Health care utilization by children with chronic illnesses: a comparison of medicaid and employer-insured managed care

Racial Disparities in Pediatric Inflammatory Bowel Disease Care: Differences in Outcomes and Health Service Utilization Between Black and White Children

OBJECTIVE

To describe racial inequities in pediatric inflammatory bowel disease care and explore potential drivers.

METHODS

We undertook a single-center, comparative cohort study of newly diagnosed Black and non-Hispanic White patients with inflammatory bowel disease, aged <21 years, from January 2013 through 2020. Primary outcome was corticosteroid-free remission (CSFR) at 1 year. Other longitudinal outcomes included sustained CSFR, time to anti-tumor necrosis factor therapy, and evaluation of health service utilization.

RESULTS

Among 519 children (89% White, 11% Black), 73% presented with Crohn's disease and 27% with ulcerative colitis. Disease phenotype did not differ by race. More patients from Black families had public insurance (58% vs 30%, P < .001). Black patients were less likely to achieve CSFR 1-year post diagnosis (OR: 0.52, 95% CI:0.3-0.9) and less likely to achieve sustained CSFR (OR: 0.48, 95% CI: 0.25-0.92). When adjusted by insurance type, differences by race to 1-year CSFR were no longer significant (aOR: 0.58; 95% CI: 0.33, 1.04; P = .07). Black patients were more likely to transition from remission to a worsened state, and less likely to transition to remission. We found no differences in biologic therapy utilization or surgical outcomes by race. Black patients had fewer gastroenterology clinic visits and 2-fold increased odds for emergency department visits.

CONCLUSIONS

We observed no differences by race in phenotypic presentation and medication usage. Black patients had half the odds of achieving clinical remission, but a degree of this was mediated by insurance status. Understanding the cause of such differences will require further exploration of social determinants of health.

Pediatric obesity and body weight following the COVID-19 pandemic

BACKGROUND

The SARS-CoV-19 pandemic and its associated lockdowns affected children's lifestyle dramatically. The effect of such changes on children's weight and obesity status is unknown. The aim of this study was to compare body weight and obesity rates in children from before the pandemic to 6 months after the major periods of lockdowns in Israel.

METHODS

We used data from medical records of pediatric emergency department visits, where weight is routinely measured, to compare weight and obesity prevalence in the fourth quartile of 2020 (n = 2468) as compared with the fourth quartiles of 2018-2019 (n = 5300). Weight was transformed to age- and sex-specific standard-deviation-scores (SDS) for analysis.

RESULTS

Weight-SDS increased by a mean of 0.07 during the first 6 months of the pandemic, yet this was only significant in preschoolers. Obesity rates also increased in this age group only, by 37%, from 8.1% to 11.1% (p = 0.01).

CONCLUSIONS

Weight-SDS and obesity prevalence increased during the SARS-CoV-19 pandemic, yet only in younger children. Additional studies from other populations are needed.

Utilization of Pediatric Psychology Services in Outpatient Pediatric Gastroenterology Within a Rural Health System

Increased utilization of pediatric psychology services has been demonstrated following integration into urban pediatric gastroenterology clinics; however, examination within rural health systems is lacking. Utilization of pediatric psychology services was assessed through a retrospective analysis of Electronic Health Record data contrasting referrals occurring six months pre- and post-integration of pediatric psychology in an outpatient pediatric gastroenterology clinic within a rural setting. Significant increases in the number of referrals to pediatric psychology and number of billed initial visits were observed after integration, as was a significant decrease in time to be seen. Patients with public insurance were 3.1 times more likely to complete a billed initial visit compared with patients with nonpublic insurance. The current findings support the integration of pediatric psychology within rural outpatient pediatric gastroenterology clinics to increase utilization and allow more traditionally underserved families to benefit from these services.

Trends in Pediatric Private Insurance and Medicaid Spending: A Repeated Cross-Sectional Analysis of Data from 2002 to 2014

