Children's receipt of health care services and family health insurance patterns

Racial Inequities in Sepsis Mortality Among Children in the United States

BACKGROUND

Racial inequities influence health outcomes in the United States, but their impact on sepsis outcomes among children is understudied. We aimed to evaluate for racial inequities in sepsis mortality using a nationally representative sample of pediatric hospitalizations.

METHODS

This population-based, retrospective cohort study used the 2006, 2009, 2012 and 2016 Kids' Inpatient Database. Eligible children 1 month to 17 years old were identified using sepsis-related International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision codes. We used modified Poisson regression to evaluate the association between patient race and in-hospital mortality, clustering by hospital and adjusting for age, sex and year. We used Wald tests to assess for modification of associations between race and mortality by sociodemographic factors, geographic region and insurance status.

RESULTS

Among 38,234 children with sepsis, 2555 (6.7%) died in-hospital. Compared with White children, mortality was higher among Hispanic (adjusted relative risk: 1.09; 95% confidence interval: 1.05-1.14), Asian/Pacific Islander (1.17, 1.08-1.27) and children from other racial minority groups (1.27, 1.19-1.35). Black children had similar mortality to White children overall (1.02, 0.96-1.07), but higher mortality in the South (7.3% vs. 6.4%; P < 0.0001). Hispanic children had higher mortality than White children in the Midwest (6.9% vs. 5.4%; P < 0.0001), while Asian/Pacific Islander children had higher mortality than all other racial categories in the Midwest (12.6%) and South (12.0%). Mortality was higher among uninsured children than among privately insured children (1.24, 1.17-1.31).

CONCLUSIONS

Risk of in-hospital mortality among children with sepsis in the United States differs by patient race, geographic region and insurance status.

Global Considerations in Asthma Treatment: Management in Low Resource Settings

Low-resource settings have a disproportionately higher burden of asthma due to factors that include environmental triggers, access to healthcare, availability of medications, and uncoordinated health systems. The application of guideline-based management can vary, which further impacts the treatment delivered. This chapter aims to outline the global landscape of asthma management, including cultural and social factors, with suggestions for interventions.

A Qualitative Study of Two Oregon Family Medicine Clinics to Explain Parent and Child Healthcare Initiation and Engagement

Background: Parental factors are associated with children's receipt of recommended care but not adequately described. Methods: We conducted a qualitative study of patients with at least two visits who were a primary caregiver for a child who also had at least two visits at the same clinic in 1/2018-12/2019 from two Oregon family medicine clinics. We stratified patients by child age and number of caregiver visits and randomly selected caregivers. Participants were interviewed in accordance with approval by our Institutional Review Board between 12/2020 and 4/2021. The data were analyzed using a grounded theory approach. Results: 12 caregivers (termed parents) were interviewed; half were single parents and three-quarters had a history of substance use disorder and/or a mental health condition. Parents focused on the importance of keeping themselves healthy to keep their families healthy. They described similar reasons for choosing to initiate and continue care for themselves and their children at the same clinic, including: convenience, trust, relationships, and receiving whole-person and whole-family care. Many valued having a healthcare "home" for their entire family. We developed a figure that highlights three themes that capture the interrelated factors parents identified as supporting healthcare use for themselves and their families. These overarching themes included: healthcare initiation; healthcare engagement and continuity; and parent bringing child to the same clinic for healthcare. Conclusion: Our data suggests that long-standing patient-clinic relationships for parents and children can support family-focused healthcare.

Effects of parental public health insurance eligibility on parent and child health outcomes

Many states expanded their Medicaid programs to low-income adults under the Affordable Care Act (ACA). These expansions increased Medicaid coverage among low-income parents and their children. Whether these improvements in coverage and healthcare use lead to better health outcomes for parents and their children remains unanswered. We used longitudinal data on a large, nationally representative cohort of elementary-aged children from low-income households from 2010 to 2016. Using a difference-in-differences approach in state Medicaid policy decisions, we estimated the effect of the ACA Medicaid expansions on parent and child health. We found that parents' self-reported health status improved significantly post-expansion in states that expanded Medicaid through the ACA by 4 percentage points (p < 0.05), a 4.7% improvement. We found no significant changes in children's use of routine doctor visits or parents' assessment of their children's health status. We observed modest decreases in children's body mass index (BMI) of about 2% (p < 0.05), especially for girls.

A space-time analysis of disparities in age at diagnosis of autism spectrum disorder: environmental and socioeconomic risk factors

INTRODUCTION

Early diagnosis of autism is a critical step for gaining early intervention. The earlier interventions begin, the greater chance to reduce symptoms of autism over the lifespan. Despite the improvement in early diagnosis, age at diagnosis varies by residential locations. In order to improve early screening services, this study aims to identify geographic clusters of early and late diagnosis of autism, in addition, it is aimed to compare cases inside the clusters with the rest of the province on characteristics and socioeconomic factors.

MATERIALS AND METHODS

Survey data were collected from 163 autistics born from 1996 to 2011 in Isfahan Province, Iran. As this study found diagnosis of autism occur at an earlier age among children, who on average every 2.5 months increased for each year of age, distance from regression line has been used to determine how early a case was diagnosed compared to other identified cases. After dividing cases into 5 classes based on their distances from the regression line, the ordinal based space-time scan statistic in SaTScan was used to identify geographic areas within specific time periods that have significantly elevated proportions of autistic children who received diagnosis at the earlier or later stages.

RESULTS

The space-time analysis identified two geographic areas that age of diagnosis was inconsistent with the overall study area, the first area has an early diagnosis in central part of Isfahan megacity between 1998 and 2006 (P = .001), the second area shows to have a late diagnosis centered by Najafabad from 2010 through 2015 (P = .007).

CONCLUSIONS

The result of our spatial analysis can be used to evaluate the performance of diagnosis services and additionally provide information to target specific at-risk population for further interventions.

Adult Medicaid benefit generosity and receipt of recommended health services among low-income children: The spillover effects of Medicaid adult dental coverage expansions

Low-income children are less likely to receive recommended health services than their high-income counterparts. This paper examines whether the design of parental Medicaid benefit packages could serve as a mechanism for reducing income-based disparities in unmet health care needs, considering dental benefits as a case study. Leveraging state-level changes to adult dental benefits over time, I find that coverage is associated with increases of 14 and 5 percentage points, respectively, in the likelihood of a recent dental visit among parents and children directly exposed to the policy. Child effects appear to be concentrated among younger children under age 12.

