Health Care for Children and Youth in the United States: 2002 Report on Trends in Access, Utilization, Quality, and Expenditures

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review

BACKGROUND

Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use.

METHODS

We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered.

RESULTS

Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies.

CONCLUSIONS

Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Correlation of mesolevel characteristics of the healthcare system and socioeconomic inequality in healthcare use: a scoping review protocol

INTRODUCTION

Although the impact of macrolevel characteristics of health systems on socioeconomic inequity in health has been studied extensively, the impact of access characteristics on a smaller scale of health systems has received less attention. These mesolevel characteristics can influence access to healthcare and might have the potential to moderate or aggravate socioeconomic inequity in healthcare use. This scoping review aims to map the existing evidence of the association of socioeconomic inequity in healthcare use and mesolevel access characteristics of the health system.

METHODS AND ANALYSIS

In conducting the scoping review, we follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols Extension for Scoping Reviews. The search will be carried out in four scientific databases: MEDLINE (via PubMed), Web of Science, Scopus and PsycINFO. Main eligibility criteria are inclusion in the analysis of a measure of socioeconomic position, a measure of individual healthcare use and a mesolevel determinant of access to healthcare services. The selection process consists of two consecutive screening stages (first: title/abstract; second: full text). At both stages, two reviewers independently assess the eligibility of studies. In case of disagreement, a third reviewer will be involved. Cohen's kappa will be calculated to report inter-rater agreement between reviewers. Results are synthesised narratively, as a high heterogeneity of studies is expected.

ETHICS AND DISSEMINATION

No primary data are collected for the presented scoping review. Therefore, ethical approval is not necessary. The scoping review will be published in an international peer-reviewed journal, and findings will be presented on national and international conferences.

Annual Report on Children's Healthcare: Healthcare Access and Utilization by Obesity Status in the United States

OBJECTIVE

To examine access to care and utilization patterns across a set of healthcare measures by obesity status and socio-demographic characteristics among children.

METHODS

Nationally representative data from the Medical Expenditure Panel Survey (2010-2015) provides data on obesity status, well-child visits, access to a usual source of care provider, preventive dental visits, and prescription medication fills in the past year.

RESULTS

Uninsured adolescents with obesity were less likely to have a usual source of care provider relative to children without obesity (73% vs 65%). Among younger children, children with obesity were less likely to report a well-child visit (difference of 8 percentage points). Younger children with obesity who lived in the Northeast were more than twice as likely as those living in the West to have a well-child visit. Children with obesity were less likely to report preventive dental use relative to their nonobese counterparts. Obesity status was associated with more prescription medication fills for adolescents, but not for younger children.

CONCLUSIONS

Our findings provide a baseline assessment for examining obesity and utilization trends among children in the future, especially as coverage patterns change with potential changes in childhood insurance coverage access through the Child Health Insurance Programs and Medicaid programs. Our findings highlight new directions for future research, particularly regarding the lower rates of preventive dental care among children with obesity.

Annual Report on Health Care for Children and Youth in the United States: Focus on 30-Day Unplanned Inpatient Readmissions, 2009 to 2014

OBJECTIVE

To describe trends in unplanned 30-day all-condition hospital readmissions for children aged 1 to 17 years between 2009 and 2014.

METHODS

Analysis was conducted with the 2009-14 Nationwide Readmissions Database from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. Annual hospital readmission rates, resource use, and the most common reasons for readmission were calculated for the 2009-14 period.

RESULTS

The rate of readmission for children aged 1 to 17 years was essentially stable between 2009 and 2014 (5.5% in 2009 and 5.9% in 2014). In 2009, the most common reason (principal diagnosis) for readmission was sickle cell anemia, whereas in 2014 the most common reason was epilepsy. Pneumonia fell from the second to the sixth most common reason for readmission over this period (from 3832 to 2418 stays). Other respiratory infections were among the top 10 principal readmission diagnoses in 2009, but not in 2014. Septicemia was among the 10 most common reasons for readmission in 2014, but not in 2009. Although the average cost of index (ie, initial) stays with a subsequent readmission were similar in 2009 and 2014, the average cost of index stays without a readmission and cost of readmission stays increased by approximately 23%. In both 2009 and 2014, the average cost of the index stays with a subsequent readmission was 73% to 89% higher than that of the index stays of children who were not readmitted within 30 days. The average cost of index stays preceding a readmission was 33% to 45% higher than average costs for readmitted stays. In 2014, the aggregate cost of index stays plus readmissions was $1.58 billion, with 42.9% of the costs attributable to readmissions. Regarding the average costs and lengths of stay for the 10 most common readmission diagnoses, in 2009 the average cost per stay for complications of devices, implants, or grafts was nearly 5 times greater than that of asthma ($21,200 vs $4500, respectively). In 2014, average cost per stay ranged from $5500 for asthma to $39,500 for septicemia. In 2009, the average length of stay (LOS) for complications of devices, implants, or grafts was more than 3 three times higher than that for asthma (7.8 days vs 2.5 days, respectively), and in 2014, the average LOS for septicemia was nearly 4 times higher than that for asthma (10.4 days vs. 2.6 days).