Given increased focus on health spending, this investigation aims to compare trends in pediatric Medicaid and private insurance spending on type of service from 2002 to 2014 in order to inform policy and research. A repeated cross-sectional analysis of 2002 to 2014 National Health Expenditure Accounts data was conducted. Total spending, per capita spending, and compounded annual growth rates for type of service were determined for children ages 0 to 18 at the national level. Per capita spending growth was higher for private insurance than for Medicaid, and the areas of high per capita spending growth differed for private insurance and Medicaid. While Medicaid spent more per capita on hospital care than private insurance, private insurance demonstrated greater per capita spending growth on hospital care than Medicaid (8.49% vs 1.99%, respectively). Conversely, per capita spending on home health care grew more for Medicaid (6.79%) than for private insurance (3.18%). Trends in private insurance and Medicaid overall and per capita spending differ. Medicaid experienced higher annual growth in total spending than per capita spending, while private insurance had greater annual growth in per capita spending than total spending. Growth in private insurance per capita spending was higher than growth in Medicaid per capita spending, but growth in Medicaid total spending was higher than growth in private insurance total spending. These data suggest that Medicaid and private insurance may have different drivers of spending growth, highlighting the need for policy makers to examine spending patterns by payer. Further research to determine why such differences in spending growth exist will better inform efforts to increase health care value.

Association of Selective Serotonin Reuptake Inhibitors With the Risk of Type 2 Diabetes in Children and Adolescents

IMPORTANCE

Concerns exist that use of selective serotonin reuptake inhibitors (SSRIs) increases the risk of developing type 2 diabetes (T2D) in adults, but evidence in children and adolescents is limited. In the absence of a randomized clinical trial, evidence must be generated using real-world data.

OBJECTIVE

To evaluate the safety of SSRI use in children and adolescents with respect to the associated risk of T2D.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of patients aged 10 to 19 years with a diagnosis for an SSRI treatment indication was conducted within the nationwide Medicaid Analytic eXtract (MAX; January 1, 2000, to December 31, 2014) and the IBM MarketScan (January 1, 2003, to September 30, 2015) databases. Data were analyzed from November 1, 2018, to December 6, 2019.

EXPOSURES

New users of an SSRI medication and comparator groups with no known metabolic adverse effects (no antidepressant exposure, bupropion hydrochloride exposure, or psychotherapy exposure). Within-class individual SSRI medications were compared with fluoxetine hydrochloride.

MAIN OUTCOMES AND MEASURES

Incident T2D during follow-up. Intention-to-treat effects were estimated using Cox proportional hazards regression models, adjusting for confounding through propensity score stratification. As-treated effects to account for continuous treatment were estimated using inverse probability weighting and marginal structural models.

RESULTS

A total of 1 582 914 patients were included in the analysis (58.3% female; mean [SD] age, 15.1 [2.3] years). The SSRI-treated group included 316 178 patients in the MAX database (publicly insured; mean [SD] age, 14.7 [2.1] years; 62.2% female) and 211 460 in the MarketScan database (privately insured; mean [SD] age, 15.8 [2.3] years; 63.9% female) with at least 2 SSRI prescriptions filled, followed up for a mean (SD) of 2.3 (2.0) and 2.2 (1.9) years, respectively. In publicly insured patients, initiation of SSRI treatment was associated with a 13% increased hazard of T2DM (intention-to-treat adjusted hazard ratio [aHR], 1.13; 95% CI, 1.04-1.22) compared with untreated patients. The association strengthened for continuous SSRI treatment (as-treated aHR, 1.33; 95% CI, 1.21-1.47), corresponding to 6.6 (95% CI, 4.2-10.4) additional cases of T2D per 10 000 patients treated for at least 2 years. Adjusted HRs were lower in privately insured patients (intention-to-treat aHR, 1.01 [95% CI, 0.84-1.23]; as-treated aHR, 1.10 [95% CI, 0.88-1.36]). Findings were similar when comparing SSRI treatment with psychotherapy (publicly insured as-treated aHR, 1.44 [95% CI, 1.25-1.65]; privately insured as-treated aHR, 1.21 [95% CI, 0.93-1.57]), whereas no increased risk was observed compared with bupropion treatment publicly insured as-treated aHR, 1.01 [95% CI, 0.79-1.29]; privately insured as-treated aHR, 0.87 [95% CI, 0.44-1.70]). For the within-class analysis, no medication had an increased hazard of T2D compared with fluoxetine.

CONCLUSIONS AND RELEVANCE

These findings suggest that children and adolescents initiating SSRI treatment may be at a small increased risk of developing T2D, particularly publicly insured patients. The magnitude of association was more modest than previously reported, and the absolute risk was small. The potential small risk should be viewed in relation to the efficacy of SSRIs for its major indications in young patients.

The direct cost of epilepsy in children: Evidence from the Medical Expenditure Panel Survey, 2003-2014

INTRODUCTION

Epilepsy is frequent in children and often requires complex healthcare interventions. There is a paucity of recent and detailed healthcare expenditures among children with epilepsy in the United States (US).