Association Between Changes in Parental Medicaid Vision Coverage and Child Use of Vision Care

OBJECTIVE

Many low-income children do not receive regular vision care despite the fact that all state Medicaid programs cover these services. The primary objective of this study was to examine whether children were more likely to have at least one past-year eye doctor visit when their parents gained Medicaid vision benefits. Other indicators of child vision care access (ie, unmet needs for glasses and difficulty seeing) and eye doctor visits among Medicaid-enrolled parents were also assessed.

METHODS

Difference-in-differences regression analysis leveraged within-state changes to Medicaid adult vision benefits. Study samples included 17,345 children with a Medicaid-enrolled parent and 12,219 parents with Medicaid coverage interviewed during the 2000 to 2013 National Health Interview Survey.

RESULTS

Providing Medicaid adult vision coverage was associated with a 5.4 percentage point increase (P = .009) in having at least one past-year eye doctor visit among parents and a 2.8 percentage point increase (P = .01) in this measure among children. These estimates represent increases of 22% and 14%, respectively, relative to unadjusted parent and child visit rates over the study period. These effects appeared to be concentrated among older children ages 12 to 17. Estimates for the other measures of child access to vision care were not statistically significant.

CONCLUSIONS

Providing adult vision benefits was associated with having at least one past-year eye doctor visit among low-income children, and may help to reduce income-based disparities in children's receipt of vision care. This research adds to the limited evidence base on the role of public policy in increasing access to vision services.

Contemporary relationship between medical expenditures and quality of life among adults with epilepsy in the United States

AIMS

Epilepsy exacts substantial adverse economic and quality of life (QoL) costs. Clarifying the quantitative and qualitative relationships between total and out-of-pocket (OOP) healthcare expenditures and QoL could shed insights into how they influence each other, and have done so over recent times.

METHODS

We used the Medical Expenditure Household Components 2003-2014 to identify a total of 2450 adults with epilepsy, representing a weighted population of 1,942,413. Quality of life was assessed using the Physical Component Summary (PCS) and the Mental Component Summary (MCS) derived from the Short-form 12 Version 2 (SF-12 V2), converted into quartiles of equal distribution, with higher quartiles indicating a better QoL. We computed unadjusted mean and adjusted (through a generalized linear model (GLM)) total and OOP healthcare expenditures by QoL categories among adults with epilepsy (reported as dollars in 2016).

RESULTS

The pooled estimates of total healthcare expenditures decreased as PCS and MCS quartiles of QoL increased [PCS: costs for quartile 1 = $21,792 (95% confidence interval (CI): $18,416-$25,168 vs. costs for quartile 4 = $6057 (95% CI: $4648-$7466) and MCS: costs for quartile 1 = $19,040 (95% CI: $15,544-$22,535) vs. quartile 4 = $12,939 (95% CI: $8450-$17,429)]. Similarly, the pooled estimates of OOP healthcare expenditures and QoL were inversely related [PCS: costs for quartile 1 = $1849 (95% CI: $1583-$2114) vs. costs for quartile 4 = $948 ($709-$1187) and MCS: costs for quartile 1 = 1812 (95% CI: $1483-2141) vs. quartile 4 = $1317 (95% CI: $982-$1652)]. The association between QoL and total and OOP healthcare expenditures was unchanged after adjusting for socioeconomic and healthcare system related confounders in the GLM. Overall, healthcare expenditures were stable across years independently of the QoL; only OOP expenditures decreased between 2003-2006 and 2011-2014 for quartile 1 of PCS and MCS.

CONCLUSION

Quality of life and OOP health expenditures are independently and inversely related to each other among adults with epilepsy. Over the decade studied in the United States, there was a decrease in OOP health expenditures among those patients with epilepsy with the lowest QoL, possibly reflecting a rise in insurance coverage after the Affordable Care Act.

Trends in Out-of-Pocket Burden in United States Adults with Kidney Disease: 2002-2011

BACKGROUND

High out-of-pocket (OOP) cost is a barrier to healthcare access and treatment compliance. Our study examined high OOP healthcare cost and burden trends in adults with kidney disease (KD).

METHODS

Using Medical Expenditure Survey 2002-2011 data, we examined the proportion of people greater than 17 years old with KD whose OOP burden was high. Trends by insurance status (private, public or none) and trends by income level (poor, low, middle or high income) were also examined in this study.

RESULTS

Approximately 16% of people with KD faced high OOP burden in 2011. The proportion of adults with high OOP burden between 2002 and 2011 fell by 9.7 percentage points. The proportion of privately insured adults facing high OOP burden decreased by 4.7, those who were publicly insured 22.4, and those who were uninsured, 3.1 percentage points. The proportion of those facing high OOP burden who were poor/near poor fell by 26.5, those who had low income 13.4, and those who had middle income, 9 percentage points.

CONCLUSIONS

Though high OOP burden declined between 2002 and 2011 in the US population with KD, most of the decline was among the publicly insured, so the uninsured populations with KD remain vulnerable. Providers and policy makers should be aware of the vulnerability of uninsured individuals with KD to high OOP burden.

Children's Health Insurance Program Expansions: What Works for Families?

We examine the impact of Children’s Health Insurance Program (CHIP) eligibility expansions 1999 to 2012 on child and joint parent/child insurance coverage. We use changes in state CHIP income eligibility levels and data from the Current Population Survey Annual Social and Economic Supplement to create child/parent dyads. We use logistic regression to estimate marginal effects of eligibility expansions on coverage in families with incomes below 300% federal poverty level (FPL) and, in turn, 150% to 300% FPL. The latter is the income range most expansions targeted. We find CHIP expansions increased public coverage among children in families 150% to 300% FPL by 2.5 percentage points (pp). We find increased joint parent/child coverage of 2.3 pp (P = .055) but only in states where the public eligibility levels for parent and child are within 50 pp. In these states, the CHIP expansion increased the probability that both parent/child are publicly insured (2.5 pp) among insured dyads, but where the eligibility levels are further apart (51-150 pp; >150 pp), CHIP expansions increase the probability of mixed coverage—one public, one private—by 0.9 to 1.5 pp. Overall, families made decisions regarding coverage that put the child first but parents took advantage of joint parent/child coverage when eligibility levels were close. Joint public parent/child coverage can have positive care-seeking effects as well as reduced financial burdens for low-income families.

