid-enrolled adolescents in Oregon

OBJECTIVES

This study aimed to evaluate the relationship between preventive dental care utilization and untreated dental caries for Medicaid-enrolled adolescents and to determine if the relationship is moderated by chronic conditions (CC).

METHODS

This analysis was based on 2015-2016 Medicaid claims files and survey data collected from adolescents ages 12-18 years enrolled in Oregon Medicaid, who received a dental screening between December 2015 and December 2016 (n = 240). To assess the relationship between preventive dental care utilization and untreated dental caries (defined as decayed tooth surfaces), prevalence ratios (PR) and 95% confidence intervals (CI) were generated using log-linear regression models. We also tested for an interaction between preventive dental care utilization and CC.

RESULTS

About 60.4% of adolescents utilized preventive dental care, 21.7% had CC, and 29.6% had ≥1 decayed tooth surfaces. There were no significant differences in untreated dental caries between adolescents who did and did not utilize preventive dental care (PR: 0.73, 95% CI: 0.33-1.60; p = 0.43). There was not a significant interaction between preventive dental care utilization and CC (p = 0.65). Preventive dental care utilization was not significantly associated with untreated dental caries for adolescents with CC (PR: 0.51, 95% CI: 0.10-2.65; p = 0.42) nor among adolescents without CC (PR: 0.79, 95% CI: 0.33-1.91; p = 0.61).

CONCLUSIONS

Preventive dental care was not shown to be associated with lower untreated dental caries for Medicaid-enrolled adolescents or those with CC. Future work that is adequately powered should continue to elucidate this relationship in Medicaid enrollees.

Depressive Symptoms, Cannabis Use, and Transition Readiness among College Students with and without Chronic Medical Conditions

Background: College students experience increased responsibility for healthcare transition. They are at increased risk for depressive symptoms and cannabis use (CU), potentially modifiable predictors of successful healthcare transition. This study investigated how depressive symptoms and CU related to transition readiness, and if CU moderated the association between depressive symptoms and transition readiness for college students. Methods: College students (N = 1,826, Mage=19.31, SD = 1.22) completed online measures of depressive symptoms, healthcare transition readiness, and past-year CU. Regression identified 1) the main effects of depressive symptoms and CU on transition readiness and 2) examined if CU moderated the relationship between depressive symptoms and transition readiness with chronic medical conditions (CMC) status as a covariate. Results: Higher depressive symptoms were correlated with past-year CU (r=.17, p<.001) and lower transition readiness (r=-0.16, p<.001). In the regression model, higher depressive symptoms were related to lower transition readiness (ß=-0.02, p<.001); CU was not related to transition readiness (ß=-0.10, p=.12). CU moderated the relationship between depressive symptoms and transition readiness (B=.01, p=.001). The negative relationship between depressive symptoms and transition readiness was stronger for those with no past-year CU (B=-0.02, p<.001) relative to those with a past-year CU (ß=-0.01, p<.001). Finally, having a CMC was related to CU and higher depressive symptoms and transition readiness. Conclusions: Findings highlighted that depressive symptoms may hinder transition readiness, supporting the need for screening and interventions among college students. The finding that the negative association between depressive symptoms and transition readiness was more pronounced among those with past-year CU was counterintuitive. Hypotheses and future directions are provided.

Prevalence and factors associated with multidimensional child deprivation: Findings from the Future of Families and Child Well-Being Study

Despite the growing importance of the multidimensional methods of assessing child poverty, few studies in the U.S. have applied a rights-based approach to examining child deprivation. This study examines multidimensional child deprivation using eight dimensions and twelve indicators based on the Convention on the Rights of the Child (CRC). Using a sample of children at age nine from the fifth wave of the Future of Families and Child Well-being Study, this study applied the multiple overlapping deprivation analysis (MODA), a comprehensive analytic method to assess the multidimensionality of child deprivation and to provide a detailed picture of material and social forms of deprivation among the U.S. children. This study found that the overall child deprivation rate was 8.89%; environmental safety (20.36%), information (15.94%), and housing security (14.23%) dimensions contributed the highest to the overall child deprivation; the overlap between deprivation and income poverty was 12.83%. Results suggest that understanding multifaceted and interrelated contexts of child deprivation is crucial to promote child rights.

The Effect of Neighborhood Disorganization on Care Engagement Among Children With Chronic Conditions Living in a Large Urban City

Neighborhood context plays an important role in producing and reproducing current patterns of health disparity. In particular, neighborhood disorganization affects how people engage in health care. We examined the effect of living in highly disorganized neighborhoods on care engagement, using data from the Coordinated Healthcare for Complex Kids (CHECK) program, which is a care delivery model for children with chronic conditions on Medicaid in Chicago. We retrieved demographic data from the US Census Bureau and crime data from the Chicago Police Department to estimate neighborhood-level social disorganization for the CHECK enrollees. A total of 6458 children enrolled in the CHECK between 2014 and 2017 were included in the analysis. Families living in the most disorganized neighborhoods, compared with areas with lower levels of disorganization, were less likely to engage in CHECK. Black families were less likely than Hispanic families to be engaged in the CHECK program. We discuss potential mechanisms through which disorganization affects care engagement. Understanding neighborhood context, including social disorganization, is key to developing more effective comprehensive care models.

The process of capacity-building for pediatric subspecialty providers to address the needs of adolescents and young adults with chronic illness

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.

Access to Healthcare for Children and Adolescents with a Chronic Health Condition during the COVID-19 Pandemic: First Results from the KICK-COVID Study in Germany

This study examines the access to healthcare for children and adolescents with three common chronic diseases (type-1 diabetes (T1D), obesity, or juvenile idiopathic arthritis (JIA)) within the 4th (Delta), 5th (Omicron), and beginning of the 6th (Omicron) wave (June 2021 until July 2022) of the COVID-19 pandemic in Germany in a cross-sectional study using three national patient registries. A paper-and-pencil questionnaire was given to parents of pediatric patients (<21 years) during the routine check-ups. The questionnaire contains self-constructed items assessing the frequency of healthcare appointments and cancellations, remote healthcare, and satisfaction with healthcare. In total, 905 parents participated in the T1D-sample, 175 in the obesity-sample, and 786 in the JIA-sample. In general, satisfaction with healthcare (scale: 0−10; 10 reflecting the highest satisfaction) was quite high (median values: T1D 10, JIA 10, obesity 8.5). The proportion of children and adolescents with canceled appointments was relatively small (T1D 14.1%, JIA 11.1%, obesity 20%), with a median of 1 missed appointment, respectively. Only a few parents (T1D 8.6%; obesity 13.1%; JIA 5%) reported obstacles regarding health services during the pandemic. To conclude, it seems that access to healthcare was largely preserved for children and adolescents with chronic health conditions during the COVID-19 pandemic in Germany.