METHODS

Data on children (aged ≤17years) from the Medical Expenditure Panel Survey-Household Component (MEPS-HC) from 2003 to 2014 were analyzed. Unadjusted overall and specific cost components were compared between children with epilepsy and those without epilepsy. We used a two-part model with gamma distribution and log link for the estimation of independent incremental cost incurred by epilepsy in children. Unadjusted and adjusted mean expenditures and aggregate burden of epilepsy were estimated.

RESULTS

Out of 54,393,387 (weighted) US children, 457,873 (0.84%) had epilepsy. Children with epilepsy had nearly six times higher healthcare expenditure than those without epilepsy ($2024 [95% confidence interval (CI): 1917-2130] vs. $12,577 [95% CI: 7922-17,231]). Unadjusted inpatient expenditure for epilepsy ($4418 [95% CI: 1550-7285) was ten times higher than that for children without epilepsy, representing more than one-third of unadjusted total direct cost. The adjusted difference in medical expenditure between children with and those without epilepsy was $8317 (95% CI: 3701-13,363). The annual unadjusted aggregate cost of epilepsy in children was approximately $5.8 billion. The annual adjusted difference in cost of epilepsy between children with and those without epilepsy was $3.8 billion.

CONCLUSION

Unadjusted and adjusted medical expenditure among children with epilepsy is high. The high expenditure is essentially driven not only by inpatient expenditure but also by home healthcare, outpatient, and medication healthcare expenditures.

Factors that Affect Nonurgent Emergency Department Visits in a Publicly Insured Pediatric Population: An Observational Study

BACKGROUND

Publicly insured children have high rates of nonurgent emergency department visits (LAVs). The factors that drive consumption of these services are unknown.

METHODS

Demographics, emergency department visits, hospitalizations, missed preventative care appointments, zip code, and asthma status as factors for LAVs were determined by univariate, multivariate, and classification/regression tree analysis. Subjects were publicly insured and received care between March 1 and December 31, 2011.

RESULTS

A total of 4,387 children were identified; 856 (19.5%) had at least 1 nonurgent and 1,173 (26.7%) had at least 1 urgent emergency department visit; 526 (12%) missed ≥2 primary care appointments and 779 children had asthma. By univariate analysis, at least one high acuity emergency department visit, hospitalization during the study period, and asthma were directly associated with LAVs; age was inversely related. Multivariate and classification tree analyses identified children younger than 31.5 months with at least 1 high acuity emergency department visit as the highest risk group (0.807 visits per patient; 95% confidence interval: 0.699-0.916, p < .00001). Missed appointments, asthma status, hospitalizations, zip code of residence, and gender were not significant factors.

CONCLUSIONS

Young age and at least one high acuity emergency department visit are associated with high rates of nonurgent emergency department use among publicly insured children.

Nationwide Healthcare utilization among children with epilepsy in the United States: 2003-2014

BACKGROUND

Epilepsy is particularly frequent among children, yet updated and nationwide healthcare utilization estimates are scanty in the United States.

OBJECTIVE

To analyze healthcare utilization among children with epilepsy.

METHODS

Data on children (≤17-year-old) were extracted from the Medical Expenditure Panel Survey (MEPS) 2003-2014. Epilepsy was identified using the clinical classification code 83. Healthcare utilization (Inpatient admission, outpatient visits, prescription medication including refill, emergency room visits, and home health provider visits) was compared between children with epilepsy and those without epilepsy. A negative binomial model was used to assess the relationship between epilepsy and healthcare utilizations accounting for the influence of extraneous factors.

RESULTS

In all, a weighted 457,873 children (0.84%) had epilepsy in United States. The unadjusted proportion and the mean annual number of health care service utilization were higher in children with epilepsy compared to those without epilepsy. Children with epilepsy had almost 3.3 more outpatient visits (95% CI: 2.281-4.274), 7.9 more medication prescriptions including refills (95% CI: 6.058-9.662), nearly 0.4 more emergency department visits (95% CI: 0.278-0.438) and nearly 12 more home health provider visits (95% CI: 1.988-21.756) than those without epilepsy. The adjusted marginal effect of epilepsy on inpatient admission was not statistically significant.

CONCLUSION

unadjusted and adjusted healthcare utilization is considerably higher in children with epilepsy compared to those without epilepsy in the United States with heterogeneity across individual services.