Reducing toxic stress in the neonatal intensive care unit to improve infant outcomes

In 2011, the American Academy of Pediatrics (AAP) published a technical report on the lifelong effects of early toxic stress on human development, and included a new framework for promoting pediatric health: the Ecobiodevelopmental Framework for Early Childhood Policies and Programs. We believe that hospitalization is a specific form of toxic stress for the neonatal patient, and that toxic stress must be addressed by the nursing profession in order to substantially improve outcomes for the critically ill neonate. Approximately 4% of normal birthweight newborns and 85% of low birthweight newborns are hospitalized each year in the highly technological neonatal intensive care unit (NICU). Neonates are exposed to roughly 70 stressful procedures a day during hospitalization, which can permanently and negatively alter the infant's developing brain. Neurologic deficits can be partly attributed to the frequent, toxic, and cumulative exposure to stressors during NICU hospitalization. However, the AAP report does not provide specific action steps necessary to address toxic stress in the NICU and realize the new vision for pediatric health care outlined therein. Therefore, this paper applies the concepts and vision laid out in the AAP report to the care of the hospitalized neonate and provides action steps for true transformative change in neonatal intensive care. We review how the environment of the NICU is a significant source of toxic stress for hospitalized infants. We provide recommendations for caregiving practices that could significantly buffer the toxic stress experienced by hospitalized infants. We also identify areas of research inquiry that are needed to address gaps in nursing knowledge and to propel nursing science forward. Finally, we advocate for several public policies that are not fully addressed in the AAP technical report, but are vital to the health and development of all newborns.

Gaps in health insurance coverage and emergency department use among children with asthma

Background: Gaps in health insurance coverage may complicate asthma management and increase emergency department (ED) use. Using two nationally-representative surveys, we characterize the prevalence of coverage gaps among children with asthma, and describe their association with ED visits in this population. Methods: De-identified data were obtained from the 2016 National Survey of Children's Health (NSCH) and National Health Interview Survey (NHIS). Among children with asthma, we classified coverage over the past year as: (1) continuous private, (2) continuous public, (3) gap in coverage, and (4) continuously uninsured. The primary outcome was all-cause ED visits in the past year (both surveys). Secondary outcomes included unmet health care needs (NSCH), asthma-related ED visits or hospitalizations (NHIS) and asthma exacerbations (NHIS). Results: The analysis included 3739 (NSCH) and 854 (NHIS) children with asthma, representing a population of 5.5 million children in the US. Estimated prevalence of coverage gaps was 5% in the NSCH and 3% in the NHIS. On multivariable ordinal logistic regression using NSCH data, coverage gaps were associated with increased all-cause ED use (OR = 2.5; 95% CI: 1.3, 4.7, p = 0.005), compared to continuous private coverage. Further analysis confirmed higher odds of unmet health care needs, asthma exacerbations, and asthma-related ED visits among children with coverage gaps. Conclusions: Children with asthma who experience insurance coverage gaps have increased ED use, possibly related to poorer access to appropriate health care. Protecting insurance coverage continuity may reduce ED use and improve clinical outcomes in this population.

Spillover Effects of Adult Medicaid Expansions on Children's Use of Preventive Services

BACKGROUND

Since the passage of the Affordable Care Act, Medicaid enrollment has increased by ∼17 million adults, including many low-income parents. One potentially important, but little studied, consequence of expanding health insurance for parents is its effect on children's receipt of preventive services.

METHODS

By using state Medicaid eligibility thresholds linked to the 2001-2013 Medical Expenditure Panel Surveys, we assessed the relationship between changes in adult Medicaid eligibility and children's likelihood of receiving annual well-child visits (WCVs). In instrumental variable analyses, we used these changes in Medicaid eligibility to estimate the relationship between parental enrollment in Medicaid and children's receipt of WCVs.

RESULTS

Our analytic sample consisted of 50 622 parent-child dyads in families with incomes <200% of the federal poverty level, surveyed from 2001 to 2013. On average, a 10-point increase in a state's parental Medicaid eligibility (measured relative to the federal poverty level) was associated with a 0.27 percentage point higher probability that a child received an annual WCV (95% confidence interval: 0.058 to 0.48 percentage points, P = .012). Instrumental variable analyses revealed that parental enrollment in Medicaid was associated with a 29 percentage point higher probability that their child received an annual WCV (95% confidence interval: 11 to 47 percentage points, P = .002).

CONCLUSIONS

In our study, we demonstrate that Medicaid expansions targeted at low-income adults are associated with increased receipt of recommended pediatric preventive care for their children. This finding reveals an important spillover effect of parental insurance coverage that should be considered in future policy decisions surrounding adult Medicaid eligibility.

Addressing Parental Health in Pediatrics: Physician Perceptions of Relevance and Responsibility

Pediatric guidelines recommend that providers address a range of parental health issues; however, adherence to these guidelines has been suboptimal. Drawing on a nationally-representative sample of children's primary care physicians, we examined whether providers view parental issues as relevant to child health and whether they believe it is their personal responsibility to address them. Issues included maternal depression, tobacco use, intimate partner violence, Tdap (tetanus, diphtheria, and acellular pertussis) immunization, family planning, and health insurance. While the majority of respondents endorsed the relevance of these issues to child health, particularly for issues with an established evidencebase, significantly fewer felt responsible for addressing them. Physicians who endorsed relevance or responsibility were almost always more likely to address these issues in their clinical practice. To advance parental health promotion practices, highlighting relevance to pediatric outcomes is an important first step, particularly for novel areas, while understanding what factors influence personal responsibility is necessary for all issues.

Dietary and Physical Activity Counseling Trends in U.S. Children, 2002-2011

INTRODUCTION

In 2007 and 2010, Expert Committee and U.S. Preventive Services Task Force guidelines were released, respectively, urging U.S. practitioners to deliver preventive obesity counseling for children. This study determined the frequency and evaluated predictors of receiving counseling for diet and physical activity among a national sample of children from 2002 to 2011.

METHODS

Children aged 6-17 years were used from the 2002-2011 Medical Expenditure Panel Surveys and analyzed in 2016. Parental report of two questions assessed whether children received both dietary and exercise counseling from the provider. Children were grouped by weight category. Bivariate analyses compared the frequency of receiving counseling; logistic regression evaluated predictors of receiving counseling.

RESULTS

The sample included 36,114 children; <50% of children received counseling. Across all time periods, children were more likely to receive counseling with increasing weight. Logistic regression models showed that obese children had greater odds of receiving counseling versus normal-weight children, even after adjusting for covariates. Additional significant positive correlates of receiving counseling were Hispanic ethnicity, living in an urban setting, and being in the highest income stratum. Being uninsured was associated with lower odds of counseling. Years 2007-2009 and 2010-2011 were associated with increased counseling versus the benchmark year category in the multivariable model.

CONCLUSIONS

Counseling appears more likely with greater weight and increased after both guidelines in 2007 and 2010. Overall counseling rates for children remain low. Future work should focus on marginalized groups, such as racial and ethnic minorities and rural populations.

