Generalist and subspecialist care for children with chronic conditions

Performance of ICD-10-CM diagnosis codes for identifying children with Sickle Cell Anemia

OBJECTIVE

To develop, test, and validate the performance of ICD-10-CM claims-based case definitions for identifying children with sickle cell anemia (SCA).

DATA SOURCES

Medicaid administrative claims (2016) for children <18 years with potential SCA (any D57x diagnosis code) and newborn screening records from Michigan and New York State.

STUDY DESIGN

This study is a secondary data analysis.

DATA COLLECTION/EXTRACTION METHODS

Using specific SCA-related (D5700, D5701, and D5702) and nonspecific (D571) diagnosis codes, 23 SCA case definitions were applied to Michigan Medicaid claims (2016) to identify children with SCA. Measures of performance (sensitivity, specificity, area under the ROC curve) were calculated using newborn screening results as the gold standard. A parallel analysis was conducted using New York State Medicaid claims and newborn screening data.

PRINCIPAL FINDINGS

In Michigan Medicaid, 1597 children had ≥1 D57x claim; 280 (18 percent) were diagnosed with SCA. Measures of performance varied, with sensitivities from 0.02 to 0.97 and specificities from 0.88 to 1.0. The case definition of ≥1 outpatient visit with a SCA-related or D571 code had the highest area under the ROC curve, with a sensitivity of 95 percent and specificity of 92 percent. The same definition also had the highest performance in New York Medicaid (n = 2454), with a sensitivity of 94 percent and specificity of 86 percent.

CONCLUSIONS

Children with SCA can be accurately identified in administrative claims using this straightforward case definition. This methodology can be used to monitor trends and use of health services after transition to ICD-10-CM.

Preventive Care Delivery to Young Children With Sickle Cell Disease

Preventive services can reduce the morbidity of sickle cell disease (SCD) in children but are delivered unreliably. We conducted a retrospective cohort study of children aged 2 to 5 years with SCD, evaluating each child for 14 months and expecting that he/she should receive ≥75% of days covered by antibiotic prophylaxis, ≥1 influenza immunization, and ≥1 transcranial Doppler ultrasound (TCD). We used logistic regression to quantify the relationship between ambulatory generalist and hematologist visits and preventive services delivery. Of 266 children meeting the inclusion criteria, 30% consistently filled prophylactic antibiotic prescriptions. Having ≥2 generalist, non-well child care visits or ≥2 hematologist visits was associated with more reliable antibiotic prophylaxis. Forty-one percent of children received ≥1 influenza immunizations. Children with ≥2 hematologist visits were most likely to be immunized (62% vs. 35% among children without a hematologist visit). Only 25% of children received ≥1 TCD. Children most likely to receive a TCD (42%) were those with ≥2 hematologist visits. One in 20 children received all 3 preventive services. Preventive services delivery to young children with SCD was inconsistent but associated with multiple visits to ambulatory providers. Better connecting children with SCD to hematologists and strengthening preventive care delivery by generalists are both essential.

Parental Preferences Regarding Outpatient Management of Children with Congenital Heart Disease

The objective of this study was to identify patterns of health care usage among children with congenital heart disease (CHD) and determine predictors for contacting cardiologists for routine care. Parents of children with CHD completed surveys, indicating which provider they would contact first for 12 concerns. Predictors for preference for cardiologist evaluation were identified by multivariable logistic regression. Surveys were completed by 307 of 925 (33.2%) parents. Median patient age was 9.4 years [interquartile range (IQR) 5.1-14.4 years] with a median of 1 cardiac surgery (IQR 1-3). Most parents agreed primary care physicians (PCPs) could identify problems related to CHD (70.0%) and when to refer to cardiologists (89.6%). More felt PCPs best understood their values (63.2 vs. 29.6%, P < 0.001) and were more accessible (63.5 vs. 33.6%, P < 0.001) than cardiologists. Parents preferred first evaluation by PCPs for 9 of 12 concerns. Preference for cardiology evaluation was independently associated with the number of cardiac catheterizations [adjusted odds ratio (AOR) for ≥2 catheterizations 2.4, 95% confidence interval (CI) 1.1-4.9], belief the cardiologist better knew the child's medical history (AOR 2.4, 95% CI 1.3-4.6), and provider accessibility (AOR 3.6, 95% CI 1.8-7.4). Parents of CHD patients reported close alignment with PCPs and would contact PCPs first for most routine care. However, some populations continue to contact cardiologists for routine care. Further study is needed to clarify best practices for clinician and parent education.