Improving Access to Eye Care: A Systematic Review of the Literature

PURPOSE

The goals were to develop a working and inclusive definition of access to eye care, identify gaps in the current system that preclude access, and highlight recommendations that have been identified in prior studies. This manuscript serves as a narrative summary of the literature.

CLINICAL RELEVANCE

Health care disparities continue to plague the nation's well-being, and eye care is no exception. Inequities in eye care negatively affect disease processes (i.e., glaucoma, cataracts, diabetic retinopathy), interventions (surgical treatment, prescription of glasses, referrals), and populations (gender, race and ethnicity, geography, age).

METHODS

A systematic review of the existing literature included all study designs, editorials, and opinion pieces and initially yielded nearly 2500 reports. To be included in full-text review, an article had to be US-based, be written in English, and address 1 or more of the key terms "barriers and facilitators to health care," "access," and "disparities in general and sub-specialty eye care." Both patient and health care professional perspectives were included. One hundred ninety-six reports met the inclusion criteria.

RESULTS

Four key themes regarding access to eye care from both patient and eye care professional perspectives emerged in the literature: (1) barriers and facilitators to access, (2) utilization, (3) compliance and adherence, and (4) recommendations to improve access. Common barriers and facilitators included many factors identified as social determinants of health (i.e., transportation, insurance, language, education). Utilization of eye care was largely attributable to having coverage for eye care, recommendations from primary care professionals, and improved health status. Geographic proximity, age, and lack of transportation surfaced as factors for compliance and adherence. There were a variety of recommendations to improve access to eye care, including improving presence in community health clinics, reimbursement for physicians, and funding of community-based programs such as DRIVE and REACH.

CONCLUSIONS

The eye care profession has abundant evidence of the disparities that continue to affect marginalized communities. Improving community-based programs and clinics, addressing social determinants of health, and acknowledging the effects of discrimination and bias on eye care serve as ways to improve equity in this field.

Protocol for targeting insomnia in school-aged children with autism spectrum disorder without intellectual disability: a randomised control trial

INTRODUCTION

Insomnia affects up to 80% of children with autism spectrum disorder (ASD). Negative consequences of insomnia in ASD include decreased quality of life (QOL), impaired learning and cognition, increased stereotypic and challenging behaviours, and increased parental stress. Cognitive behavioural treatment for childhood insomnia (CBT-CI) is a promising treatment for dealing with insomnia and its negative consequences but has not yet been studied in school-aged children with ASD and comorbid insomnia. Access to healthcare is another challenge for children with ASD, particularly in rural and underserved regions. Previous studies indicate that ASD and insomnia share common arousal-based underpinnings, and we hypothesise that CBT-CI will reduce the hyperarousal associated with insomnia and ASD. This trial will be the first to examine CBT-CI adapted for children with ASD and will provide new information about two different modes of delivery across a variety of primary and secondary child and parent sleep and related outcomes. Knowledge obtained from this trial might allow us to develop new or modify current treatments to better target childhood insomnia and ASD.

METHODS AND ANALYSIS

Children (N=180) 6-12 years of age with ASD and insomnia will be recruited from an established autism database, a paediatric clinic and community outreach in the Columbia, MO and surrounding areas. Participants will be randomised to CBT-CI adapted for children with ASD (in-person or remote using computers with cameras) or Sleep Hygiene and Related Education. Participants will be assessed at baseline, post-treatment, 6-month and 12-month follow-ups. The following assessments will be completed regarding the children: objective and subjective sleep, daytime functioning (adaptive functioning, attention, challenging behaviours, anxiety), QOL and physiological arousal (heart rate variability) and parents: objective and subjective sleep, daytime functioning (anxiety, depression, fatigue), QOL, physiological arousal and parental burden/stress.

ETHICS AND DISSEMINATION

Ethics approval was obtained in January 2020 from the University of Missouri. Ethics approval was obtained in July 2020 from the US Army Medical Research and Development Command, Office of Research Protections and Human Research Protection Office. All data are expected to be collected by 2024. Full trial results are planned to be published by 2025. Secondary analyses of baseline data will be subsequently published.

TRIAL REGISTRATION NUMBER

NCT04545606; Pre-results.

Children With Special Health Care Needs: How Special Are Their Health Care Needs?

OBJECTIVE

To assess use and needs for general practitioner, specialist, emergency department, hospital inpatient, and hospital outpatient services for children with special health care needs (CSHCN). To assess the level of CSHCN's needs compared with other children.

METHODS

Health service use and needs for children aged 4 to 15 years were assessed using the nationally representative Longitudinal Study of Australian Children survey with 25,011 observations. Odds ratios of service use and unmet needs for CSHCN compared to other children were estimated. CSHCN were further grouped as those 1) needing only additional medication, 2) needing only additional medical care, or 3) needing both as defined by the CSHCN screener questions.

RESULTS

The prevalence of those meeting criteria for CSHCN was 16.1%. In the past 12 months, 77.7% of CSHCN used any general practitioner care and 46.4%, 21.7%, 12.4%, and 15.0%, respectively, used specialty care, emergency department, hospital inpatient, and outpatient services. Approximately half of CSHCN were identified as having special needs due to needing additional medication. Their service use and unmet needs are only slightly elevated. Another group of CSHCN who need both more medication and medical care comprises less than one third of all CSHCN. These children have the highest odds of using specialty care (odds ratio 12.3, P < .001), and of having unmet specialty care need (odds ratio 7.4, P < .001) compared to children without special needs.

CONCLUSIONS

Our findings highlight the importance of ensuring specialty care for CSHCN, especially the one third with most elevated needs. This estimate might guide future care planning.