CONCLUSIONS

This study provides a baseline assessment for examining trends in 30-day unplanned pediatric readmissions, an important quality metric as the provisions of the Children's Health Insurance Program Reauthorization Act and the Affordable Care Act are changed and implemented in the future. More than 50,000 pediatric hospital stays in 2014 occurred within 30 days of a previous hospitalization, with an average cost of $13,800. This report is timely, as the health care system works to become more patient-centered and public and private payers grapple with how to pay for quality care for children. The report provides baseline information that can be used to further explore ways to reduce unplanned readmissions.

Spending on Children's Personal Health Care in the United States, 1996-2013

IMPORTANCE

Health care spending on children in the United States continues to rise, yet little is known about how this spending varies by condition, age and sex group, and type of care, nor how these patterns have changed over time.

OBJECTIVE

To provide health care spending estimates for children and adolescents 19 years and younger in the United States from 1996 through 2013, disaggregated by condition, age and sex group, and type of care.

EVIDENCE REVIEW

Health care spending estimates were extracted from the Institute for Health Metrics and Evaluation Disease Expenditure 2013 project database. This project, based on 183 sources of data and 2.9 billion patient records, disaggregated health care spending in the United States by condition, age and sex group, and type of care. Annual estimates were produced for each year from 1996 through 2013. Estimates were adjusted for the presence of comorbidities and are reported using inflation-adjusted 2015 US dollars.

FINDINGS

From 1996 to 2013, health care spending on children increased from $149.6 (uncertainty interval [UI], 144.1-155.5) billion to $233.5 (UI, 226.9-239.8) billion. In 2013, the largest health condition leading to health care spending for children was well-newborn care in the inpatient setting. Attention-deficit/hyperactivity disorder and well-dental care (including dental check-ups and orthodontia) were the second and third largest conditions, respectively. Spending per child was greatest for infants younger than 1 year, at $11 741 (UI, 10 799-12 765) in 2013. Across time, health care spending per child increased from $1915 (UI, 1845-1991) in 1996 to $2777 (UI, 2698-2851) in 2013. The greatest areas of growth in spending in absolute terms were ambulatory care among all types of care and inpatient well-newborn care, attention-deficit/hyperactivity disorder, and asthma among all conditions.

CONCLUSIONS AND RELEVANCE

These findings provide health policy makers and health care professionals with evidence to help guide future spending. Some conditions, such as attention-deficit/hyperactivity disorder and inpatient well-newborn care, had larger health care spending growth rates than other conditions.

Annual Report on Children's Health Care: Dental and Orthodontic Utilization and Expenditures for Children, 2010-2012

OBJECTIVE

To examine general dental and orthodontic utilization and expenditures by health insurance status, public health insurance eligibility, and sociodemographic characteristics among children aged 0 to 17 years using data from 2010-2012.

METHODS

Nationally representative data from the Medical Expenditure Panel Survey (2010-2012) provided data on insurance status, public health insurance eligibility, and visits to dental providers for both general dental care and orthodontic care.

RESULTS

Overall, 41.9% of US children reported an annual dental office-based visit for general (nonorthodontic) dental care. Fewer Hispanic (34.7%) and non-Latino black children (34.8%) received dental care compared to non-Hispanic whites (47.3%) and Asians (40.3%). Children living in families with the lowest income were also the least likely to have a visit (32.9%) compared to children in the highest-income families (54.7%). Among children eligible for public coverage, Medicaid-eligible children had the lowest percentage of preventive dental visits (29.2%). Socioeconomic and racial/ethnic disparities in use and expenditures for orthodontic care are much greater than those for general and preventive dental care. Average expenditures for orthodontic care were $1,823, of which 56% ($1,023) was paid out of pocket by families.

CONCLUSIONS

Our findings provide a baseline assessment for examining trends in the future, especially as coverage patterns for children may change as the Affordable Care Act is implemented and the future of the State Child Health Insurance Program remains uncertain beyond 2017.

Annual report on health care for children and youth in the United States: national estimates of cost, utilization and expenditures for children with mental health conditions

OBJECTIVE

To examine national trends in hospital utilization, costs, and expenditures for children with mental health conditions.

METHODS

The analyses of children aged 1 to 17 are based on AHRQ's 2006 and 2011 Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) and Nationwide Emergency Department Sample (NEDS) databases, and on AHRQ's pooled 2006 to 2011 Medical Expenditure Panel Survey (MEPS). All estimates are nationally representative, and standard errors account for the complex survey designs.