Two-year impact of the alternative quality contract on pediatric health care quality and spending

OBJECTIVE

To examine the 2-year effect of Blue Cross Blue Shield of Massachusetts' global budget arrangement, the Alternative Quality Contract (AQC), on pediatric quality and spending for children with special health care needs (CSHCN) and non-CSHCN.

METHODS

Using a difference-in-differences approach, we compared quality and spending trends for 126,975 unique 0- to 21-year-olds receiving care from AQC groups with 415,331 propensity-matched patients receiving care from non-AQC groups; 23% of enrollees were CSHCN. We compared quality and spending pre (2006-2008) and post (2009-2010) AQC implementation, adjusting analyses for age, gender, health risk score, and secular trends. Pediatric outcome measures included 4 preventive and 2 acute care measures tied to pay-for-performance (P4P), 3 asthma and 2 attention-deficit/hyperactivity disorder quality measures not tied to P4P, and average total annual medical spending.

RESULTS

During the first 2 years of the AQC, pediatric care quality tied to P4P increased by +1.8% for CSHCN (P < .001) and +1.2% for non-CSHCN (P < .001) for AQC versus non-AQC groups; quality measures not tied to P4P showed no significant changes. Average total annual medical spending was ~5 times greater for CSHCN than non-CSHCN; there was no significant impact of the AQC on spending trends for children.

CONCLUSIONS

During the first 2 years of the contract, the AQC had a small but significant positive effect on pediatric preventive care quality tied to P4P; this effect was greater for CSHCN than non-CSHCN. However, it did not significantly influence (positively or negatively) CSHCN measures not tied to P4P or affect per capita spending for either group.

Ambulatory care connections of Medicaid-insured children with sickle cell disease

BACKGROUND

Sickle cell disease (SCD) requires coordinated ambulatory care from generalists and hematologists. We examined when children with SCD establish ambulatory care connections, whether these connections are maintained, and how these connections are used before and after hospitalizations.

PROCEDURE

We conducted a retrospective cohort study of Medicaid-insured Maryland children with SCD from 2002 to 2008. For children enrolled from birth, time to first, second, and third generalist and first hematologist visits was plotted. For all children, we analyzed ambulatory visits by age group, by emergency department (ED) and hospital use, and before and after hospitalizations.

RESULTS

The overall study cohort comprised 851 children; 178 provided data from birth. Ambulatory care connections to generalists were made rapidly; connections to hematologists occurred more slowly, if at all (38% of children had not seen a hematologist by age 2 years). Visits with generalists decreased as patients aged, as did visits with hematologists (54% of children in the 12-17 year age group had no hematology visits in 2 years). Children with higher numbers of ED visits or hospitalizations also had higher numbers of ambulatory visits (generalist and hematologist). Most children had visits with neither generalists nor hematologists in the 30 days before and after hospitalizations.

CONCLUSIONS

Medicaid-insured children with SCD rapidly connect with generalists after birth; connections to hematologists occur more slowly. The observation that connections to generalists and hematologists diminish with time and are infrequently used around hospitalizations suggests that the ambulatory care of many Medicaid-insured children with SCD may be inadequate.

Mother-child interactions and the associations with child healthcare utilization in low-income urban families