Variation in access to pediatric surgical care among coexisting public and private providers: inguinal hernia as a model

BACKGROUND

Faced with growing healthcare demand, the Saudi government is increasingly relying on privatization as a tool to improve patient access to care. Variation in children's access to surgical care between public (PB) and private providers (PV) has not been previously analyzed.

OBJECTIVES

To compare access to pediatric surgical services between two coexisting PB and PV.

DESIGN

Retrospective comparative study.

SETTINGS

A major teaching hospital and the largest PV group in Saudi Arabia.

PATIENTS AND METHODS

The outcomes for children who underwent inguinal herniotomy (IH) between May 2010 and December 2014 at both providers were with IH serving as the model. Data collected included patient demographics, insurance coverage, referral pattern and access parameters including time-to-surgery (TTS), surgery wait time (SWT) and duration of symptoms (DOS).

MAIN OUTCOME MEASURE(S)

TTS, SWT and DOS.

RESULTS

Of 574 IH cases, 56 cases of in-hospital referrals were excluded leaving 290 PB and 228 PV cases. PV patients were younger (12.0 vs 16.4 months, P=.043) and more likely to be male (81.6% vs 72.8%, P=.019), expatriates (18% vs 3.4%, P < .001) and insured (47.4% vs 0%, P < .001). The emergency department was more frequently the source for PB referrals (35.2% vs 12.7%, P < .001) while most PV patients were self-referred (72.8% vs 16.7%, P < .001). Access parameters were remarkably better at PV: TTS (21 vs 66 days, P < .001), SWT (4 vs 31 days, P < .001) and DOS (33 vs 114 days, P < .001).

CONCLUSION

When coexisting, PV offers significantly better access to pediatric surgical services compared to PB. Diverting public funds to expand children's access to PV can be a valid choice to improve access to care in case when outcomes with the two providers are similar.

LIMITATIONS

Although it is the first and largest comparison in the pediatric population, the sample may not represent the whole population since it is confined to a single selected surgical condition.

Outcomes for Children with Chronic Conditions Associated with Parent- and Provider-reported Measures of the Medical Home

PURPOSE

Assess relationships between having a patient-centered medical home (PCMH) and health care utilization among low-income children with chronic conditions using parent and practice perspectives.

METHODS

We analyzed data from 240 publicly insured children with chronic conditions. Parents completed surveys assessing PCMH access and their child's primary care practice completed the Medical Home Index (MHI) self-assessment. Multivariate negative binomial analyses were conducted to investigate relationships between PCMH and service use.

RESULTS

Parent-report of a usual source of care was associated with lower rates of emergency care (ED) encounters and hospitalizations. Practice report of higher organizational capacity (e.g., communication, staff education) was associated with lower rates of ED visits and hospitalizations. Parent report of a PCMH was positively associated with practice MHI score.

CONCLUSIONS

Among low-income children with chronic conditions, having a usual source of care and higher quality organizational capacity were associated with lower rates of ED visits and hospitalizations.

Saudi SCD patients' symptoms and quality of life relative to the number of ED visits

Background

Individuals living with sickle cell disease (SCD) have significantly increased emergency department (ED) use compared to the general population. In Saudi Arabia, health care is free for all individuals and therefore has no bearing on increased ED visits. However, little is known about the relationship between quality of life (QoL) and frequency of acute care utilization in this patient population.

Methods

A cross-sectional study was conducted on 366 patients with SCD who attended the outpatient department at King Fahad Hospital, Hofuf, Saudi Arabia. Data were collected through self-administered surveys, which included: demographics, SCD-related ED visits, clinical issues, and QoL levels. We assessed the ED use by asking for the number of SCD-related ED visits within a 6-month period.

Results

The self-report survey of ED visits was completed by 308 SCD patients. The median number of SCD-related ED visits within a 6-month time period (IQR) was four (2-7 visits). According to the unadjusted negative binomial model, the rate of SCD-related ED visits increased by (46, 39.3, 40, and 53.5 %) for patients with fever, skin redness with itching, swelling, and blood transfusion, respectively. Poor QoL tends to increase the rate of SCD-related ED visits. Well education and poor general health positively influenced the rate of SCD-related ED visits. Well education tends to increase the rate of SCD-related ED visits by 50.2 %. The rate of SCD-related ED visits decreased by 1.4 % for every point increase in general health.

Conclusion

Saudi patients with sickle cell disease reported a wide range of SCD-related ED visits. It was estimated that six of 10 SCD patients had at least three ED visits within a 6-month period. Well education and poor general health resulted in an increase in the rate of SCD-related ED visits.