Healthcare Utilization After a Children's Health Insurance Program Expansion in Oregon

OBJECTIVE

The future of the Children's Health Insurance Program (CHIP) is uncertain after 2017. Survey-based research shows positive associations between CHIP expansions and children's healthcare utilization. To build on this prior work, we used electronic health record (EHR) data to assess temporal patterns of healthcare utilization after Oregon's 2009-2010 CHIP expansion. We hypothesized increased post-expansion utilization among children who gained public insurance.

METHODS

Using EHR data from 154 Oregon community health centers, we conducted a retrospective cohort study of pediatric patients (2-18 years old) who gained public insurance coverage during the Oregon expansion (n = 3054), compared to those who were continuously publicly insured (n = 10,946) or continuously uninsured (n = 10,307) during the 2-year study period. We compared pre-post rates of primary care visits, well-child visits, and dental visits within- and between-groups. We also conducted longitudinal analysis of monthly visit rates, comparing the three insurance groups.

RESULTS

After Oregon's 2009-2010 CHIP expansions, newly insured patients' utilization rates were more than double their pre-expansion rates [adjusted rate ratios (95 % confidence intervals); increases ranged from 2.10 (1.94-2.26) for primary care visits to 2.77 (2.56-2.99) for dental visits]. Utilization among the newly insured spiked shortly after coverage began, then leveled off, but remained higher than the uninsured group.

CONCLUSIONS

This study used EHR data to confirm that CHIP expansions are associated with increased utilization of essential pediatric primary and preventive care. These findings are timely to pending policy decisions that could impact children's access to public health insurance in the United States.

Socioeconomic status (SES) and childhood acute myeloid leukemia (AML) mortality risk: Analysis of SEER data

Socioeconomic status (SES) is a complex construct of multiple indicators, known to impact cancer outcomes, but has not been adequately examined among pediatric AML patients. This study aimed to identify the patterns of co-occurrence of multiple community-level SES indicators and to explore associations between various patterns of these indicators and pediatric AML mortality risk. A nationally representative US sample of 3651 pediatric AML patients, aged 0-19 years at diagnosis was drawn from 17 Surveillance, Epidemiology, and End Results (SEER) database registries created between 1973 and 2012. Factor analysis, cluster analysis, stratified univariable and multivariable Cox proportional hazards models were used. Four SES factors accounting for 87% of the variance in SES indicators were identified: F1) economic/educational disadvantage, less immigration; F2) immigration-related features (foreign-born, language-isolation, crowding), less mobility; F3) housing instability; and, F4) absence of moving. F1 and F3 showed elevated risk of mortality, adjusted hazards ratios (aHR) (95% CI): 1.07(1.02-1.12) and 1.05(1.00-1.10), respectively. Seven SES-defined cluster groups were identified. Cluster 1 (low economic/educational disadvantage, few immigration-related features, and residential-stability) showed the minimum risk of mortality. Compared to Cluster 1, Cluster 3 (high economic/educational disadvantage, high-mobility) and Cluster 6 (moderately-high economic/educational disadvantages, housing-instability and immigration-related features) exhibited substantially greater risk of mortality, aHR(95% CI)=1.19(1.0-1.4) and 1.23 (1.1-1.5), respectively. Factors of correlated SES-indicators and their pattern-based groups demonstrated differential risks in the pediatric AML mortality indicating the need of special public-health attention in areas with economic-educational disadvantages, housing-instability and immigration-related features.

Predictors of Age of Diagnosis for Children with Autism Spectrum Disorder: The Role of a Consistent Source of Medical Care, Race, and Condition Severity

Having a consistent source of medical care may facilitate diagnosis of autism spectrum disorders (ASD). This study examined predictors of age of ASD diagnosis using data from the 2011-2012 National Survey of Children's Health. Using multiple linear regression analysis, age of diagnosis was predicted by race, ASD severity, having a consistent source of care (CSC), and the interaction between these variables after controlling for birth cohort, birth order, poverty level, parental education, and health insurance. While African American children were diagnosed earlier than Caucasians, this effect was moderated by ASD severity and CSC. Having a CSC predicted earlier diagnosis for Caucasian but not African American children. Both physician and parent behaviors may contribute to diagnostic delays in minority children.

Disparities in access to preventive health care services among insured children in a cross sectional study

Children with insurance have better access to care and health outcomes if their parents also have insurance. However, little is known about whether the type of parental insurance matters. This study attempts to determine whether the type of parental insurance affects the access to health care services of children.I used data from the 2009-2013 Medical Expenditure Panel Survey and estimated multivariate logistic regressions (N = 26,152). I estimated how family insurance coverage affects the probability that children have a usual source of care, well-child visits in the past year, unmet medical and prescription needs, less than 1 dental visit per year, and unmet dental needs.Children in families with mixed insurance (child publicly insured and parent privately insured) were less likely to have a well-child visit than children in privately insured families (odds ratio = 0.86, 95% confidence interval 0.76-0.98). When restricting the sample to publicly insured children, children with privately insured parents were less likely to have a well-child visit (odds ratio = 0.82, 95% confidence interval 0.73-0.92), less likely to have a usual source of care (odds ratio = 0.79, 95% confidence interval 0.67-0.94), and more likely to have unmet dental needs (odds ratio = 1.68, 95% confidence interval 1.10-2.58).Children in families with mixed insurance tend to fare poorly compared to children in publicly insured families. This may indicate that children in these families may be underinsured. Expanding parental eligibility for public insurance or subsidizing private insurance for children would potentially improve their access to preventive care.

Trends in Costs of Depression in Adults with Diabetes in the United States: Medical Expenditure Panel Survey, 2004-2011

OBJECTIVE

To investigate differences in healthcare cost trends over 8 years in adults with diabetes and one of four categories of comorbid depression: no depression, unrecognized depression, asymptomatic depression, or symptomatic depression.

RESEARCH DESIGN AND METHODS

Data from the 2004-2011 Medical Expenditure Panel Survey (MEPS) was used to create nationally representative estimates. The dependent variable was total healthcare expenditures for the calendar year, including office-based, hospital outpatient, emergency room, inpatient hospital, prescription, dental, and home health care expenditures. The 2004-2011 direct medical costs were adjusted to a common 2014 dollar value. The primary independent variable was four mutually exclusive depression categories created from ICD-9-CM codes and the PHQ-2 depression screening tool. Healthcare expenditures were estimated using a two-part model and were adjusted for age, sex, race, marital status, education, health insurance, metropolitan statistical area status, region, income level, and comorbidities.