Studies have demonstrated that low-income families often have disproportionately high utilization of emergency department (ED) and hospital services, and low utilization of preventive visits. A possible contributing factor is that some mothers may not respond optimally to their infants' health needs, either due to their own responsiveness or due to the child's ability to send cues. These mother-child interactions are measurable and amenable to change. We examined the associations between mother-child interactions and child healthcare utilization among low-income families. We analyzed data from the Nurse-Family Partnership trial in Memphis, TN control group (n = 432). Data were collected from child medical records (birth to 24 months), mother interviews (12 and 24 months postpartum), and observations of mother-child interactions (12 months postpartum). We used logistic and ordered logistic regression to assess independent associations between mother-child interactions and child healthcare utilization measures: hospitalizations, ED visits, sick-child visits to primary care, and well-child visits. Better mother-child interactions, as measured by mother's responsiveness to her child, were associated with decreased hospitalizations (OR: 0.51; 95% CI: 0.32, 0.81), decreased ambulatory-care-sensitive ED visits (OR: 0.65, 95% CI: 0.44, 0.96), and increased well-child visits (OR: 1.55, 95% CI: 1.06, 2.28). Mother's responsiveness to her child was associated with child healthcare utilization. Interventions to improve mother-child interactions may be appropriate for mother-child dyads in which child healthcare utilization appears unbalanced with inadequate primary care and excess urgent care. Recognition of these interactions may also improve the care clinicians provide for families.

Self-efficacy as a mediator between maternal depression and child hospitalizations in low-income urban families

The objective of this study is to examine the role of maternal self-efficacy as a potential mediator between maternal depression and child hospitalizations in low-income families. We analyzed data from 432 mother-child pairs who were part of the control-group for the Nurse-Family Partnership trial in Memphis, TN. Low-income urban, mostly minority women were interviewed 12 and 24 months after their first child's birth and their child's medical records were collected from birth to 24 months. We fit linear and ordered logistic regression models to test for mediation. We also tested non-linear relationships between the dependent variable (child hospitalization) and covariates (depressive symptoms and self-efficacy). Elevated depressive symptoms (OR: 1.70; 90% CI: 1.05, 2.74) and lower maternal self-efficacy (OR: 0.674; 90% CI: 0.469, 0.970) were each associated with increased child hospitalizations. When both maternal self-efficacy and depressive symptoms were included in a single model, the depressive symptoms coefficient decreased significantly (OR decreased by 0.13, P = 0.069), supporting the hypothesis that self-efficacy serves as a mediator. A non-linear, inverse-U shaped relationship between maternal self-efficacy and child hospitalizations was supported: lower compared to higher self-efficacy was associated with more child hospitalizations (P = 0.039), but very low self-efficacy was associated with fewer hospitalizations than low self-efficacy (P = 0.028). In this study, maternal self-efficacy appears to be a mediator between maternal depression and child hospitalizations. Further research is needed to determine if interventions specifically targeting self-efficacy in depressed mothers might decrease child hospitalizations.

Differences in pediatric drug information sources used by general versus subspecialist pediatricians

OBJECTIVE

To describe pediatric labeling information needs and sources of general and subspecialist pediatricians. Study design. Self-administered questionnaire of Fellows of the American Academy of Pediatrics (AAP).

RESULTS

The response rate was 48%. Top sources used by pediatricians to obtain pediatric labeling information were journals (86%), pediatric dosage books (84%), AAP News (77%), drug representatives (65%), and PDA-based databases (35%). Generalists were more likely than subspecialists to use AAP News (82% vs 60%; P < .001) and drug representatives (72% vs 41%; P < .001) to obtain prescribing information. Both groups reported that it was most important to have additional prescribing information for mental health and cardiovascular medications.

CONCLUSIONS

Despite differences in the methods used to obtain pediatric labeling information, generalist and subspecialist pediatricians both prioritized mental health and cardiovascular medications as needing additional prescribing information. Interventions to effectively disseminate new or revised pediatric labeling information to pediatricians should consider using methods identified in this study.

Research Consortium on Children with Chronic Conditions (RCCCC): a vehicle for interdisciplinary collaborative research

To describe the evolution, accomplishments, and limitations of a research consortium after 25 years of existence. A narrative historical account supplemented by data documenting citations to all group papers. In 1980 the Research Consortium on Children with Chronic Conditions was established. Since then, we have met 2-3 times a year to discuss issues related to research and policies for children with special health care needs. We describe the origin of the Consortium, its operation, and some of its accomplishments, as well as the difficulties it encountered. Our interactions helped promote and sustain research on an emerging topic and did so in an interdisciplinary manner. We include a citation analysis suggesting that group papers published by Consortium members are reasonably well cited by others. We believe our work has been of value in developing influencing research, clinical practice, and policy. This paper is intended to serve as a guide for others who believe that this type of interaction can do much to promote an emerging field. However, it also highlights some of the difficulties in forging and maintaining a productive, research-focused relationship over an extended period of time. The most important lesson learned is that a small group of committed individuals able to meet on a regular basis can accelerate movement in a new field. However, unless stable funding can be secured, maintaining a consortium is truly challenging.