Neighborhood socioeconomic deprivation is associated with worse patient and graft survival following pediatric liver transplantation

Long-term outcomes remain suboptimal following pediatric liver transplantation; only one third of children have normal biochemical liver function without immunosuppressant comorbidities 10 years posttransplant. We examined the association between an index of neighborhood socioeconomic deprivation with graft and patient survival using the Scientific Registry of Transplant Recipients. We included children <19 years who underwent liver transplantation between January 1, 2008 to December 31, 2013 (n = 2868). Primary exposure was a neighborhood socioeconomic deprivation index-linked via patient home ZIP code-with a range of 0-1 (values nearing 1 indicate neighborhoods with greater socioeconomic deprivation). Primary outcome measures were graft failure and death, censored at 10 years posttransplant. We modeled survival using Cox proportional hazards. In univariable analysis, each 0.1 increase in the deprivation index was associated with a 14.3% (95% confidence interval [CI]): 3.8%-25.8%) increased hazard of graft failure and a 12.5% (95% CI: 2.5%-23.6%) increased hazard of death. In multivariable analysis adjusted for race, each 0.1 increase in the deprivation index was associated with a 11.5% (95% CI: 1.6%-23.9%) increased hazard of graft failure and a 9.6% (95% CI: -0.04% to 20.7%) increased hazard of death. Children from high deprivation neighborhoods have diminished graft and patient survival following liver transplantation. Greater attention to neighborhood context may result in improved outcomes for children following liver transplantation.

Unmet health care needs among children of mothers exposed to violence

BACKGROUND

Existing literature shows that maternal exposure to violence has negative consequences on the health and behavioral outcomes of their children, but how it affects unmet child healthcare needs is unknown.

OBJECTIVES

To examine associations between maternal violence exposure and unmet child healthcare needs in vulnerable families.

PARTICIPANTS AND SETTING

We used data from the third and fifth years of Fragile Families and Child Wellbeing Study, a birth cohort study of urban children born between 1998 and 2000 n = 2848.

METHODS

Mothers completed a self-reported questionnaire or interview. Maternal violence exposure was measured through direct (victim) and indirect (witness) exposure. Unmet child healthcare needs was operationalized through: not having seen a doctor when needed, not having a well-child visit in the past year, and never had a dental check-up.

RESULTS

In adjusted logistic regression models, children of mothers who were victims of violence were more likely to not have seen a doctor when needed (odds ratio = 3.36, p < 0.01), not have a well-child visit in the past year (odds ratio = 2.50, p < 0.01), and never have a dental check-up (odds ratio = 1.54, p < 0.01). There was no association between maternal witnessing violence and unmet child healthcare needs.

CONCLUSIONS

In this study of urban children, having a mother who was a victim of violence was associated with unmet healthcare needs. These findings underscore the need to invest in efforts to reduce the prevalence of violence. Such efforts would reduce unmet child healthcare needs in vulnerable families.

Relationships Between Material Hardship, Resilience, and Health Care Use

BACKGROUND

Material hardship has been associated with adverse health care use patterns for children with special health care needs (CSHCN). In this study, we assessed if resilience factors were associated with lower emergency department (ED) visits and unmet health care needs and if they buffered associations between material hardship and health care use for CSHCN and children without special health care needs.

METHODS

A cross-sectional study using the 2016 National Survey of Children's Health, restricted to low-income participants (<200% federal poverty level). Separately, for CSHCN and children without special health care needs, weighted logistic regression was used to measure associations between material hardship, 2 resilience factors (family resilience and neighborhood cohesion), and 2 measures of use. Moderation was assessed using interaction terms. Mediation was assessed using structural equation models.

RESULTS

The sample consisted of 11 543 children (weighted: n = 28 465 581); 26% were CSHCN. Material hardship was associated with higher odds of ED visits and unmet health care needs for all children. Resilience factors were associated with lower odds of unmet health care needs for CSHCN (family resilience adjusted odds ratio: 0.58; 95% confidence interval: 0.36-0.94; neighborhood cohesion adjusted odds ratio: 0.53; 95% confidence interval: 0.32-0.88). For CSHCN, lower material hardship mediated associations between resilience factors and unmet health care needs. Neighborhood cohesion moderated the association between material hardship and ED visits (interaction term: P = .02).

CONCLUSIONS

Among low-income CSHCN, resilience factors may buffer the effects of material hardship on health care use. Future research should evaluate how resilience factors can be incorporated into programs to support CSHCN.

How do we live with chronic disease? A rights-based approach promoting the wellbeing of children with chronic disease

This paper focuses on the life experiences of children with chronic disease, a group whose invisibility involves particular challenges in their relationship with professionals in important life contexts, such as family, school and hospital. The study includes two complementary phases: i) Phase 1, composed of 15 interviews with parents, education and health professionals and two focus group discussions with children, and children and their mothers; and ii) Phase 2, which included self-report questionnaires administered to parents (n = 152) and children with chronic disease (n = 176). Based on a mixed methodology, this study combines quantitative and qualitative methods assuming that plural approaches allow for a deeper understanding of the life conditions of children with chronic disease and their families. The results reinforce the reproduction of social stereotypes and the tendency to focus on the individual ability to solve problems, which still remain to be circumscribed to the people's chronic disease sphere. Moreover, this paper reveals the central role that inclusive contexts have on children's wellbeing.

Impact of multiple co-occurring emotional and behavioural conditions on children with autism and their families

BACKGROUND

Comorbid conditions are very common in children and adults with autism spectrum disorder (ASD) and can affect school performance, adaptive skills and peer relationships. Comorbid conditions place strain on the family as well as the individual with ASD. This project aimed to determine the affect of comorbid conditions over and above child and family characteristics.

METHODS

The present authors examined 3,055 cases of children with ASD who had varying numbers of comorbid conditions (i.e., ADHD, depression, anxiety or behaviour problems).

RESULTS

Multiple comorbid conditions did have a unique impact on difficulties accessing services. A greater number of comorbid conditions impacted daily activity participation, but not a family's receipt of mental health care or respite, work changes or number of weekly hours dedicated to caring for a child with ASD.

CONCLUSIONS

Families, practitioners, paraprofessionals and educators of children with autism should address comorbid conditions to ensure both child and family well-being.