RESULTS

Although overall all-cause children's hospitalizations did not increase between 2006 and 2011, hospitalizations for all listed mental health conditions increased by nearly 50% among children aged 10 to 14 years, and by 21% for emergency department (ED) visits. Behavioral disorders experienced a shift in underlying patterns between 2006 and 2011: inpatient stays for alcohol-related disorders declined by 44%, but ED visits increased by 34% for substance-related disorders and by 71% for impulse control disorders. Inpatient visits for suicide, suicidal ideation, and self-injury increased by 104% for children ages 1 to 17 years, and by 151% for children ages 10 to 14 years during this period. A total of $11.6 billion was spent on hospital visits for mental health during this period. Medicaid covered half of the inpatient visits, but with 50% to 30% longer length of stays in 2006 and 2011, respectively, than private payers. Medicaid's overall share of the ED visits increased from 45% in 2006 to 53% in 2011.

CONCLUSIONS

These alarming trends highlight the renewed need for research on mental health care for children. This study also provides a baseline for evaluating the impact of the Affordable Care Act and the mental health parity legislation on mental health utilization and expenditures for children.

Experiences from a community based substance use treatment centre in an urban resettlement colony in India

Background. There are limited community based treatment services for drug dependence in India. Rural areas and urban resettlement colonies are in particular deficient in such services. Aims. The current study aimed at preliminary assessment of substance use disorder management services at a community based substance use treatment clinic in an urban resettlement colony. Methods. The study was carried out at community based substance use treatment centre in a resettlement colony in India. The records of the centre were chart reviewed. Results. A total of 754 patients were registered at the clinic during the study period. Heroin was the primary drug of abuse for 63% of the patients. The mean duration of follow-up for the patients with opioid and alcohol dependence was 13.47 (SD ± 10.37; range 0–39) months. A total of 220 patients of opioid dependence were prescribed substation or abstinence directed therapy. Buprenorphine (87), slow release oral morphine (SROM) (16), and dextropropoxyphene (98) were used for opioid substitution. Conclusion. It is possible to deliver substance use disorder treatment services in community setting. There is a need to develop area specific community based treatment services for substance abuse in socially disadvantaged populations such as urban resettlement colonies.

Annual report on health care for children and youth in the United States: trends in racial/ethnic, income, and insurance disparities over time, 2002-2009

OBJECTIVE

To examine trends in children's health access, utilization, and expenditures over time (2002-2009) by race/ethnicity, income, and insurance status/expected payer.

METHODS

Data include a nationally representative random sample of children in the United States in 2002-2009 from the Medical Expenditure Panel Survey (MEPS) and a nationwide sample of pediatric hospitalizations in 2005 and 2009 from the Healthcare Cost and Utilization Project (HCUP).

RESULTS

The percentage of children with private insurance coverage declined from 65.3% in 2002 to 60.6% in 2009. At the same time, the percentage of publicly insured children increased from 27.0% in 2002 to 33.1% in 2009. Fewer children reported being uninsured in 2009 (6.3%) compared to 2002 (7.7%). The most significant progress was for Hispanic children, for whom the percentage of uninsured dropped from 15.0% in 2002 to 10.3% in 2009. The uninsured were consistently the least likely to have access to a usual source of care, and this disparity remained unchanged in 2009. Non-Hispanic whites were most likely to report a usual source of care in both 2002 and 2009. The percentage of children with a doctor visit improved for whites and Hispanics (2009 vs 2002). In contrast, black children saw no improvement during this time period. Between 2002 and 2009, children's average total health care expenditures increased from $1294 to $1914. Average total expenditures nearly doubled between 2002 and 2009 for white children with private health insurance. Among infants, hospitalizations for pneumonia decreased in absolute number (41,000 to 34,000) and as a share of discharges (0.8% to 0.7%). Fluid and electrolyte disorders also decreased over time. Influenza appeared only in 2009 in the list of top 15 diagnoses with 11,000 hospitalization cases. For children aged 1 to 17, asthma hospitalization increased in absolute number (from 119,000 to 134,000) and share of discharges (6.6% to 7.6%). Skin infections appeared in the top 15 categories in 2009, with 57,000 cases (3.3% of total).

CONCLUSIONS

Despite significant improvement in insurance coverage, disparities by race/ethnicity and income persist in access to and use of care. Hispanic children experienced progress in a number of measures, while black children did not. Because racial/ethnic and socioeconomic disparities are often reported as single cross-sectional studies, our approach is innovative and improves on prior studies by examining population trends during the time period 2002-2009. Our study sheds light on children's disparities during the most recent economic crisis.

Annual report on health care for children and youth in the United States: focus on trends in hospital use and quality

OBJECTIVE

The aim of this study was to describe selected trends in hospital inpatient care for children between 2000 and 2007.

STUDY DESIGN

Analysis was conducted of administrative data from annual nationwide databases of hospital discharges from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project, along with survey data from a nationally representative random sample of children from the Medical Expenditure Panel Survey. Hospital utilization rates and expenses, risk-adjusted rates of potentially avoidable hospitalization, and safety indicators in the hospital are calculated and tracked with established and downloadable software.