Practice parameter for the psychiatric assessment and management of physically ill children and adolescents

This practice parameter describes the psychiatric assessment and management of physically ill children and adolescents. It reviews the epidemiology, clinical presentation, assessment, and treatment of psychiatric symptoms in children and adolescents with physical illnesses and the environmental and social influences that can affect patient outcome.

Correlates of behavioral care management strategies used by primary care pediatric providers

OBJECTIVE

To identify correlates of behavioral management strategies and to test whether children with more severe behavioral problems have care transferred to mental health specialists.

METHODS

Secondary analysis of the Child Behavior Study. Children aged 4 to 15 years were identified with new behavioral problems at nonurgent visits to primary care clinicians. Treatment strategies were categorized into mutually exclusive groups: primary care (psychotropic prescription and/or office-based counseling), mental health care (referral for or ongoing specialist mental health care), joint care (primary care and mental health care), or observation. Child-, family-, clinician-, and practice-level characteristics were assessed for association with management strategies by use of multivariate methods.

RESULTS

A total of 1377 children from 201 practices in 44 states and Puerto Rico were newly identified with behavioral problems. Behavioral/conduct (41 per cent), attentional/hyperactivity (37 per cent), adjustment (32 per cent), and emotional (22 per cent) problems were most commonly identified. Children with comorbid behavioral problems were more likely to be managed with joint care than other treatment strategies. In addition, clinicians who were male or who had greater mental health orientation were more likely to provide joint care than mental health care only.

CONCLUSIONS

Clinicians were more likely to manage new behavioral problems jointly with mental health providers than use other strategies if children had coexisting mental health problems or if providers had stronger beliefs about psychosocial aspects of care. These results do not support the hypothesis that children with more severe behavioral problems are transferred to specialists but suggest that primary care and mental health care clinicians may benefit from collaborating on treatment plans.

Are minority children the last to benefit from a new technology? Technology diffusion and inhaled corticosteriods for asthma

BACKGROUND

Racial and ethnic disparities in health and health care have been well documented, but few studies have addressed how disparities may change over time.

OBJECTIVE

We sought to determine the change in relative rates over time of corticosteroid metered dose inhaler (MDI) use in minority and nonminority populations with asthma.

DESIGN AND SETTING

We used a cross-sectional survey for 5 periods of 2 years' each (1989-1990, 1991-1992, 1993-1994, 1995-1996, 1997-1998) using the National Ambulatory Medical Care Surveys (NAMCS).

PARTICIPANTS

A total of 3671 visits by adults and children with asthma to U.S. office-based physicians comprised our sample.

MAIN OUTCOME MEASURE

We sought to measure differences in inhaled corticosteroid use for minority and nonminority adults and children controlling for gender, specialty, U.S. region, and type of insurance.

RESULTS

Minority patients with asthma were less than half as likely as nonminority patients to have had a steroid MDI prescribed during 1989-1990. By 1995-1996, minority and nonminority patients with asthma were equally likely to have had a steroid MDI prescribed. Although differences between black and white patients resolved, differences between white and Hispanic patients persisted even after adjusting for insurance. Children initially were less likely than adults with asthma to have steroid MDI prescribed, and this difference persisted. Minority children had the greatest delay in adoption of steroid MDIs.

CONCLUSION

Steroid MDIs diffused into minority and nonminority adult and child populations at different rates.

Factors associated with ease of using community-based systems of care for CSHCN in Hawai'i

OBJECTIVES

To study factors contributing to difficulty using community-based services by families of children with special health care needs (CSHCN) in Hawai'i.

METHODS

Data source was the 2001 National Survey of Children With Special Health Care Needs. The study population included the 449 respondents who were surveyed after additional items were added to the original questionnaire. Outcome of interest was "% of CSHCN whose families report community-based service systems are organized so they can use them easily." Explanatory variables included child health conditions (functional limitation, degree of severity, types of service needs), child and family characteristics (child age, maternal education, poverty level), and health services characteristics (partnership of family in decision making, family-centered coordinated care, adequate health insurance).