Access to the Medical Home Among Children With and Without Special Health Care Needs

: media-1vid110.1542/5840358562001PEDS-VA_2018-1795Video Abstract OBJECTIVES: The medical home is central to providing quality health care for children. Access to the medical home has historically been tracked by using the National Survey of Children With Special Health Care Needs and the National Survey of Children's Health (NSCH). Between 2012 and 2015, the NSCH was redesigned, combining the 2 surveys into a single, annual assessment. In this study, we provide the latest estimates of medical home access among children in the United States.

METHODS

We used data from the 2016 NSCH (N = 50 212). Medical home access was defined as a composite measure composed of 5 subcomponents (usual source of care, personal doctor or nurse, referral access, receipt of care coordination, and receipt of family-centered care) for 50 177 US children aged 0 to 17 years. We conducted bivariate analyses and logistic regression to examine the sociodemographic and health characteristics associated with reported attainment of the medical home composite measure and each subcomponent. Analyses were survey weighted.

RESULTS

In 2016, 43.2% of children with special health care needs (CSHCN) and 50.0% of non-CSHCN were reported to have access to a medical home. Attainment of the medical home composite measure varied significantly by sociodemographic characteristics among both CSHCN and non-CSHCN, as did attainment rates for each of the 5 subcomponents. The medical complexity of CSHCN was also associated with attainment rates of all outcomes.

CONCLUSIONS

The medical home incorporates elements of care considered necessary for providing comprehensive, quality care. Our results indicate that there is still room to improve access to the medical home among all children.

Feasibility of systematic poverty screening in a pediatric oncology referral center

BACKGROUND

Based on the strong link between poverty and child health outcomes, both the American Academy of Pediatrics (AAP) and national pediatric oncology associations have advocated for routine clinical poverty screening. Systematic implementation of this recommendation in pediatric oncology is not yet standard, and feasibility data are needed. We report the feasibility of routine poverty screening in a pediatric oncology referral center and baseline poverty characteristics of this population.

METHODS

From 2013 to 2017, 448 families with newly diagnosed pediatric cancer at Dana-Farber/Boston Children's Cancer and Blood Disorders Center were offered the Psychosocial Assessment Tool 2.0 (PAT) as part of routine care. The PAT includes a two-item screen for household material hardship (HMH). All families were asked about annual household income by a resource specialist. Data were abstracted with sociodemographic and child/disease characteristics. Descriptive statistics are reported.

RESULTS

Four hundred and thirteen families completed the PAT (response rate 92%), of whom 394 (95%) completed specific questions assessing for HMH. Ninety-four percent of families who met with a resource specialist disclosed their annual household income. One quarter (27%) of families was ≤200% federal poverty level at diagnosis, and 44% of families endorsed at least one domain of HMH. The most frequent domains of HMH included housing (24%), utilities (20%), and transportation (20%).

CONCLUSIONS

Systematic poverty screening per AAP and pediatric oncology psychosocial standards of care is feasible in routine cancer care. There is a high baseline incidence (44%) of HMH in at least one domain in families with newly diagnosed pediatric cancer who may benefit from early identification and resource intervention.

Health Care Utilization and Unmet Need Among Youth With Special Health Care Needs

PURPOSE

To examine unmet health needs and health care utilization among youth with special health care needs (YSHCN).

METHODS

We analyzed data among youth aged 12-17 years using the 2016 National Survey of Children's Health. We conducted descriptive analyses comparing YSHCN with non-YSHCN, and bivariate and multivariable analyses examining associations between dependent and independent measures. Six dependent variables represented unmet needs and utilization. Adjusted analyses controlled for sociodemographic and health measures.

RESULTS

A total of 5,862 individuals were identified as YSHCN, and nearly 70% had three or more comorbid conditions. Over 90% used medical care, preventive care, or dental care in the past 12 months, while 8% reported having unmet health needs (compared with 2.8% of non-YSHCN). Using a typology of qualifying criteria for special health care needs, we found that YSHCN with increasing complexity of needs were more likely to report unmet health needs, use of mental health care services, and emergency department use, compared with YSHCN using medication only to manage their conditions. All YSHCN living in households below 400% federal poverty level were less likely to utilize nearly all types of health care examined, with the exception of mental health care use, compared with those at or above 400% federal poverty level.

CONCLUSIONS

Differences in complexity of needs, race/ethnicity, and poverty status highlight existing gaps in health care utilization and persistent unmet health needs among YSHCN. Efforts should focus on strengthening coordinated systems of care that optimally meet the needs of YSHCN so they may thrive in their families and communities.

Navigating the health-care system in community: Perspectives from Asian immigrant parents of children with special health-care needs

Children with special health-care needs (CSHCNs) face notable barriers to health-care access and to receiving quality and family-centered care, despite higher health-care utilization rates. Within the population of CSHCNs, there are significant inequities in health-care quality impacting immigrants who have migrated to the United States. However, little is known about the experiences and needs of Asian immigrant families who have CSHCNs. This study aimed to explore how Asian immigrant parents of CSHCNs view their child's health-care access, quality, and utilization. We conducted semi-structured qualitative interviews with 22 Vietnamese- and Cantonese-speaking parents of CSHCNs. Participants were recruited through community partners. Interviews were transcribed, translated, and coded using content analysis. Participants were generally satisfied with their children's care and had strong relationships with their primary care doctors who were often culturally 'matched'. However, participants experienced several important and culturally specific barriers, including gaps in their understanding of the health-care system, language barriers, and a sense of alienation. Parents frequently turned to informal and community supports for assistance in navigating the US health-care system. Further research to understand the drivers of health disparities and policy level solutions is warranted.

Insurance status, mortality, and hospital use among pediatric trauma patients over three decades

BACKGROUND

We investigated the association between lack of insurance and mortality, resource use, and medical comorbidities among pediatric trauma patients.

METHODS

Our trauma database was queried for patients <18 years old from 1989 through 2013. Data collected included demographics, injury severity score (ISS), and insurance status. Dependent variables included major medical comorbidities, hospital and ICU lengths of stay (LOS), and mortality. Logistic regression and tests of equivalence were used to analyze the data.