RESULTS

The rate of hospital discharges for children aged 15 to 17 years declined significantly, mainly due to fewer maternity-related discharges. The leading principal conditions by age group were similar to the report for 1995 to 2000; however, the rate of admissions for skin infections doubled to 9 per 10,000. Hospital cost per discharge increased by an annual average of 4.5% per year compared with 2.6% annual growth in the gross domestic product deflator. Medicaid is increasingly important relative to private insurance as a payer for hospital care for children. The rate of potentially preventable hospitalizations for both acute and chronic conditions declined substantially (18%, adjusted for age and gender). Several measures of patient safety improved--the rates of postoperative sepsis, iatrogenic pneumothorax, and selected infections due to medical care declined by 14.2%, 17.8%, and 23.5%, respectively. However, the rate of accidental punctures and lacerations and the rate of decubitus ulcer increased by 25.6% and 34.5%, respectively. The trends in safety indicators varied somewhat by age group, income quartile of zip codes, insurance, region, and type of location without a consistent pattern.

CONCLUSIONS/IMPLICATIONS

Although teenage pregnancy rates were declining, there was a worsening trend in skin infections. The latter may eventually be impacted by recent publication of new guidelines for treatment by office-based physicians. A gradually increasing role of Medicaid as a payer for hospital care for children will likely put an increasing strain on public resources in advance of the full implementation of the health insurance reforms recently enacted. The decline in potentially avoidable admissions reduces the use of the most expensive resources. For asthma and diabetes, children in the lowest income zip codes had persistently higher rates of admission, but the rate fell by one third during the period. Children in the South and West regions had substantial and significant declines in preventable admissions. Particular indicators of safety were improving, whereas others were worsening. Trends were not the same in all types of hospitals, all regions, and income categories. This is already a rich area for further research on the impact of quality improvement strategies; however, attention is needed to developing more tools to more thoroughly track quality of care for children.

Annual report on health care for children and youth in the United States: racial/ethnic and socioeconomic disparities in children's health care quality

OBJECTIVE

The aim of this study was to explore the joint effect of race/ethnicity and insurance status/expected payer or income on children's health care quality.

METHODS

The analyses are based on data from a nationally representative random sample of children in the United States in 2004 and 2005 from the Medical Expenditure Panel Survey (MEPS) and pediatric hospitalizations from a nationwide sample of hospitals in 2005 from the State Inpatient Databases disparities analysis file from the Healthcare Cost and Utilization Project (HCUP). We provide estimates of differences in race/ethnicity within income and insurance/expected payer categories on key pediatric quality indicators to provide a more nuanced understanding of disparities in care for children. Our indicators of quality cover several domains from the Institute of Medicine report, including effectiveness, patient centeredness, timeliness, and patient safety.

RESULTS

Across a broad set of 23 quality indicators, findings indicate that racial/ethnic disparities vary by income levels and types of insurance. Key highlights include the finding that racial/ethnic differences within income or insurance/payer groups are more pronounced for some racial/ethnic groups than others. Hispanic children followed by Asian children had worse quality than whites as measured by the majority of quality indicators. Exceptions included rates of admissions for diabetes, admissions for gastroenteritis, accidental puncture during procedures, and decubitus ulcers. Many indicators showed less than ideal quality for all subgroups of children, even whites with private insurance.

CONCLUSIONS

The extensive findings in this report make clear that patterns of racial/ethnic disparity vary by income and insurance/expected payer subgroup. However, disparities in quality are not similar across all measures of quality, and strategies to address these disparities need to be designed with these nuances in mind.

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.

Annual report on health care for children and youth in the United States: focus on injury-related emergency department utilization and expenditures

OBJECTIVE

To examine state differences in children's utilization of injury-related emergency department (ED) care across 14 states, benchmarking aggregate state estimates against national expenditure estimates for outpatient injury-related ED care.

METHODS

A retrospective analysis was performed using the 2003 State Emergency Department Databases and State Inpatient Databases from the Healthcare Cost and Utilization Project and data from the Medical Expenditure Panel Survey. Pediatric ED visits with any injury International Classification of Diseases Ninth Version Clinical Modification (ICD-9-CM) diagnosis code were selected. The Barell Injury Diagnosis Matrix, ICDMAP-90 software, and the Trauma Information Exchange Program data were used to classify injuries, produce injury severity scores, and examine utilization in trauma centers. Aggregate and state-specific descriptive analyses compared differences in patient and injury characteristics and admission status by age, severity of injury, and expected payer.

RESULTS

Over 1.5 million or nearly one-third of ED visits were for pediatric injuries in the 14 states studied. Nationally, 5.4% of children had an injury-related ED visit, and approximately $2.3 billion was spent on outpatient injury-related ED visits in 2003. The pattern of injury-related ED visit care varied considerably by state. For example, injury-related ED visit rates ranged from 63.3 to 164.4 per 1000 children. Infants, adolescents, children from very low income communities, and children from nonmetropolitan and nonmicropolitan areas were more likely to have an injury-related ED visit than their peers. Although patient characteristics were fairly consistent across states, admission rates and expected source of payment for injury-related ED visits varied considerably by state. Hospital admission rates ranged from 1.5% to 4.4% of injury-related ED visits and expected payer estimates ranged from 37.1% to 71.0% of visits billed to private insurance, 17.9% to 47.0% billed to Medicaid, and 2.1% to 10.4% billed as uninsured.