National trends in off-label use of atypical antipsychotics in children and adolescents in the United States

The objectives of the study were as follows: to examine the national trend of pediatric atypical antipsychotic (AAP) use in the United States; to identify primary mental disorders associated with AAPs; to estimate the strength of independent associations between patient/provider characteristics and AAP use. Data are from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. First, average AAP prescription rates among 4 and 18-year-old patients between 1993 and 2010 were estimated. Second, data from 2007 to 2010 were combined and analyzed to identify primary mental disorders related to AAP prescription. Third, a multivariate logistic regression model was developed having the presence of AAP prescription as the dependent variable and patient/provider characteristics as explanatory variables. Adjusted odds ratios (AORs) with associated 95% confidence intervals (CIs) were estimated. Outpatient visits including an AAP prescription among 4 to 18-year-old patients significantly increased between 1993 and 2010 in the United States, and over 65% of those visits did not have diagnoses for US Food and Drug Administration-approved AAP indications. During 2007 to 2010, the most common mental disorder was attention-deficit hyperactivity disorder, accounting for 24% of total pediatric AAP visits. Among visits with attention-deficit hyperactivity disorder diagnosis, those with Medicaid as payer (AOR 1.66, 95% CI 1.01-2.75), comorbid mental disorders (e.g., psychoses AOR 3.34, 95% CI 1.35-8.26), and multiple prescriptions (4 or more prescriptions AOR 4.48, 95% CI 2.08-9.64) were more likely to have an AAP prescription. The off-label use of AAPs in children and adolescents is prevalent in the United States. Our study raises questions about the potential misuse of AAPs in the population.

Self-Management and Health Care Use in an Adolescent and Young Adult Medicaid Population With Differing Chronic Illnesses

INTRODUCTION

Few studies of adults question the validity of the claim that self-management reduces the use of health care services and, as a result, health care costs. The aim of our study was to determine the relationship between self-management and health care use in a population of adolescent and young adult recipients of North Carolina Medicaid with chronic health conditions, who received care in either the pediatric or adult clinic. Our secondary objective was to characterize the patterns of health care use among this same population.

METHODS

One hundred and fifty adolescents or young adults aged 14 to 29 were recruited for this study. Participants completed a demographics questionnaire and the self-management subdomain of the University of North Carolina TRxANSITION Scale. Information on each participant's emergency department and inpatient use was obtained by using the North Carolina Medicaid Provider Portal.

RESULTS

This cohort had a high level of emergency health care use; average lifetime use was 3.18 (standard deviation [SD], 5.58) emergency department visits, 2.02 (SD, 3.42) inpatient visits, and 12.5 (SD, 23.9 ) days as an inpatient. Age group (pediatric or adult), diagnosis, race/ethnicity, and sex were controlled for in all analyses. Results indicate that patients with a high rate of disease self-management had more emergency department visits and hospitalizations and a longer length of stay in the hospital than did those with a low rate.

CONCLUSION

In a group of North Carolina Medicaid recipients with chronic conditions, better self-management is associated with more health care use. This is likely the result of many factors, including more interactions with health care professionals, greater ability to recognize the need for emergency medical attention, and the use of the emergency department for primary health care.

Atypical antipsychotic initiation and the risk of type II diabetes in children and adolescents

PURPOSE

To estimate the risk of type II diabetes (T2DM) in children and adolescents initiating atypical antipsychotic (AAP) therapy.

METHODS

We conducted a retrospective cohort study using a new user design approach. Medical and pharmacy claims data between 1 January 2007 and 31 December 2009 for dependents ages 4 to 18 from an employed, commercially insured population from across the USA were included. AAP exposure was defined in the presence of a pharmacy claim preceded by at least six months of AAP-free history. We used propensity score (PS) methodology to identify and match incident AAP users and non-users. New-onset T2DM, was defined based on medical and pharmacy claims. Follow-up was extended until the date of new-onset T2DM or the end of the study period. The risk of T2DM was evaluated in an intent to treat fashion using the Kaplan-Meier estimator and Cox proportional hazard regression that provided hazard ratio (HR) and associated 95% confidence interval (CI).

RESULTS

Our study population included 6236 new AAP users and 22 080 non-users. In this PS-matched sample, the estimated risk of T2DM was twice as high in AAP users as non-users (HR 2.18, 95% CI 1.45-3.29). Noticeable risk differences between AAP-treated and control groups materialized within four months of AAP initiation and became constant after six months until the end of the follow-up.