RESULTS

Based on a national sample of adults with diabetes (unweighted sample of 15,548, weighted sample of 17,465,579), 10.2 % had unrecognized depression, 13.6 % had asymptomatic depression, and 8.9 % had symptomatic depression. In the pooled sample, after adjusting for covariates, the incremental cost of unrecognized depression was $2872 (95 % CI 1660-4084), asymptomatic depression increased by $3347 (95 % CI 2568-4386), and symptomatic depression increased by $5170 (CI 95 % 3610-6731) compared to patients with no depression.

CONCLUSIONS

Adjusted analyses showed that expenditures were $2000-3000 higher for unrecognized and asymptomatic depression than no depression, and $5000 higher for symptomatic depression. Higher medical expenditures persisted over time, with only symptomatic depression showing a sustained decrease over time.

The Association Between Medicaid Coverage for Children and Parents Persists: 2002-2010

To assess the association between a child's and their parent's public health insurance status during a time when children had access to coverage independent of policies that impacted adults' access. Secondary data from the Oregon Health Plan (OHP) [Oregon's Medicaid and Children's Health Insurance Programs] for families with at least one parent and one child with OHP coverage at any time during the study period (2002-2010). We linked children to their parents in the OHP data set and examined longitudinal associations between the coverage patterns for children and their parents, controlling for several demographic and economic confounders. We tested for differences in the strength of associations in monthly coverage status in five time periods throughout the nine-year study period. The odds of a child being insured by the OHP in months in which at least one parent had OHP coverage were significantly higher than among children whose parents were not enrolled at that time. Children with at least one parent who maintained or gained OHP coverage in a given month had a much higher probability of being enrolled in the OHP in that month, compared to children who had no covered parents in the given month or the month prior. Despite implementation of policies that differentially affected eligibility requirements for children and adults, strong associations persisted between coverage continuity for parents and children enrolled in Oregon public health insurance programs.

Trends in Type of Health Insurance Coverage for US Children and Their Parents, 1998-2011

OBJECTIVE

To examine trends in health insurance type among US children and their parents.

METHODS

Using the Medical Expenditure Panel Survey (1998-2011), we linked each child (n = 120,521; weighted n ≈ 70 million) with his or her parent or parents and assessed patterns of full-year health insurance type, stratified by income. We examined longitudinal insurance trends using joinpoint regression and further explored these trends with adjusted regression models.

RESULTS

When comparing 1998 to 2011, the percentage of low-income families with both child and parent or parents privately insured decreased from 29.2% to 19.1%, with an estimated decline of -0.86 (95% confidence interval, -1.10, -0.63) unadjusted percentage points per year; middle-income families experienced a drop from 74.5% to 66.3%, a yearly unadjusted percentage point decrease of -0.73 (95% confidence interval, -0.98, -0.48). The discordant pattern of publicly insured children with uninsured parents increased from 10.4% to 27.2% among low-income families and from 1.4% to 6.7% among middle-income families. Results from adjusted models were similar to joinpoint regression findings.

CONCLUSIONS

During the past decade, low- and middle-income US families experienced a decrease in the percentage of child-parent pairs with private health insurance and pairs without insurance. Concurrently, there was a rise in discordant coverage patterns-mainly publicly insured children with uninsured parents.

Predictors of children's health insurance coverage discontinuity in 1998 versus 2009: parental coverage continuity plays a major role

To identify predictors of coverage continuity for United States children and assess how they have changed in the first 12 years since implementation of the Children's Health Insurance Program in 1997. Using data from the nationally-representative Medical Expenditure Panel Survey, we used logistic regression to identify predictors of discontinuity in 1998 and 2009 and compared differences between the 2 years. Having parents without continuous coverage was the greatest predictor of a child's coverage gap in both 1998 and 2009. Compared to children with at least one parent continuously covered, children whose parents did not have continuous coverage had a significantly higher relative risk (RR) of a coverage gap [RR 17.96, 95 % confidence interval (CI) 14.48-22.29 in 1998; RR 12.88, 95 % CI 10.41-15.93 in 2009]. In adjusted models, parental continuous coverage was the only significant predictor of discontinuous coverage for children (with one exception in 2009). The magnitude of the pattern was higher for privately-insured children [adjusted relative risk (aRR) 29.17, 95 % CI 20.99-40.53 in 1998; aRR 25.54, 95 % CI 19.41-33.61 in 2009] than publicly-insured children (aRR 5.72, 95 % CI 4.06-8.06 in 1998; aRR 4.53, 95 % CI 3.40-6.04 in 2009). Parental coverage continuity has a major influence on children's coverage continuity; this association remained even after public health insurance expansions for children. The Affordable Care Act will increase coverage for many adults; however, 'churning' on and off programs due to income fluctuations could result in coverage discontinuities for parents. If parental coverage instability persists, these discontinuities may continue to have a negative impact on children's coverage stability as well.

Linkage methods for connecting children with parents in electronic health record and state public health insurance data

The objective of this study was to develop methodologies for creating child-parent 'links' in two healthcare-related data sources. We linked children and parents who were patients in a network of Oregon clinics with a shared electronic health record (EHR), using data that reported the child's emergency contact information or the 'guarantor' for the child's visits. We also linked children and parents enrolled in the Oregon Health Plan (OHP; Oregon's public health insurance programs), using administrative data; here, we defined a 'child' as aged <19 years and identified potential 'parents' from among adults sharing the same OHP household identification (ID) number. In both data sources, parents had to be 12-55 years older than the child. We used OHP individual client ID and EHR patient ID numbers to assess the quality of our linkages through cross-validation. Of the 249,079 children in the EHR dataset, we identified 62,967 who had a 'linkable' parent with patient information in the EHR. In the OHP data, 889,452 household IDs were assigned to at least one child; 525,578 with a household ID had a 'linkable' parent (272,578 households). Cross-validation of linkages revealed 99.8 % of EHR links validated in OHP data and 97.7 % of OHP links validated in EHR data. The ability to link children and their parents in healthcare-related datasets will be useful to inform efforts to improve children's health. Thus, we developed strategies for linking children with their parents in an EHR and a public health insurance administrative dataset.

Trends in health care expenditure in U.S. adults with diabetes: 2002-2011

OBJECTIVE

Direct medical cost of diabetes in the U.S. has been estimated to be 2.3 times higher relative to individuals without diabetes. This study examines trends in health care expenditures by expenditure category in U.S. adults with diabetes between 2002 and 2011.

RESEARCH DESIGN AND METHODS

We analyzed 10 years of data representing a weighted population of 189,013,514 U.S. adults aged ≥18 years from the Medical Expenditure Panel Survey. We used a novel two-part model to estimate adjusted mean and incremental medical expenditures by diabetes status, while adjusting for demographics, comorbidities, and time.