CONCLUSIONS

This study suggests that injuries account for a significant portion of pediatric ED visits. There is substantial variation in ED use and hospital admissions for injured children across states and payers. This variation suggests that there are several opportunities for improvement in emergency care for children. To better understand the underlying reason for the variation, multivariate and hypothesis-driven research should focus on the nature and outcomes of injury-related ED care in the context of small area practice patterns and state programs, policies, and care system characteristics.

Improving underserved children's access to health care: practitioners' views

This article describes the results of three focus groups conducted with a variety of children's health care providers in a county in the southeastern United States. The purpose of the research was to investigate practitioners' views on the barriers impeding access to health care for medically underserved children. The focus groups were the third phase of a larger study designed to collect data on communication patterns among children's health care providers as well as information on children's access to care. The results include suggestions for actions practitioners can take to improve medically underserved children's access to health care.

Short-term persistence of high health care costs in a nationally representative sample of children

OBJECTIVES

Little is known about the persistence of health care costs in children. Determining whether children with high health expenses continue to have high expenses over time can help in the development of targeted programs and policies to decrease costs, plan equitable health insurance strategies, and provide insights into the effects of costly conditions on families. The objectives of this study were to (1) identify the characteristics of children who are in the top 10th percentile for health costs, (2) investigate whether those in the top percentiles for costs in 1 year continue in the same percentiles the next year, and (3) identify factors that predict whether a child stays in the top percentiles.

METHODS

Data from 2 consecutive years (2000-2001) of the Medical Expenditure Panel Survey were analyzed. Changes in a child's position in the expenditure distribution were examined. An estimated multivariate model conditional on insurance was developed to predict the true resource costs of providing services. Statistical analyses, including logistic-regression and multivariate linear-regression modeling, were done to account for the weighted sampling used in Medical Expenditure Panel Survey.

RESULTS

A total of 2938 children were included in the survey for both years. In 2000, the top 10% of the children accounted for 54% of all costs. They had a mean total expenditure of 6422 dollars with out-of-pocket expenditures of 1236 dollars; 49% of the children in the top decile in 2000 persisted in the top decile in 2001, whereas 12% dropped into the bottom half. Children who had been in the top 10% in 2000 were 10 times more likely than other children to be in the top 10% for 2001. Other characteristics in 2000 that predicted membership in the top decile for 2001 included age (11-15 and 16-17 years), having any insurance (public and private), being positive on the standardized Children With Special Health care Need screener, and having a functional limitation.

CONCLUSIONS

Almost half of the children in the top 10% for costs in 2000 persisted in the top 10% in 2001. Older children, children with special health care needs, and children with functional limitations were more likely to be in the top decile. These findings do not support the belief that black and Latino children who are on Medicaid account for a disproportionate share of costs or expenditures. Because the children who were among the top 10% used health care services in a variety of inpatient, emergency department, outpatient, and ancillary venues, providing care coordination throughout the entire health care system is important to address both the cost and the quality aspects of health care for the most costly children. Targeted programs to decrease expenditures for those with the greatest costs have the potential to save future health care dollars. Assessment of the factors that predict persistence of high expenditures can be used to help in the planning of equitable health insurance strategies such as catastrophic care, carve-outs, reinsurance, and risk adjustment. Clinicians should review regularly the extent of care coordination that they are providing for their high-need and high-cost patients, especially preteens and adolescents. Studies that examine the persistence of expenditures over longer periods and include assessment of quality of care are needed.

Epidemiology of a pediatric emergency medicine research network: the PECARN Core Data Project

OBJECTIVE

To examine the epidemiology of pediatric patient visits to emergency departments (ED).

METHODS

We conducted a cross-sectional study of pediatric ED visits at the participating Pediatric Emergency Care Applied Research Network (PECARN) hospitals in 2002. We provide descriptive characteristics of pediatric ED visits and a comparison of the study database to the National Hospital Ambulatory Medical Care Survey (NHAMCS). Bivariate analyses were calculated to assess characteristics associated with hospital admission, death in the ED, and length of ED visit. We also performed multivariate regression to model the likelihood of admission to the hospital.

RESULTS

Mean patient age was 6.2 years; 53.5% were boys; 47.5% black; and 43.2% had Medicaid insurance. The most common ED diagnoses were fever, upper respiratory infection, asthma, otitis media, and viral syndromes. The inpatient admission rate was 11.6%. The most common diagnoses requiring hospitalization were asthma, dehydration, fever, bronchiolitis, and pneumonia. In multivariate analysis, patients who were black or Hispanic, had Medicaid insurance or were uninsured, or were older than 1 year were less likely to be hospitalized. Demographics of the PECARN population were similar to NHAMCS, with notable exceptions of a larger proportion of black patients and of admitted patients from the PECARN EDs.