CONCLUSIONS

Children and adolescents who were prescribed an AAP medication had a two times higher risk of developing T2DM; our study raises questions about continued AAP use in children and adolescents.

Cost analysis of tonsillectomy in children using medicaid data

OBJECTIVE

To evaluate the cost-effectiveness of adenotonsillectomy (T&A) for adenotonsillar hypertrophy and recurrent tonsillitis through the use of Missouri Medicaid data.

STUDY DESIGN

Children ages 2-16 years who had a diagnosis of adenotonsillar hypertrophy (based on medical claim codes) in 2006 (n = 4276) were included in this population-based study. The main outcome was direct total costs paid by Medicaid. Costs 2 years before and after T&A were compared in children who underwent surgical intervention with those who did not as well as costs comparison pre- and post-T&A. Wilcoxon rank-sum or Wilcoxon Signed-rank test was used for costs comparisons.

RESULTS

Children with adenotonsillar hypertrophy who underwent T&A were significantly less likely to be African American. They had more adenotonsillar infections before undergoing T&A and greater total costs (median costs $2313 vs. $1945; P = .009). The median costs were $1228 pre-T&A, compared with $823 post-T&A (P < .0001). This reduction in costs of $405 (33%) compares with a median cost of the procedure of $1088. The reduction in costs was mostly because of less antibiotic use and outpatient visits.

CONCLUSIONS

African American children have fewer T&A procedures for adenotonsillar hypertrophy than white children, which represents an unexplained racial disparity. Children with adenotonsillar hypertrophy who underwent T&A compared with those who did not had more adenotonsillar infections and greater health care costs. T&A leads to a reduction in costs that, after 2 years, is 37% of the costs of the procedure. Future studies should examine the effects of demographics, obesity, and disease severity on health care costs in children with adenotonsillar hypertrophy.

Regional differences in healthcare delivery for gastroparesis

AIM

Few studies have examined the effects of various interventions in gastroparesis. The goal of the present study was to determine whether inpatient management and outcomes differed among states across the United States.

METHODS

Using population statistics and the State Inpatient Database (Agency for Healthcare Research and Quality), regional differences in admissions for gastroparesis, inpatient mortality, length of stay, nursing home transfers, and rates of endoscopy, gastrostomy placement, and nutritional support were assessed.

RESULTS

Admissions for gastroparesis ranged from 24.3 ± 0.8/100,000 in Utah to 117.1 ± 9.7/100,000 in Maryland, with mortality rates similarly varying fourfold from 0.5 ± 0.1/100,000 in Colorado to 2.3 ± 0.1/100,000 in Florida. Intervention rates differed between states (endoscopy: 6.8 ± 0.8 % in Wyoming versus 23.1 ± 0.4 % in Florida; gastrostomy: 0.8 ± 0.1 % in North Carolina versus 3.3 ± 0.8 % in Hawaii; nutritional support: 1.2 ± 0.2 % in West Virginia versus 7.0 ± 0.6 % in New Jersey). Admissions rates were independently predicted by high overall hospitalizations within a state. Higher population density, median incomes and admissions to for-profit hospitals correlated with endoscopy rates. Coexisting heart failure and male gender were associated with higher likelihood of gastrostomy placement, while initiation of nutritional support was predicted by physician supply and insurance status. Age cohort, Medicare coverage, poverty rates and endoscopic testing independently predicted mortality, while length of stay correlated with diagnostic and therapeutic interventions.

CONCLUSIONS

There is a significant variability in admissions, interventions and outcomes for gastroparesis. While biological factors, such as comorbidities and age, contribute to this variability, the data suggest that socioeconomic variables significantly affect approaches to gastroparesis treatment in the United States.

Regional differences in hospitalizations and cholecystectomies for biliary dyskinesia

Background/Aims

Published studies suggest that socioeconomic factors contribute to increasing cholecystectomy rates for biliary dyskinesia (BD). The aim of this study was to identify factors driving admissions and operations for BD by examining regional variability in hospitalizations and cholecystectomies for this disorder.

Methods

Annual hospitalizations and cholecystectomy rates for biliary diseases were assessed using the State Inpatient Databases of the Agency for Healthcare Research and Quality based on diagnosis codes for biliary dyskinesia, cholecystolithiasis and cholecystitis.