RESULTS

A total of 3120 patients were included. The mortality among patients with insurance was 3.6% compared to 8.4% among those without insurance (p=0.0001, OR =2.42, 95% CI=1.53-3.82). This relationship remained statistically significant with adjustment via multivariable logistic regression (p=0.0001, OR =2.83, 95% CI: 1.64-4.74). Hospital and ICU LOS were significantly greater among insured patients in severely and moderately injured samples, respectively. There was no correlation between insurance and medical comorbidities. The uninsured mortality rate was 12.9% from 1989 to 1997 compared to 3.9% in 2006-2013.

CONCLUSION

Lack of insurance was associated with mortality but not preexisting comorbidity. This relationship persisted over time despite an overall decline in mortality. Additionally, lack of insurance was associated with decreased hospital stay and ICU utilization.

LEVEL OF EVIDENCE

Treatment Study, Level III.

Receipt of Recommended Adolescent Vaccines Among Youth With Special Health Care Needs

We examined vaccination coverage among youth with special health care needs (YSHCN) using data from parents of adolescents (11-17 years) who responded to a statewide survey in 2010-2012 (n = 2156). Using a validated screening tool, we identified 29% of adolescents as YSHCN. Weighted multivariable logistic regression assessed associations between special health care needs and receipt of tetanus booster, meningococcal, and human papillomavirus (HPV) vaccines. Only 12% of youth had received all 3 vaccines, with greater coverage for individual vaccines (tetanus booster, 91%; meningococcal, 32%; HPV, 26%). YSHCN had greater odds of HPV vaccination than other youth (33% vs 23%, OR = 1.70, 95% CI = 1.16-2.50) but vaccination coverage was similar ( P ≥ .05) for other outcomes. In subgroup analyses, HPV vaccination also differed depending on the number and type of special health care needs identified. Findings highlight low levels of vaccination overall and missed opportunities to administer recommended vaccines among all youth, including YSHCN.

ECHO Autism

Children with autism spectrum disorder (ASD) have complex medical problems, yet they are at high risk for unmet health care needs. Primary care providers are perfectly positioned to meet these needs; however, they often lack training in ASD. This pilot project developed and tested a new model for training primary care providers in best-practice care for ASD using the Extension for Community Healthcare Outcomes (ECHO) framework. The 6-month ECHO Autism pilot project consisted of 12 biweekly clinics focused on screening and identification of ASD symptoms and management of medical and psychiatric comorbidities. Participants completed measures of practice behavior and self-efficacy in screening and management of children with ASD at baseline (pretest) and after 6 months of ECHO Autism (posttest). Statistically significant improvements were observed in self-efficacy, in adherence to ASD screening guidelines, and in use of ASD-specific resources. Participants also reported high satisfaction with the program.

Inequities in health care needs for children with medical complexity

Children with special health care needs are believed to be susceptible to inequities in health and health care access. Within the group with special needs, there is a smaller group of children with medical complexity: children who require medical services beyond what is typically required by children with special health care needs. We describe health care inequities for the children with medical complexity compared to children with special health care needs but without medical complexity, based on a secondary analysis of data from the 2005-06 and 2009-10 National Survey of Children with Special Health Care Needs. The survey examines the prevalence, health care service use, and needs of children and youth with special care needs, as reported by their families. The inequities we examined were those based on race/ethnicity, primary language in the household, insurance type, and poverty status. We found that children with medical complexity were twice as likely to have at least one unmet need, compared to children without medical complexity. Among the children with medical complexity, unmet need was not associated with primary language, income level, or having Medicaid. We conclude that medical complexity itself can be a primary determinant of unmet needs.

Factors Associated with Travel Time and Distance to Access Hospital Care Among Infants with Spina Bifida

OBJECTIVES

Using geographic information systems (GIS), we examined travel time and distance to access hospital care for infants with spina bifida (SB).

METHODS

This study was a statewide, population-based analysis of Florida-born children with SB, 1998-2007, identified by the Florida Birth Defects Registry and linked to hospitalizations. We geocoded maternal residence at delivery and identified hospital locations for infants (<1 year). Using 2007 Florida Department of Transportation road data, we calculated one-way mean travel time and distance to access hospital care. We used Poisson regression to examine selected factors associated with travel time and distance [≤30 vs. >30 min/miles (reference)], including presence of hydrocephalus and SB type [isolated (no other major birth defect) versus non-isolated SB].

RESULTS

For 612 infants, one-way mean (median) travel time was 45.1 (25.9) min. Infants with both non-isolated SB and hydrocephalus traveled longest to access hospitals (mean 60.8 min/48.5 miles; median 34.2 min/26.9 miles). In adjusted results, infants with non-isolated SB and whose mothers had a rural residence were less likely to travel ≤30 min to hospitals. Infants born to mothers in minority racial/ethnic groups were more likely to travel ≤30 min.

CONCLUSIONS

Birth defects registry data and GIS-based methods can be used to evaluate geographic accessibility to hospital care for infants with birth defects. Results can help to identify geographic barriers to accessing hospital care, such as travel time and distance, and inform opportunities to improve access to care for infants with SB or other special needs.

Is implementation fidelity associated with improved access to care in a school-based Child and Family Team model?

Effective child and family centered service planning is crucial to addressing vulnerable children's needs. However, there is limited evidence about what facets of these processes improve service use and outcomes. The current study used a Poisson random effects hazard model to test correlations between fidelity to NC's Child and Family Support Team model and time to service receipt, using case management data for 3396 children served by that program during the 2008-2009 school year. Students were more likely to receive recommended services more quickly when caregivers and the students attended planning meetings, when their plans included services for caregivers, and when child and family team leaders followed up after meetings to verify service receipt. Contrary to the Child and Family Support Team theory of change, match between student needs and the lead agency of the meeting was not associated with the odds of quicker service receipt, nor was attendance by natural supports. Findings from this study demonstrate the potential effectiveness of using case management systems to measure service planning process fidelity, as well as how results thereof can both inform process improvement and potential refinements to models' theories of change.

Changing trends of childhood disability, 2001-2011

BACKGROUND

Over the past half century the prevalence of childhood disability increased dramatically, coupled with notable increases in the prevalence of mental health and neurodevelopmental conditions. This study provides a detailed assessment of recent trends in childhood disability in relation to health conditions and sociodemographic factors.