CONCLUSION

We describe previously unavailable epidemiological information about childhood illnesses and injuries that can inform development of future studies on the effectiveness, outcomes, and quality of emergency medical services for children. Most pediatric ED patients in our study sought care for infectious causes or asthma and were discharged from the ED. Hospital admission rate differed according to age, payer type, race/ethnicity, and diagnosis.

Health Care for Children and Youth in the United States: Annual Report on Patterns of Coverage, Utilization, Quality, and Expenditures by a County Level of Urban Influence

OBJECTIVE

To examine child and hospital demographics and children's health care coverage, use, expenditures, and quality by a county-level measure of urban influence.

METHODS

Two national health care databases serve as the sources of data for this report: the 2002 Medical Expenditure Panel Survey (MEPS) and the 2002 Nationwide Inpatient Sample (NIS) and State Inpatient Databases (SID) from the Healthcare Cost and Utilization Project (HCUP). In both data sets, county urbanicity is defined by use of a collapsed version of the 2003 Urban Influence Codes, to distinguish among children residing in and hospitals located in large metropolitan (metro) counties, small metro counties, micropolitan counties, and noncore counties.

RESULTS

Demographics. In large metro counties, greater percentages of the child population are Hispanic or black non-Hispanic than in small metro, micropolitan, and noncore counties; in micropolitan and noncore counties, higher proportions of children are below 200% of the federal poverty level than in large metro and small metro counties. Noncore areas have a greater percentage of children in fair or poor health compared with those in small metro and micropolitan counties. Most hospitals are located in large and small metro areas, and large metro areas have a higher proportion of teaching hospitals compared with other areas. Health care. In general, there were no overall differences by place of residence in the proportion of children with and without insurance, although differences emerged in subpopulations within Urban Influence Code types. Hispanic children residing in large metro counties were more likely to be uninsured than those in small metro counties. Overall, the proportion of children with at least one dental visit was larger in small metro areas compared with both large metro and noncore areas. The proportion of children with medicines prescribed was generally lower in large metro areas compared with all other areas both overall and among subpopulations of children. Children in noncore areas were more likely to have a hospital inpatient stay and any emergency department use compared with children in large metro areas. Children in large metro counties had longer average inpatient stays and a higher hospital inpatient charge per day compared with children in all other counties. Although most hospitalizations for children from large metro areas occurred in large metro areas, over half of hospitalizations for noncore children occurred outside of noncore counties. Further, children from noncore counties appear to be hospitalized for ambulatory sensitive conditions more than children from all other areas.

CONCLUSIONS

County-level data analyses performed using a collapsed version of the Urban Influence Codes with MEPS and HCUP data shed additional light on the health care patterns for children that were not previously evident when only the dichotomous metropolitan/nonmetropolitan geographic schema was used.

Guiding mothers' management of health problems of very low birth-weight infants

OBJECTIVE

Explore the feasibility, usefulness, and outcomes of a pilot program to support mothers in developing competencies for managing health problems of their very low birth-weight (VLBW) infants in partnership with the primary care clinician (PCC).

DESIGN

In a randomized study, mothers who received guided participation (GP) and printed guidelines for managing VLBW infant health problems were compared with mothers who received only the guidelines and standard care (GL group).

SAMPLE

All mothers (GP = 20; GL = 11) were at least 18 years old and English speaking. Infants were all VLBW (< or =1,500 g).

INTERVENTION

GP began during the infant's neonatal intensive care unit stay and continued with public health nurses (PHNs) and a family service clinician through the infant's first 4 postterm months.

MEASUREMENTS

Intervention feasibility and usefulness were assessed with maternal and clinician feedback. Outcomes included maternal and clinician appraisal of mothers' use of clinical resources and mothers' perceptions of primary-care quality and the family-PCC relationship.

RESULTS

Intervention feasibility and usefulness were supported. GP and GL groups did not differ significantly on outcomes.

CONCLUSIONS

Findings indicate a longer intervention period, GP organized by infant problem episodes, and enhancement of the PHN role in the context of interdisciplinary and interagency collaboration.

Dimensions of the local health care environment and use of care by uninsured children in rural and urban areas

OBJECTIVE

Despite concerted policy efforts, a sizeable percentage of children lack health insurance coverage. This article examines the impact of the health care safety net and health care market structure on the use of health care by uninsured children.

METHODS

We used the Medical Expenditure Panel Survey linked with data from multiple sources to analyze health care utilization among uninsured children. We ran analyses separately for children who lived in rural and urban areas and assessed the effects on utilization of the availability of safety net providers, safety net funding, supply of primary care physicians, health maintenance organization penetration, and the percentage of people who are uninsured, controlling for other factors that influence use.

RESULTS

Fewer than half of uninsured children had office-based visits to health care providers during the year, 8% of rural and 10% of urban children visited the emergency department at least once, and just over half of children had medical expenditures or charges during the year. Among uninsured children in rural areas, living closer to a safety net provider and living in an area with a higher supply of primary care physicians were positively associated with higher use and medical expenditures. In urban areas, the supply of primary care physicians and the level of safety net funding were positively associated with uninsured children's medical expenditures, whereas the percentage of the population that was uninsured was negatively associated with use of the emergency department.