RESULTS

Children with special health care needs comprised 11.0% of < 18 years old children. Overall, 69% of respondents reported that community-based services could be used easily. Logistic regression analysis showed that the odds of reporting difficulties in using community-based services were almost 5 times higher for families who did not partner in decision making, 2.9 times higher for families who did not receive family-centered coordinated care, and 2.7 times higher for families who did not have adequate health insurance compared with families who were satisfied with the care received. Need for services contributed independently to reporting difficulties in community-based service use. Contrary to the hypothesized associations, severe health conditions or limited functionality did not contribute significantly to reporting difficulties in service use.

CONCLUSIONS

Families who reported difficulties in using community-based services were those who have children who need extensive and varied services. Lack of involvement in decision making, lack of coordinated care in a medical home, and insufficient health insurance were the main obstacles to their ability to use community-based services easily.

Gaps in enrollment from a Medicaid managed care program: effects on emergency department visits and hospitalizations for children with asthma

BACKGROUND

For high-risk children with asthma enrolled in Medicaid, loss of Medicaid coverage is a potential threat to access to quality asthma care.

OBJECTIVE

We sought to quantify the effect of gaps in enrollment on emergency department visits and hospitalizations for children with asthma in TennCare, Tennessee's managed care program for Medicaid-eligible and uninsured children.

METHODS

Children with asthma were identified from a research database of files maintained by the state. Gaps in enrollment in the state insurance program were measured between 1998 and 2002. Children with gaps were compared with children without gaps with respect to emergency department visits and hospitalizations for asthma, respiratory illnesses, croup, and other diagnoses.

RESULTS

Among children who met study definitions of asthma, 2373 experienced a gap in enrollment during the study period (10.4%). The rate of hospitalizations and emergency department visits for children with gaps (7402/10,000 person years) was significantly lower than the rate of study events for children with no gaps (9230/10,000 person years) (adjusted incidence rate ratio 0.88; 95% confidence interval 0.81-0.96). The rate of hospitalizations for asthma and other respiratory conditions was not different between the 2 groups; however, there was a significantly lower rate of hospitalizations for other reasons for children with gaps (adjusted incidence rate ratio 0.59; 95% confidence interval 0.41-0.86).

CONCLUSIONS

Children with asthma who had gaps in a Medicaid managed care insurance program had no increase in asthma related emergency department visits and hospitalizations. Children who had gaps did have fewer nonrespiratory emergency department visits and hospitalizations than their non-gap counterparts. Further study is needed to explore the reasons for this unexpected finding.

Disease burden in the managed care population at an academic medical center: the effect of adding local partners

PURPOSE

Academic medical centers (AMCs) have traditionally cared for the most severely ill patients. AMCs' effort to meet the challenges of managed care contracts may be nullified by adverse selection unless payment mechanisms adequately consider the health risk of the AMC's managed care population. The authors compared the disease burden between the University of Michigan Health System (UMHS) and its community competitors and assessed the effect of adding local primary care partners through strategic outsourcing on these differences in disease burden.

METHOD

This is a population-based study from one managed care plan in Michigan. The study population was commercial members (n = 127, 892) enrolled in the plan for the entire 12 months of 2001. The authors derived several morbidity measures from age and sex, Adjusted Clinical Groups, and Aggregated Diagnosis Groups using administrative data.

RESULTS

Compared to community groups, the UMHS consistently had a higher disease burden, while the nonacademic groups as a whole had more young members with acute conditions. After the UMHS partnered with two local primary care practice groups in their area, this AMC-local partner group had an equal or lower disease burden than the remainder of the community groups that experienced a slightly higher proportion of members with multiple medical conditions.

CONCLUSIONS

The higher disease burden borne by AMCs is a complex phenomenon. Without local partners, the UMHS did experience higher disease burden, although the degree depends on the measurement of morbidity. Partnering with carefully selected local primary care groups may ameliorate the AMC's disproportionate disease burden.