Results

Annual admissions for BD varied nearly sevenfold among different states within the United States. Hospitalizations for gallstone disease and its complication showed less variability, differing 2-fold between states. Nearly 70% of admissions for BD and about 85% of admissions for gallstone disease resulted in cholecystectomies. Higher admission rates for BD were best predicted by high overall hospitalization rates, admission rate for gallstone disease and the physician workforce within a state. Cholecystectomy rates for BD were higher in states with low population density and high rates of cholecystectomy for gallstone disease.

Conclusions

These data suggest that established medical practice patterns significantly contribute to the variability in admissions and operations for biliary dyskinesia. The findings also indicate that lower thresholds for operative interventions are an important determinant in the approach to this disorder. Considering the benign course of functional illnesses, the bar for surgical interventions should be raised rather than lowered; in addition active conservative treatment options should be developed for these patients.

Disparity in preoperative patient factors between insurance types in total joint arthroplasty

Equity in health care has become a focal point of debate. However, the disparity between insurance payer types in total joint arthroplasty is poorly defined. The authors identified 1312 consecutive patients who underwent elective primary total hip or knee arthroplasty with available preoperative Short Form 36 and Western Ontario and McMaster University Osteoarthritis Index surveys and stratified them into groups based on insurance type (Iowa Care [a state-run insurance program for patients who are indigent], Medicare, Medicaid, or private insurance) to compare demographics, access to care, and functional data. Significance was a P value less than .05 after a Turkey-Kramer adjustment for multiple comparisons. A multivariate analysis identified independent predictors of Short Form 36 and Western Ontario and McMaster University Osteoarthritis Index preoperative functional status. Few differences existed between patients with Iowa Care and Medicaid, but both groups had significantly lower Short Form 36 and Western Ontario and McMaster University Osteoarthritis Index scores across every category compared with patients with Medicare or private insurance (P<.05 for each comparison). In addition, patients with Iowa Care and Medicaid had a higher incidence of current smoking and higher mean body mass index and traveled an average of 29 to 30 miles farther for access to care (P<.05 for each comparison). Payer type was an independent predictor of preoperative Short Form 36 and Western Ontario and McMaster University Osteoarthritis Index functional scores in the multivariate analysis (P<.02). Significant differences exist between payer types in total joint arthroplasty. Further research is necessary to better inform health policy decisions.

Disparity in total joint arthroplasty patient comorbidities, demographics, and postoperative outcomes based on insurance payer type

Little is known about how patient characteristics differ between insurance types. We reviewed 293 consecutive primary total joint arthroplasty patients with 12-month follow-up and stratified them based on insurance type. As compared with patients with either Medicare or private insurance, Medicaid patients traveled an extra 160 to 170 miles for access to care, both Iowa Care and Medicaid were more than 3 times more likely to be current smokers, and both Iowa Care and Medicaid had lower preoperative and 12-month postoperative 36-Item Short Form Health Survey and WOMAC outcomes scores. Payer type was a significant predictor of 36-Item Short Form Health Survey physical function at final follow-up in a multivariate analysis. Significant disparities exist between patients with different insurance payer types in total joint arthroplasty, and further research into these differences is necessary.

Factors that predict frequency of emergency department utilization in children with diabetes-related complaints

OBJECTIVES

The primary purpose of the study was to determine the factors that are associated with repeat emergency department (ED) visits in children with diabetes.

METHODS

Emergency department charts and billing data for children up to 18 years of age presenting to the ED with diabetic diagnoses over a 4-year period were reviewed.

RESULTS

The overall rate of repeat visits to the ED was 0.24 visits per person-year of follow-up time. In univariate analyses, there were statistically significant effects of age, insurance category, sex, type of practice, and income. In a multivariate analysis, there was a significant interaction of insurance category and age. Revisit rate ratios for children older than 6 years were higher for those with Medicaid compared with those with commercial insurance. Diabetic boys were less likely to revisit the ED than were girls.

CONCLUSIONS

Type of insurance was associated with repeated visits to the ED in children with diabetes. Other contributing factors included age group and sex.

Risk factors for increased ED utilization in a multinational cohort of children with sickle cell disease

OBJECTIVES

The objective was to identify clinical, social, and environmental risk factors for increased emergency department (ED) use in children with sickle cell disease (SCD).

METHODS

This study was a secondary analysis of ED utilization data from the international multicenter Silent Cerebral Infarct Transfusion (SIT) trial. Between December 2004 and June 2010, baseline demographic, clinical, and laboratory data were collected from children with SCD participating in the trial. The primary outcome was the frequency of ED visits for pain. A secondary outcome was the frequency of ED visits for acute chest syndrome.