CONCLUSIONS

Uninsured children had low levels of utilization over a range of different health care provider types and settings. The availability of safety net providers in the local area and the safety net's capacity to serve the uninsured influence access to care among children. Possible measures for ensuring access to health care among uninsured children include increasing the density of safety net providers in rural areas, enhancing funding for the safety net, and policies to increase primary care physician supply.

Are rates of functional limitations associated with access to care? A state-level analysis of the national survey of children with special health care needs

OBJECTIVES

Health-related services and compensatory mechanisms have a potential role in minimizing functional limitations and increasing quality of life among children with special health care needs (CSHCN). We examined whether rates of functional limitations among CSHCN in the 50 states and District of Columbia were associated with state-level characteristics that reflect access to such services among CSHCN.

METHODS

We aggregated child-level survey data from the National Survey of CSHCN to create 51 state-level estimates of the proportions who had functional limitations, had >/=1 unmet health needs, and lacked medical insurance coverage. State-level information about Medicaid spending per child enrollee in federal fiscal year 2000 was obtained from The Henry J. Kaiser Family Foundation website. We examined correlations between the percentages of CSHCN having functional limitations and each of the other state-level variables, and conducted multiple regression analyses that examined these associations while controlling for the statewide percentages of children living in poverty.

RESULTS

The proportions of CSHCN with functional limitations were higher in states with higher rates of uninsured CSHCN (r = .49; p < .0001) and higher rates of CSHCN with unmet health needs (r = .62; p < .0001). Proportions of CSHCN with functional limitations were unrelated to per child Medicaid spending. These findings were robust when we controlled for percentages of children in poverty across states.

CONCLUSIONS

Fewer unmet needs for health-related services are associated with lower statewide rates of functional limitations in CSHCN. As health care costs increase and state revenues decrease, CSHCN are at increasing risk of losing access to required services. Were this to happen we might expect an increase in the proportion of CSHCN who experience significant functional limitations. Thus, a key challenge is to provide CSHCN access to the amount and quality of health-related care they require to achieve their potential.

Open access in primary care: results of a North Carolina pilot project

OBJECTIVE

Appointment delays impede access to primary health care. By reducing appointment delays, open access (OA) scheduling may improve access to and the quality of primary health care. The objective of this pilot study was to assess the potential impact of OA on practice and patient outcomes by using pilot-study data from 4 North Carolina primary care practices.

METHODS

We conducted an interrupted time-series pilot study of 4 North Carolina primary care practices (2 family medicine and 2 pediatric practices) participating in a quality-improvement (QI) collaborative from May 2001 to May 2002. The year-long collaborative comprised 25 practices and consisted of three 2-day meetings led by expert faculty, monthly data feedback, and monthly conference calls. Our main outcome measures were appointment delays, appointment no-shows, patient satisfaction, continuity of care, and staff satisfaction during the 12-month study period.

RESULTS

Providers in all 4 practices successfully implemented OA. On average, providers reduced their delay to the third available preventive care appointment from 36 to 4 days. No-show rates declined (first quarter [Q1] rate: 16%; fourth quarter [Q4] rate: 11%; no-show reduction: 5% [95% confidence interval: 1%, 10%]), and overall patient satisfaction improved (Q1: 45% rated overall visit quality as excellent; Q4: 61% rated overall visit quality as excellent; change in satisfaction: 16% [95% confidence interval: 0.2%, 30%]). Continuity of care followed a similar pattern of improvement, but the change was not statistically significant. Staff satisfaction neither improved nor declined.

CONCLUSIONS

This pilot study suggests that primary care practices can implement OA successfully by using QI-collaborative methods. These results provide preliminary evidence that OA may improve practice and patient outcomes in primary care. These analyses should be repeated in larger groups of practices with longer follow-up.

Children's Health Care in the First National Healthcare Quality Report and National Healthcare Disparities Report

BACKGROUND

The first National Healthcare Quality Report (NHQR) and National Healthcare Disparities Report (NHDR) are landmark events for children's health care quality and are expected to stimulate local measurement, benchmarking, and quality improvement efforts.

METHOD

The authors select findings from the NHQR and NHDR, focusing on topics reflecting a range of health care and health care settings affecting children. They highlight disparities by race/ethnicity, socioeconomic status, and insurance source. They critique the first NHQR and NHDR from a child health perspective. SELECT NHQR/DR FINDINGS: Quality-of-care issues in the effectiveness domain were identified for black infant mortality, low and very low birth weight rates, antibiotic use for the common cold, and childhood hospitalizations for asthma. Immunization rates have improved. Patient centeredness and timeliness results vary by race, ethnicity and income. The NHDR found that Hispanic and low-income children are most likely to be uninsured for part of the year. Groups of children most likely to have public coverage are American Indian/Alaska native, black, and Hispanic. CRITIQUE OF REPORTS: The structure and criteria used for the first reports limit their usefulness from a child health perspective. A basic problem is that the conceptualizations of health and health care that are driving national initiatives on quality are based largely on an adult chronic care model focused on conditions with high expenditures as treated in the mainstream health care delivery system.