METHODS

Secondary data analysis of National Health Interview Survey (NHIS) datasets 2001-2002, 2004-2005, 2007-2008, and 2010-2011 (N = 198888) was conducted to calculate the prevalence, rate of change, severity, and sociodemographic disparities of parent-reported childhood disability.

RESULTS

The prevalence of childhood disability has continued to increase, growing by 15.6% between 2001-2002 and 2010-2011. Nearly 6 million children were considered disabled in 2010-2011. Children living in poverty experienced the highest rates of disability, 102.6 cases per 1000 population in 2010-2011, but unexpectedly, children living in households with incomes ≥ 400% above the federal poverty level experienced the largest increase (28.4%) over this 10-year period. The percentage of disability cases related to any physical health condition declined 11.8% during the decade, whereas cases related to any neurodevelopmental or mental health condition increased by 20.9%.

CONCLUSIONS

Over the past decade, parent-reported childhood disability steadily increased. As childhood disability due to physical conditions declined, there was a large increase in disabilities due to neurodevelopmental or mental health problems. For the first time since the NHIS began tracking childhood disability in 1957, the rise in reported prevalence is disproportionately occurring among socially advantaged families. This unexpected finding highlights the need to better understand the social, medical, and environmental factors influencing parent reports of childhood disability.

Accessibility of medical services for persons with disabilities: comparison with the general population in Korea

PURPOSE

This study investigated the accessibility of medical services to people with disabilities (PWD) in Korea in comparison with the general population (GP) and examined factors influencing access to health care.

METHODS

Data from the 2011 Korean National Health and Nutrition Examination Survey and the 2011 National Survey of Disabled People were used. Participants included PWD (n = 5636) and the GP (n = 6646) aged 19 and above.

RESULTS

Of the PWD group, 807 (14.8%) reported difficulty in accessing medical services compared with 284 (4.2%) of the GP group (p < 0.001). In the PWD group, the most frequently reported reasons for not receiving medical services when needed were lack of money (58.8%) and lack of transportation (18.6%). Problems accessing medical services were associated with sex, age, employment status, household income, health insurance type, chronic disease, and disability type and grade.

CONCLUSIONS

PWD experienced more barriers in accessing medical services despite needing services more frequently than did those in the GP group. Compared to barriers faced by the GP, barriers for PWD were environmental rather than personal, which indicates the need for social policies to remove or reduce barriers and improve access to care. Implications for Rehabilitation Health Care Environment People with disabilities are likely to have difficulty in accessing medical services. Barriers are associated with environmental factors (e.g. lack of money or transportation), necessitating policies to reduce them.

Influenza-associated pediatric deaths in the United States, 2004-2012

BACKGROUND

Influenza-associated deaths in children occur annually. We describe the epidemiology of influenza-associated pediatric deaths from the 2004-2005 through the 2011-2012 influenza seasons.

METHODS

Deaths in children <18 years of age with laboratory-confirmed influenza virus infection were reported to the Centers for Disease Control and Prevention by using a standard case report form to collect data on demographic characteristics, medical conditions, clinical course, and laboratory results. Characteristics of children with no high-risk medical conditions were compared with those of children with high-risk medical conditions.

RESULTS

From October 2004 through September 2012, 830 pediatric influenza-associated deaths were reported. The median age was 7 years (interquartile range: 1-12 years). Thirty-five percent of children died before hospital admission. Of 794 children with a known medical history, 43% had no high-risk medical conditions, 33% had neurologic disorders, and 12% had genetic or chromosomal disorders. Children without high-risk medical conditions were more likely to die before hospital admission (relative risk: 1.9; 95% confidence interval: 1.6-2.4) and within 3 days of symptom onset (relative risk: 1.6; 95% confidence interval: 1.3-2.0) than those with high-risk medical conditions.

CONCLUSIONS

Influenza can be fatal in children with and without high-risk medical conditions. These findings highlight the importance of recommendations that all children should receive annual influenza vaccination to prevent influenza, and children who are hospitalized, who have severe illness, or who are at high risk of complications (age <2 years or with medical conditions) should receive antiviral treatment as early as possible.

An explanatory model of factors related to well baby visits by age three years for Medicaid-enrolled infants: a retrospective cohort study

BACKGROUND

Well baby visits (WBVs) are a cornerstone of early childhood health, but few studies have examined the correlates of WBVs for socioeconomically vulnerable infants. The study objective was to identify factors related to the number of WBVs received by Medicaid-enrolled infants in the first three years of life and to present a preliminary explanatory model.

METHODS

We analyzed Iowa Medicaid claims files and birth certificate data for infants born in calendar year 2000 (N = 6,085). The outcome measure was the number of well baby visits (WBVs) received by Medicaid-enrolled infants between age 1 and 41 months (range: 0 to 10). An ecological health model and existing literature were used to evaluate 12 observed factors as potential WBV correlates. We ran multiple variable linear regression models with robust standard errors (α = 0.05).

RESULTS

There were a number of infant, maternal, and health system factors associated with the number of WBVs received by Medicaid-enrolled infants. Infants whose mothers had a greater number of prenatal healthcare visits (ß = 0.24 to 0.28; P = .001) or were married (ß = 0.20; P = .002) received more WBVs. Having a chronic health condition (ß = 0.51; P < .0001) and enrollment in a case management program (ß = 0.48; P < .0001) were also positively associated with WBVs. Eligibility for Medicaid through the Supplemental Security Income Program (ß = -0.70; P = .001), increased maternal age (ß = -0.27 to -0.35; P = .004), higher levels of maternal education (ß = -0.18; P = .005), maternal smoking (ß = -0.13; P = .018), and enrollment in a health maintenance organization plan (ß = -1.15; P < .0001) were negatively associated with WBVs. There was a significant interaction between enrollment in a health maintenance organization plan and enrollment in a Medicaid case management program (P = .015). Maternal race, maternal alcohol use during pregnancy, and rurality were not significantly related to the number of WBVs.

CONCLUSIONS

Multiple infant, maternal, and health system variables were related to the number of WBVs received by Medicaid-enrolled infants. Additional research is needed to develop strategies to optimize access to WBVs for Medicaid-enrolled infants at risk for poor use of preventive medical care services.