RESULTS

Relative to individuals without diabetes ($5,058 [95% CI 4,949-5,166]), individuals with diabetes ($12,180 [11,775-12,586]) had more than double the unadjusted mean direct expenditures over the 10-year period. After adjustment for confounders, individuals with diabetes had $2,558 (2,266-2,849) significantly higher direct incremental expenditures compared with those without diabetes. For individuals with diabetes, inpatient expenditures rose initially from $4,014 in 2002/2003 to $4,183 in 2004/2005 and then decreased continuously to $3,443 in 2010/2011, while rising steadily for individuals without diabetes. The estimated unadjusted total direct expenditures for individuals with diabetes were $218.6 billion/year and adjusted total incremental expenditures were approximately $46 billion/year.

CONCLUSIONS

Our findings show that compared with individuals without diabetes, individuals with diabetes had significantly higher health expenditures from 2002 to 2011 and the bulk of the expenditures came from hospital inpatient and prescription expenditures.

Provider Visits for Asthma: Potential Barriers for Insured Children

OBJECTIVE

The barriers to provider visits for asthma in insured children are not well understood. Our objective was to examine the relationship between parent, family, and child attributes and asthma visits in insured children.

METHODS

This retrospective, cross-sectional analysis of 2007 Medical Expenditure Panel Survey-Household Component data included insured children 0-17 years old reported to have active asthma. We summed the number of provider visits during which asthma was treated or diagnosed to represent the frequency of asthma visits during the year. Probit models were used to estimate the relationship between parent, family, and child attributes and asthma visits.

RESULTS

Seventy percent of the 542 children did not have an asthma visit during the year. Children with parents employed full time were 16 percentage points less likely to have an asthma visit than children whose parents were not working (P=.01).

CONCLUSION

Many insured children go more than a year without seeing a provider for their asthma, signaling that insurance is not sufficient to guarantee children will receive asthma monitoring. The attributes related to asthma visits suggest potential barriers that providers might want to consider to increase participation in asthma visits.

Trends in health insurance status of US children and their parents, 1998-2008

In the United States (US), a parent's health insurance status affects their children's access to health care making it critically important to examine trends in coverage for both children and parents. To gain a better understanding of these health insurance trends, we assessed the coverage status for both children and their parents over an 11-year time period (1998-2008). We conducted secondary analysis of data from the nationally-representative Medical Expenditure Panel Survey. We examined frequency distributions for full-year child/parent insurance coverage status by family income, conducted Chi-square tests of association to assess significant differences over time, and explored factors associated with full-year insurance coverage status in 1998 and in 2008 using logistic regression. When considering all income groups together, the group with both child and parent insured decreased from 72.4 % in 1998 to 67.2 % in 2008. When stratified by income, the percentage of families with an insured child, but an uninsured parent increased for low-income families from 12.4 to 25.1 % and from 3.8 to 7.1 % for middle-income families when comparing 1998-2008. In regression analyses, family income remained the strongest characteristic associated with a lack of full-year health insurance. As future policy reforms take shape, it will be important to look beyond children's coverage patterns to assess whether gains have been made in overall family coverage.

Recent health insurance trends for US families: children gain while parents lose

In the past decade, political and economic changes in the United States (US) have affected health insurance coverage for children and their parents. Most likely these policies have differentially affected coverage patterns for children (versus parents) and for low-income (versus high-income) families. We aimed to examine--qualitatively and quantitatively--the impact of changing health insurance coverage on US families. Primary data from interviews with Oregon families (2008-2010) were analyzed using an iterative process. Qualitative findings guided quantitative analyses of secondary data from the nationally-representative Medical Expenditure Panel Survey (MEPS) (1998-2009); we used Joinpoint Regression to assess average annual percent changes (AAPC) in health insurance trends, examining child and parent status and type of coverage stratified by income. Interviewees reported that although children gained coverage, parents lost coverage. MEPS analyses confirmed this trend; the percentage of children uninsured all year decreased from 9.6 % in 1998 to 6.1 % in 2009; AAPC = -3.1 % (95 % confidence interval [CI] from -5.1 to -1.0), while the percentage of parents uninsured all year rose from 13.6 % in 1998 to 17.1 % in 2009, AAPC = 2.7 % (95 % CI 1.8-3.7). Low-income families experienced the most significant changes in coverage. Between 1998 and 2009, as US children gained health insurance, their parents lost coverage. Children's health is adversely affected when parents are uninsured. Investigation beyond children's coverage rates is needed to understand how health insurance policies and changing health insurance coverage trends are impacting children's health.

Family out-of-pocket health care burden and children's unmet needs or delayed health care

OBJECTIVE

To assess the relationship between family members' out-of-pocket (OOP) health care spending and unmet needs or delayed health care due to cost for children with and without special health care needs (SHCN).

METHODS

Data come from the Medical Expenditure Panel Survey, 2002-2009, and include 63,462 observations representing 41,748 unique children. The primary outcome was having any unmet needs/delayed care as a result of the cost of medical care, dental care, or prescription drugs. We also examined having unmet needs/delayed care due to cost for each service separately. Key explanatory variables were OOP spending on the index child and OOP spending on other family members. We estimated multivariate instrumental variable models to adjust the results for potential bias from any unobserved factors that might influence both other family OOP costs and the outcome variable.

RESULTS

An increase of other family OOP costs from $500 (50th percentile) to $3000 (90th percentile) was associated with a higher adjusted rate of any unmet need/delayed care due to cost (1.39% to 5.62%, P < .001, among children without SHCN; 3.17% to 7.87%, P = .01, among those with SHCN). Among children without SHCN, higher OOP costs among other family members were associated with higher levels of unmet needs or delays in medical, prescription drug, and dental care, while among children with SHCN, higher OOP costs among other family members was primarily associated with unmet or delayed dental care.

CONCLUSIONS

Programs and policies that reduce the OOP costs of family members other than the child may improve the child's access to care.

Continuity of Public Insurance Coverage

Publicly financed insurance programs are tasked with maintaining coverage for eligible children, but published measures to assess coverage have not been evaluated. Therefore, we sought to identify and categorize measures of health insurance continuity for children and adolescents. We conducted a systematic review of Medline and HealthStar databases, review of reference lists of eligible articles, and contact with experts. We categorized measures into 8 domains based on a conceptual framework. We identified 147 measures from 84 eligible articles. Most measures evaluated the following domains: always insured (41%), repeatedly uninsured (36%), and transition out of coverage (29%), while fewer assessed single gap in coverage, always uninsured, transition into coverage, change in coverage, and eligibility. Only 18% of measures assessed associations between continuity of coverage and child and adolescent health outcomes. These results suggest that a number of measures of continuity of coverage exist, but few measures have assessed impact on outcomes.