CONCLUSION

NHQR and NHDR provide essential information on children's health care quality. Future reports can be improved by including child-relevant perspectives in priority-setting and data-gathering efforts.

Health Care for Children and Youth in the United States: Annual Report on Patterns of Coverage, Utilization, Quality, and Expenditures by Income

OBJECTIVES

To examine differences by income in insurance coverage, health care utilization, expenditures, and quality of care for children in the United States.

METHODS

Two national health care databases serve as the sources of data for this report: the 2000-2002 Medical Expenditure Panel Survey (MEPS) and the 2001 Nationwide Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). In the MEPS analyses, low income is defined as less than 200% of the federal poverty level and higher income is defined as 200% of the federal poverty level or more. For the HCUP analyses, median household income for the patient's zip code of residence is used to assign community-level income to individual hospitalizations.

RESULTS

Coverage. Children from low-income families were more likely than children from middle-high-income families to be uninsured (13.0% vs 5.8%) or covered by public insurance (50.8% vs 7.3%), and less likely to be privately insured (36.2% vs 87.0%). Utilization. Children from low-income families were less likely to have had a medical office visit or a dental visit than children from middle-high-income families (63.7% vs 76.5% for office-based visits and 28.8% vs 51.4% for dental visits) and less likely to have medicines prescribed (45.1% vs 56.4%) or have utilized hospital outpatient services (5.2% vs 7.0%), but more likely to have made trips to the emergency department (14.6% vs 11.4%). Although low-income children comprise almost 40% of the child population, one quarter of total medical expenditures were for these children. Hospital Discharges. Significant differences by community-level income occurred in specific characteristics of hospitalizations, including admissions through the emergency department, expected payer, mean total charges per day, and reasons for hospital admission. Leading reasons for admission varied by income within and across age groups. Quality. Low-income children were more likely than middle-high-income children to have their parents report a big problem getting necessary care (2.4% vs 1.0%) and getting a referral to a specialist (11.5% vs 5.3%). Low-income children were at least twice as likely as middle-high-income children to have their parents report that health providers never/sometimes listened carefully to them (10.0% vs 5.1%), explained things clearly to the parents (9.6% vs 3.4%), and showed respect for what the parents had to say (9.2% vs 4.2%). Children from families with lower community-level incomes were more likely to experience ambulatory-sensitive hospitalizations. Racial/Ethnic Differences Between Income Groups. Use and expenditure patterns for most services were not significantly different between low- and middle-high-income black children and were lower than those for white children.

CONCLUSIONS

While health insurance coverage is still an important factor in obtaining health care, the data suggest that efforts beyond coverage may be needed to improve access and quality for low-income children overall and for children who are racial and ethnic minorities, regardless of income.

Access and quality in child health services: voltage drops

Children require a health care system that promotes healthy development for all children while reaching out to the neediest. Barriers to care have been described as "voltage drops"-resistance points at which patients drop from the system like voltage from an electrical current. We examine the size and nature of these drops, ranging from insurance access to service quality, with respect to children. We find critical policy needs (such as expanded insurance opportunities, increased care coordination, and improved quality measurement) at all system levels. Comprehensive access to insurance and services does not guarantee that children will receive high-quality (safe and effective) care.

Private Dental and Prescription-Drug Coverage in Children: Data From the Medical Expenditure Panel Survey

OBJECTIVE

Most studies on health insurance have examined primarily basic medical insurance coverage; few have looked at supplemental insurance and/or dental-insurance coverage. Prescription-drug and dental-insurance coverage are becoming increasingly important due to continued increase in health care costs and changes in cost-sharing structure of health plans. This study examined prescription-drug coverage and dental-insurance coverage in the context of overall insurance coverage.

METHOD

This study utilized the Household Component File from the 2000 Medical Expenditure Panel Survey (MEPS), a national survey on medical care conducted by the Agency for Healthcare Research and Quality (AHRQ). Univariate and bivariate analyses were performed to provide estimates on children's prescription-drug and dental-insurance coverage. Multivariate logistic regression analyses were conducted to identify demographic and socioeconomic factors that influence coverage.

RESULTS

In 2000, 68.5% of US children had private insurance, 22.2% had public insurance, and 9.3% were uninsured. Among children with private insurance, only 56.9% had dental-insurance coverage and 76.3% had prescription-drug coverage. Family income level, maternal education, and race were significant predictors of dental insurance and prescription-drug coverage.

CONCLUSION

Although significant strides have been made to insure US children, a large percentage of children still do not have comprehensive coverage. Even among privately insured children, many are without dental or prescription-drug coverage. Those who were poor, minority, and with low maternal education had lower likelihood of dental and prescription-drug coverage.