Delayed or forgone care among children with special health care needs: an analysis of the 2001 National Survey of Children with Special Health Care Needs

OBJECTIVE

To examine the associations of sociodemographic characteristics with both the prevalence and the causes of delayed or forgone care in a nationally representative sample of children with special health care needs.

METHODS

Data were abstracted from the 2001 National Survey of Children with Special Health Care Needs. The families of children with special health care needs (CSHCN) who reported delayed or forgone care were asked about the reasons. The 12 reasons in the questionnaire were grouped into 5 categories. Bivariate and multivariate logistic regression analyses were conducted in SUDAAN to examine the relationship between sociodemographic characteristics of CSHCN and the incidence of delayed or forgone care by its reasons.

RESULTS

Nearly 10% of CSHCN had experienced delayed or forgone health care in the past 12 months in 2001. Logistic regression showed that delayed or forgone care was more likely to be reported by the families of CSHCN who were adolescents, who had more severe limitations, lived in the South or West, lacked medical insurance, and who lived in families under or near the federal poverty line. Hispanics were more likely to report "lack of medical specialty" and "had language, communication, or cultural problems with provider." Both Hispanics and non-Hispanic others were twice as likely to report "provider not accessible" as reasons for the delayed or forgone care compared with non-Hispanic whites or blacks. conclusion: CSHCN with certain socioeconomic status and sociodemographic characteristics, as well as those with severe limitations in activity, were more likely to be affected by circumstances that result in delayed or forgone care.

Managed care organizational characteristics and health care use among children with special health care needs

OBJECTIVE

To examine the relationship between features of managed care organizations (MCOs) and health care use patterns by children.

DATA SOURCES

Telephone survey data from 2,223 parents of children with special health care needs, MCO-administrator interview data, and health care claims data.

STUDY DESIGN

Cross-sectional survey data from families about the number of consequences of their children's conditions and from MCO administrators about their plans' organizational features were used. Indices reflecting the MCO characteristics were developed using data reduction techniques. Hierarchical models were developed to examine the relationship between child sociodemographic and health characteristics and the MCO indices labeled: Pediatrician Focused (PF) Index, Specialist Focused (SF) Index, and Fee for Service (FFS) Index, and outpatient use rates and charges, inpatient admissions, emergency room (ER) visits, and specialty consultations.

DATA COLLECTION/EXTRACTION METHODS

The telephone and MCO-administrator survey data were linked to the enrollment and claims files.

PRINCIPAL FINDINGS

The child's age, gender, and condition consequences were consistent predictor variables related to health care use and charges. The PF Index was associated with decreased outpatient use rates and charges and decreased inpatient admissions. The SF Index was associated with increased ER visits and decreased specialty consultations, while the FFS Index was associated with increased outpatient use rates and charges.

CONCLUSION

After controlling for sociodemographic and health characteristics, the PF, SF, and FFS indices were significantly associated with children's health care use patterns.

Generalist-subspecialist communication about children with chronic conditions: an analysis of physician focus groups

OBJECTIVE

To describe barriers and facilitators to effective generalist-subspecialist communication in the care of children with chronic conditions.

METHODS

We conducted 5 focus groups with 14 general pediatricians and 10 pediatric specialty providers to discuss factors that facilitate or obstruct effective communication. The specialty groups included 2 nurse practitioners; the rest were pediatricians from an academic medical center and the surrounding community. We performed a content analysis to generate groups of themes and classify them as barriers or facilitators, and we returned to the participants to solicit their feedback.

RESULTS

We identified 201 themes in 6 domains: the method, content, and timing of communication; system factors; provider education; and interpersonal issues. Barriers to communication mostly involved the method of communication and system factors. Most facilitating themes promoted timely communication, understanding of the reasons for referral and the nature of the child's condition, or appropriate definition of generalist and specialist roles. Participants described numerous examples where communication had direct effects on patient outcomes. Generalists and specialists agreed on many issues, although specialists discussed the pros and cons of curbside consults at length whereas generalists emphasized the importance of their own education in the referral-consultation process.

CONCLUSIONS

Efforts to improve communication between pediatric generalists and specialists in the care of children with chronic conditions should emphasize the importance of timely information transfer. The content of messages is important, but lack of receipt when needed is more of a problem. Improving generalist-subspecialist communication has great potential to improve the quality of care.