Healthy people 2010 leading health indicators: how children with special health care needs fared

OBJECTIVES

We compared estimates for children with and without special health care needs (SHCN) at 2 time periods for national health objectives related to the Healthy People 2010 leading health indicators (LHIs).

METHODS

Data were from the 2003 and 2007 National Surveys of Children's Health. Seven survey items were relevant to the LHIs and available in both survey years: physical activity, obesity, household tobacco use, current insurance, personal health care provider, past-month depressive symptoms, and past-year emergency department visits.

RESULTS

In 2003 and 2007, children with SHCN fared worse than those without SHCN with respect to physical activity, obesity, household tobacco exposure, depressive symptomology, and emergency department visits, but fared better on current insurance and having a personal health care provider. Physical activity and access to a personal health care provider increased for all children, whereas the absolute disparity in personal provider access decreased 4.9%.

CONCLUSIONS

Significant disparities exist for key population health indicators between children with and without SHCN. Analyses illustrated how population-based initiatives could be used to frame health challenges among vulnerable populations.

Assessing the health, functional characteristics, and health needs of youth attending a noncategorical transition support program

PURPOSE

To assess the health, functional characteristics, and health care service needs of youth and young adults with special health care needs attending a comprehensive, noncategorical transition program.

METHODS

A self-administered survey was developed from national health surveys and clinical experience to assess concepts identified as important for successful transition to adulthood. Surveys were mailed to 198 parents of youth and young adults with special health care needs attending the transition clinic. Parents were asked about the youth's health, functional status, and health care services needed. The clinical database provided demographic and patient health characteristics. Results were compared against the 2005-2006 National Survey of Children with Special Health Care Needs.

RESULTS

Forty-four percent of surveys were returned. Average age of youth was 17.5 (11-22) years old and diagnoses included cerebral palsy (36%), spina bifida (10%), developmental delay or Down syndrome (17%), and autism (6%). Most youth needed assistance with personal care (69%) and routine needs (91%) and used assistive devices (59%). Compared with the 2005-2006 National Survey of Children with Special Health Care Needs, parents reported higher needs for all services except mental health care and tobacco or substance use counseling. Forty three percent reported at least one unmet health need. Few parents reported the need for counseling on substance use (1%), sexual health screening (16%), nutrition (34%), and exercise (41%).

CONCLUSIONS

Youth attending our transition program had more functional limitations, poorer reported health status, different diagnosis distribution, and higher levels of needed health services. Few parents identified needs for other recommended adolescent preventive services. Transition programs should assess patient health characteristics and service needs to design effective patient-centered services.

Use of the integrated health interview series: trends in medical provider utilization (1972-2008)

The Integrated Health Interview Series (IHIS) is a public data repository that harmonizes four decades of the National Health Interview Survey (NHIS). The NHIS is the premier source of information on the health of the U.S. population. Since 1957 the survey has collected information on health behaviors, health conditions, and health care access. The long running time series of the NHIS is a powerful tool for health research. However, efforts to fully utilize its time span are obstructed by difficult documentation, unstable variable and coding definitions, and non-ignorable sample re-designs. To overcome these hurdles the IHIS, a freely available and web-accessible resource, provides harmonized NHIS data from 1969-2010. This paper describes the challenges of working with the NHIS and how the IHIS reduces such burdens. To demonstrate one potential use of the IHIS we examine utilization patterns in the U.S. from 1972-2008.

Unmet health care needs in children with cerebral palsy: a cross-sectional study

Children with potentially severe health conditions such as cerebral palsy (CP) are at risk for unmet health care needs. We sought to determine whether children with CP had significantly greater unmet health care needs than children with other special health care needs (SHCN), and whether conditions associated with CP increased the odds of unmet health care needs. We analyzed data from the National Survey of Children with Special Health Care Needs, 2005-2006, using multivariate logistic regression to calculate the adjusted odds of children with CP having one or more unmet health care needs compared to children with other SHCN. We also determined the association of CP-related conditions with unmet health care needs in children with CP. After weighting to national averages, our sample represented 178,536 children with CP (1.9%), and 9,236,794 with children with other SHCN (98.1%). Although having CP increased the odds that children had unmet health care needs (OR = 1.46, 95% CI [1.07-1.99]), the presence of a "severe" health condition weakened the association. Gastrointestinal problems and emotional problems increased the odds that children with CP would have unmet health care needs above that of children without the associated conditions (p ≤ .01). Children with CP are similar to children with other SHCN and may benefit from collaborative programs targeting severe chronic conditions. However, children with CP and associated conditions have increased odds of unmet health care needs in comparison to children without those problems.

A Half Century of Health Data for the U.S. Population: The Integrated Health Interview Series

The U.S. National Health Interview Survey (NHIS) is the world's longest survey time series of health data and a rich source of information on health conditions, behaviors, and care from the 1960s to the present. NHIS public-use files are difficult to use for long-term analysis, due to complex file structure, changes in questionnaire content, and evolving variable names and coding schemes. Researchers at the Minnesota Population Center have created the Integrated Health Interview Series (IHIS) to overcome these problems. IHIS provides access to thousands of consistently coded and well-documented NHIS variables on the Internet and makes it easy to analyze health trends and differentials. IHIS multiplies the value of NHIS data by allowing researchers to make consistent comparisons over half a century and thus to study U.S. health status as a dynamic process. This article describes the main features of IHIS and suggests fruitful avenues for historical research using these invaluable health data.

Health disparities in low-income families with infants and toddlers: needs and challenges related to disability

This study examines disparities in health status, health care utilization, insurance coverage and satisfaction in US low-income parents of infants and toddlers with disabilities compared to low-income parents of children without disabilities. The Early Head Start Research and Evaluation Project is a longitudinal study involving 2087 families in 17 communities across the United States. Families completed interviews at enrollment and at 7, 16, and 28 months after enrollment. Descriptive analyses were conducted to characterize children's status in terms of health, health care use, and insurance coverage. Children with disabilities were more likely to experience poor health and to use more health care services. Parents of children with disabilities were more likely to report that medical care was inadequate. Hispanic children were less likely to experience excellent health. Hispanic parents were less likely to have health insurance or to report that their medical care was adequate. Low-income parents of young children with disabilities perceived their children as less healthy, more vulnerable and needing more health services. This study demonstrates the importance of providing accessible, culturally-competent services to this vulnerable population.