Marked ethnic, nativity, and socioeconomic disparities in disability and health insurance among US children and adults: the 2008-2010 American community survey

We used the 2008–2010 American Community Survey Micro-data Sample (N = 9,093,077) to estimate disability and health insurance rates for children and adults in detailed racial/ethnic, immigrant, and socioeconomic groups in the USA. Prevalence and adjusted odds derived from logistic regression were used to examine social inequalities. Disability rates varied from 1.4% for Japanese children to 6.8% for Puerto Rican children. Prevalence of disability in adults ranged from 5.6% for Asian Indians to 22.0% among American Indians/Alaska Natives. More than 17% of Korean, Mexican, and American Indian children lacked health insurance, compared with 4.1% of Japanese and 5.9% of white children. Among adults, Mexicans (43.6%), Central/South Americans (41.4%), American Indians/Alaska Natives (32.7%), and Pakistanis (29.3%) had the highest health-uninsurance rates. Ethnic nativity disparities were considerable, with 58.3% of all Mexican immigrants and 34.0% of Mexican immigrants with disabilities being uninsured. Socioeconomic gradients were marked, with poor children and adults having 3–6 times higher odds of disability and uninsurance than their affluent counterparts. Socioeconomic differences accounted for 24.4% and 60.2% of racial/ethnic variations in child health insurance and disability and 75.1% and 89.7% of ethnic inequality in adult health insurance and disability, respectively. Health policy programs urgently need to tackle these profound social disparities in disability and healthcare access.

Does health insurance continuity among low-income adults impact their children's insurance coverage?

Parent's insurance coverage is associated with children's insurance status, but little is known about whether a parent's coverage continuity affects a child's coverage. This study assesses the association between an adult's insurance continuity and the coverage status of their children. We used data from a subgroup of participants in the Oregon Health Care Survey, a three-wave, 30-month prospective cohort study (n = 559). We examined the relationship between the length of time an adult had health insurance coverage and whether or not all children in the same household were insured at the end of the study. We used a series of univariate and multivariate logistic regression models to identify significant associations and the rho correlation coefficient to assess collinearity. A dose response relationship was observed between continuity of adult coverage and the odds that all children in the household were insured. Among adults with continuous coverage, 91.4% reported that all children were insured at the end of the study period, compared to 83.7% of adults insured for 19-27 months, 74.3% of adults insured for 10-18 months, and 70.8% of adults insured for fewer than 9 months. This stepwise pattern persisted in logistic regression models: adults with the fewest months of coverage, as compared to those continuously insured, reported the highest odds of having uninsured children (adjusted odds ratio 7.26, 95% confidence interval 2.75, 19.17). Parental health insurance continuity is integral to maintaining children's insurance coverage. Policies to promote continuous coverage for adults will indirectly benefit children.

Changes in health insurance for US children and their parents: comparing 2003 to 2008

BACKGROUND AND OBJECTIVES

Recent policy changes have affected access to health insurance for families in the United States. Private health insurance premiums have increased, and state Medicaid programs have cut back coverage for adults. Concurrently, the Children's Health Insurance Program has made public insurance available to more children. We aimed to better understand how child and parent health insurance coverage patterns may have changed as a result of these policies.

METHODS

We analyzed data from the nationally representative Medical Expenditure Panel Survey, comparing cohorts from 2003 and 2008. We assessed cross-sectional and full-year coverage patterns for child/parent pairs, stratified by income. We conducted chi-square tests to assess significant differences in coverage over time.

RESULTS

Middle-income child/parent pairs had the most significant changes in their coverage patterns. For example, those with full-year health insurance coverage significantly decreased from 85.4% in 2003 to 80.6% in 2008. There was also an increase in uninsured middle-income child/parent pairs for the full year (5.6% in 2003 to 8.3% in 2008) and an increase in pairs who had a gap in coverage (9.7% in 2003 to 13.0% in 2008).

CONCLUSIONS

The percentage of middle-income child/parent pairs who were lacking insurance, for part or all of the year, has risen, suggesting that these families may be caught between affording private coverage and being eligible for public coverage. Unless private coverage becomes more affordable, insurance instability among middle-income families may persist despite the passage of the Patient Protection and Affordable Care Act.

Predictors of delayed or forgone needed health care for families with children

BACKGROUND

We sought to determine how health care-related financial burden, childhood activity limitations, health insurance, and other access-related factors predict delayed or forgone care for families with children, using a nationally representative, population-based sample.

METHODS

Our sample included families with children aged 0 to 17 years whose family was interviewed about their health care expenditures in 1 of 7 panels of the 2001 to 2008 Medial Expenditure Panel Survey (N = 14 138). Financial burden was defined as (1) the sum of out-of-pocket health service expenditures during the first survey year and (2) that sum divided by adjusted family income. Delayed or forgone care was defined as self-report of delayed or forgone medical care or prescription medications for the reference parent or child during the second survey year.

RESULTS

Financial burden, discordant insurance, and having a child with an activity limitation were some of the strongest predictors of delayed or forgone care. Additionally, significant health insurance and income-related disparities exist in the experience of delayed or forgone care.

CONCLUSIONS

Children and their families are delaying or forgoing needed care due to health care-related financial burden. Policies are needed to effectively reduce financial burden and improve the concordance of insurance between parents and children because this may reduce the frequency of unmet need among families. Moreover, reducing the occurrence of delayed or forgone care may improve health outcomes by increasing the opportunity to receive timely and preventive care.

Trends in preventive asthma medication use among children and adolescents, 1988-2008

OBJECTIVE

To examine trends in preventive asthma medication (PAM) use among children with current asthma in the United States from 1988 to 2008.

METHODS

We performed a cross-sectional analysis of PAM use among 2499 children aged 1 to 19 years with current asthma using nationally representative data from the National Health and Nutrition Examination Survey (NHANES) during 3 time periods: 1988-1994, 1999-2002, and 2005-2008. PAMs included inhaled corticosteroids, leukotriene receptor antagonists, long-acting β-agonists, mast-cell stabilizers, and methylxanthines.