Pediatric resident attitudes toward caring for children with severe disabilities

OBJECTIVE

To survey pediatric residents' attitudes toward caring for children with severe disabilities.

DESIGN

A cross-sectional survey of residents in a university-affiliated pediatric residency program between October and December 2005. Residents were asked to complete a newly designed, 13-item survey. For each item, participants selected the degree to which they did or did not agree with a statement about disabilities or caring for children with severe disabilities.

RESULTS

Fifty-five (43%) of 129 eligible residents participated. Eighty-nine percent felt that caring for children with severe disabilities was as rewarding as caring for other children. Ninety-two percent felt that there is a societal responsibility to care for such children; 98% felt families of children with disabilities love their children as much as other families. Two-thirds (66%) admitted frustration related to caring for children who cannot be cured or function independently, and 71% questioned the aggressive treatment of such children. Residents in their second and third postgraduate years were more likely to question the aggressive treatment compared with their junior colleagues.

CONCLUSIONS

Although pediatric residents had positive attitudes toward children with severe disabilities, emotional and moral tensions did arise around their care.

A population-based assessment of the health, functional status, and consequent family impact among children with Down syndrome

BACKGROUND

Many health conditions have been described in children with Down syndrome (DS). However, there are little comparative population-based data available.

OBJECTIVE/HYPOTHESES

We sought to examine the health impacts associated with DS and other disabling conditions in U.S. children included in the 2005-2006 National Survey of Children with Special Health Care Needs.

METHODS

We assessed numerous health and functional outcomes in children with DS and without DS but with (1) mental retardation/developmental delay(1) and another developmental disability associated with a high functional impact; (2) mental retardation/developmental delay but no co-occurring high-impact disability; (3) other special health care needs; and (4) no special health care needs (referent).

RESULTS

Children with DS and in all 3 special health care needs comparison groups had substantially more health and functional difficulties than did the referent sample. Overall, children with DS were fairly comparable to children in the other mental retardation/developmental delay groups on health indicators; however, young children with DS were more likely than young children in both "other mental retardation" groups to have difficulties with breathing/respiration and swallowing/digestion/metabolism. Children with both DS and mental retardation associated with another high-impact disability had the highest levels of functional difficulties, unmet health needs, and family financial impacts. Nearly 60% of families in both groups provided home health care; in over 40%, a family member stopped working because of the child's condition; and about 40% reported the child's condition caused financial problems.

CONCLUSIONS

Children with DS can have substantial health and functional difficulties, with numerous financial impacts on their families.

Unmet prescription medication need in U.S. children

OBJECTIVES

To examine the nature and extent of unmet prescription medication need (UPMN) in children and its predictors using the 2003 National Survey of Children's Health (NSCH).

DESIGN

Retrospective cross-sectional survey.

SETTING

United States in 2003-2004.

PARTICIPANTS

Parents or guardians who knew most about child's (<18 years of age) health and health care and reported about their children's prescription medication use.

INTERVENTION

NSCH-a population-based telephone survey-based on complex probability sampling design.

MAIN OUTCOME MEASURES

Nature and extent of UPMN in children and predictors of UPMN for any reason and as a result of cost, health plan problems, and lack of insurance within the conceptual framework of the Andersen behavioral model.

RESULTS

According to NSCH, 0.54 million (95% CI 0.46-0.62) or 1.23% (1.05-1.41%) of children experienced UPMN. The highest prevalence of UPMN was seen among blacks (2.3%), families with income less than 200% of federal poverty level (2.4%), and those having good, fair, or poor perceived health status (3.2%). A high prevalence of UPMN was also found in children with gained (5.3%), lost (3.7%), or no insurance (6.4%). Among children with UPMN, 35.39% (28.56-42.23%) did not receive medications because of cost, 26.51% (20.28-32.74%) because of health plan problems, and 40.73% (33.21-48.24%) because of lack of insurance. Multivariate logistic regression analysis revealed that predisposing (race), enabling (poverty and insurance), and need (perceived health status and depression) factors were significantly associated with UPMN for any reason. Factors significantly associated with UPMN due to cost included enabling (insurance) and need (attention deficit hyperactivity disorder and asthma) factors. The predictors of UPMN resulting from health plan problems included predisposing (race) and enabling (insurance) factors, whereas UPMN caused by lack of insurance was only associated with an enabling factor (age).

CONCLUSION

More than 0.5 million children in the United States experienced UPMN, mainly as a result of cost, health plan problems, or lack of insurance. The study findings suggest that a need exists for addressing racial disparities and continuity of coverage issues in children to improve access to needed prescription medications.

What factors are associated with state performance on provision of transition services to CSHCN?

OBJECTIVE

To examine whether individual, condition-related, and system-related characteristics are associated with state performance (high, medium, low) on the provision of transition services to children with special health care needs (CSHCN).

METHODS

We conducted descriptive, bivariate, and multivariable analyses of 16876 children aged 12 to 17 years by using data from the 2005-2006 National Survey of Children With Special Health Care Needs. Polytomous logistic regression was used to compare the characteristics of CSHCN residing within high-, medium-, and low-performance states, with low-performance states serving as the reference group.

RESULTS

Compared with non-Hispanic white CSHCN, Hispanic (adjusted odds ratio [aOR]: 0.25 [95% confidence interval (CI): 0.17-0.37]) and non-Hispanic black (aOR: 0.44 [95% CI: 0.30-0.62]) CSHCN were less likely to reside in a high-performance than in a low-performance state. Compared with CSHCN who had a medical home or adequate insurance coverage, CSHCN who did not have a medical home or adequate insurance coverage were less likely to reside in a high-performance than in a low-performance state (aOR: 0.73 [95% CI: 0.57-0.95]; aOR: 0.73 [95% CI: 0.58-0.93], respectively).

CONCLUSIONS

Key factors found to be important in a state's performance on provision of transition services to CSHCN were race/ethnicity and having a medical home and adequate insurance coverage. Efforts to support the Maternal and Child Health Bureau's integration of system-level factors in quality-improvement activities, particularly establishing a medical home and attaining and maintaining adequate insurance, are likely to help states improve their performance on provision of transition services.