RESULTS

Among children with current asthma, there was an increase in the use of PAMs from 17.8% (SE: 3.3) in 1988-1994 to 34.9% (SE: 3.3) in 2005-2008 (P < .001 for trend). Adjusting for age, gender, race/ethnicity, and health insurance status, the odds of PAM use were higher in 2005-2008 compared with 1988-1994 (adjusted odds ratio [aOR] = 2.6; 95% confidence interval [CI]: 1.5-4.5). A multivariate analysis, combining all 3 time periods, showed lower use of PAMs among non-Hispanic black (aOR = 0.5 [95% CI: 0.4-0.7]) and Mexican American (aOR = 0.6 [95% CI: 0.4-0.9]) children compared to non-Hispanic white children. PAM use was also lower in 12 to 19 year olds compared with 1 to 5 year olds and also in children who did not have health insurance compared with those who did.

CONCLUSIONS

Between 1988 and 2008, the use of PAM increased among children with current asthma. Non-Hispanic black and Mexican American children, adolescents aged 12 to 19 years, and uninsured children with current asthma had lower use of PAM.

Parent and child usual source of care and children's receipt of health care services

PURPOSE In the United States, children who have a usual source of care (USC) have better access to health care than those who do not, but little is known about how parental USC affects children's access. We examined the association between child and parent USC patterns and children's access to health care services. METHODS We undertook a secondary analysis of nationally representative, cross-sectional data from children participating in the 2002-2007 Medical Expenditure Panel Survey (n = 56,302). We assessed 10 outcome measures: insurance coverage gaps, no doctor visits in the past year, less than yearly dental visits, unmet medical and prescription needs, delayed care, problems getting care, and unmet preventive counseling needs regarding healthy eating, regular exercise, car safety devices, and bicycle helmets. RESULTS Among children, 78.6% had a USC and at least 1 parent with a USC, whereas 12.4% had a USC but no parent USC. Children with a USC but no parent USC had a higher likelihood of several unmet needs, including an insurance coverage gap (adjusted risk ratio [aRR] 1.33; 95% confidence interval [CI], 1.21-1.47), an unmet medical or prescription need (aRR 1.70; 95% CI 1.09-2.65), and no yearly dental visits (aRR 1.12; 95% CI 1.06-1.18), compared with children with a USC whose parent(s) had a USC. CONCLUSIONS Among children with a USC, having no parent USC was associated with a higher likelihood of reporting unmet needs when compared with children whose parent(s) had a USC. Policy reforms should ensure access to a USC for all family members.

Comparing types of health insurance for children: a public option versus a private option

BACKGROUND

Many states have expanded public health insurance programs for children, and further expansions were proposed in recent national reform initiatives; yet the expansion of public insurance plans and the inclusion of a public option in state insurance exchange programs sparked controversies and raised new questions with regard to the quality and adequacy of various insurance types.

OBJECTIVES

We aimed to examine the comparative effectiveness of public versus private coverage on parental-reported children's access to health care in low-income and middle-income families. METHODS/PARTICIPANTS/MEASURES: We conducted secondary data analyses of the nationally representative Medical Expenditure Panel Survey, pooling years 2002 to 2006. We assessed univariate and multivariate associations between child's full-year insurance type and parental-reported unmet health care and preventive counseling needs among children in low-income (n=28,338) and middle-income families (n=13,160).

RESULTS

Among children in families earning <200% of the federal poverty level, those with public insurance were significantly less likely to have no usual source of care compared with privately insured children (adjusted relative risk, 0.79; 95% confidence interval, 0.63-0.99). This was the only significant difference in 50 logistic regression models comparing unmet health care and preventive counseling needs among low-income and middle-income children with public versus private coverage.

CONCLUSIONS

The striking similarities in reported rates of unmet needs among children with public versus private coverage in both low-income and middle-income groups suggest that a public children's insurance option may be equivalent to a private option in guaranteeing access to necessary health care services for all children.

Electronic health records vs Medicaid claims: completeness of diabetes preventive care data in community health centers

PURPOSE

Electronic Health Record (EHR) databases in community health centers (CHCs) present new opportunities for quality improvement, comparative effectiveness, and health policy research. We aimed (1) to create individual-level linkages between EHR data from a network of CHCs and Medicaid claims from 2005 through 2007; (2) to examine congruence between these data sources; and (3) to identify sociodemographic characteristics associated with documentation of services in one data set vs the other.

METHODS

We studied receipt of preventive services among established diabetic patients in 50 Oregon CHCs who had ever been enrolled in Medicaid (N = 2,103). We determined which services were documented in EHR data vs in Medicaid claims data, and we described the sociodemographic characteristics associated with these documentation patterns.

RESULTS

In 2007, the following services were documented in Medicaid claims but not the EHR: 11.6% of total cholesterol screenings received, 7.0% of total influenza vaccinations, 10.5% of nephropathy screenings, and 8.8% of tests for glycated hemoglobin (HbA(1c)). In contrast, the following services were documented in the EHR but not in Medicaid claims: 49.3% of cholesterol screenings, 50.4% of influenza vaccinations, 50.1% of nephropathy screenings, and 48.4% of HbA(1c) tests. Patients who were older, male, Spanish-speaking, above the federal poverty level, or who had discontinuous insurance were more likely to have services documented in the EHR but not in the Medicaid claims data.

CONCLUSIONS

Networked EHRs provide new opportunities for obtaining more comprehensive data regarding health services received, especially among populations who are discontinuously insured. Relying solely on Medicaid claims data is likely to substantially underestimate the quality of care.

Pediatric urinary tract infections: an analysis of hospitalizations, charges, and costs in the USA

This study evaluates the impact of pediatric urinary tract infection (UTI)s on the economy and inpatient healthcare utilization in the USA. A retrospective analysis of patient demographics and hospital economics was performed on children less than 18 years of age admitted with a UTI between 2000 and 2006 using the Healthcare Cost and Utilization Project Kids' Inpatient Database. Our results were stratified as follows. Hospital admissions-nearly 50,000 children/year were admitted with a UTI. Pediatric UTIs represented 1.8% of all pediatric hospitalizations. Seventy-three percent of patients were female and 40% were under 1 year of age. Payer information-from 2000 to 2006, pediatric insurance coverage shifted from the private sector to the public sector. Hospital cost-in 2000, estimated hospital costs for UTIs were $2,858 per hospitalization and rose to $3,838 by 2006. Mean hospital charges increased from $6,279 to $10,489 per stay. By 2006, aggregate hospital charges exceeded $520 million. Our results indicate that UTIs are among the most common pediatric admission diagnoses. Hospitalization is more common in females and younger children. Since 2000, hospital charges for UTIs increased disproportionately to hospital costs. Over time, more children hospitalized with a UTI depend on public agencies to cover healthcare expense. More efforts are needed to evaluate cost-effective strategies for evaluation and treatment of UTIs.