RESULTS

The sample included 985 children from the United States, Canada, England, and France, for a total of 2,955 patient-years of data. There were 0.74 ED visits for pain per patient-year. A past medical history of asthma was associated with an increased risk of ED utilization for both pain (rate ratio [RR] = 1.28, 95% confidence interval [CI] = 1.04 to 1.58) and acute chest syndrome (RR = 1.60, 95% CI = 1.03 to 2.49). Exposure to environmental tobacco smoke in the home was associated with 73% more ED visits for acute chest syndrome (RR = 1.73, 95% CI = 1.09 to 2.74). Each $10,000 increase in household income was associated with 5% fewer ED visits for pain (RR = 0.95, 95% CI = 0.91 to 1.00, p = 0.05). The association between low income and ED utilization was not significantly different in the United States versus countries with universal health care (p = 0.51).

CONCLUSIONS

Asthma and exposure to environmental tobacco smoke are potentially modifiable risk factors for greater ED use in children with SCD. Low income is associated with greater ED use for SCD pain in countries with and without universal health care.

Validation of classification algorithms for childhood diabetes identified from administrative data

OBJECTIVE

Type 1 diabetes is the most common form of diabetes among children; however, the proportion of cases of childhood type 2 diabetes is increasing. In Canada, the National Diabetes Surveillance System (NDSS) uses administrative health data to describe trends in the epidemiology of diabetes, but does not specify diabetes type. The objective of this study was to validate algorithms to classify diabetes type in children <20 yr identified using the NDSS methodology.

PATIENTS AND METHODS

We applied the NDSS case definition to children living in British Columbia between 1 April 1996 and 31 March 2007. Through an iterative process, four potential classification algorithms were developed based on demographic characteristics and drug-utilization patterns. Each algorithm was then validated against a gold standard clinical database.

RESULTS

Algorithms based primarily on an age rule (i.e., age <10 at diagnosis categorized type 1 diabetes) were most sensitive in the identification of type 1 diabetes; algorithms with restrictions on drug utilization (i.e., no prescriptions for insulin ± glucose monitoring strips categorized type 2 diabetes) were most sensitive for identifying type 2 diabetes. One algorithm was identified as having the optimal balance of sensitivity (Sn) and specificity (Sp) for the identification of both type 1 (Sn: 98.6%; Sp: 78.2%; PPV: 97.8%) and type 2 diabetes (Sn: 83.2%; Sp: 97.5%; PPV: 73.7%).

CONCLUSIONS

Demographic characteristics in combination with drug-utilization patterns can be used to differentiate diabetes type among cases of pediatric diabetes identified within administrative health databases. Validation of similar algorithms in other regions is warranted.

Persistence of stimulants in children and adolescents with attention-deficit/hyperactivity disorder

OBJECTIVE

To examine the persistence of three newly initiated stimulant preparations among Medicaid children and adolescents with attention-deficit/hyperactivity disorder (ADHD) diagnosis.

METHODS

A retrospective longitudinal claims analysis was conducted by using Medicaid analytical eXtract data of four states. The study focused on patients between 6 and 19 years of age with ADHD diagnosis and a stimulant prescription from January 2003 to December 2005. Stimulants were grouped into short-acting stimulants (SAS), intermediate-acting stimulants (IAS), and long-acting stimulants (LAS). Persistence was measured by totaling the number of days the patient remained on the index stimulant therapy from the index prescription date provided the refill gap between two consecutive stimulant claims was no more than 30 days. All the stimulant recipients were uniformly followed for 1 year (365 days). Survival time ratios (STR) were calculated by using accelerated failure time models to examine variation in index stimulant persistence for each stimulant class.

RESULTS

Among the 46,135 patients with ADHD continuously followed for 1 year, 8,260 were SAS users, 4,314 were IAS users, and 33,561 were LAS users. Children who received IAS medications had 4% shorter persistence (STR, 0.96 [95% confidence interval [CI], 0.93-0.98]) when compared with those who received SAS medications, whereas those who received index LAS medications had 29% longer persistence (STR, 1.29 [95% CI, 1.27-1.32]). Multivariate accelerated failure time models revealed that Blacks and Hispanics had consistently lower persistence than their counterparts. Foster care was positively associated with index stimulant persistence in the three stimulant types. Further, addition of another stimulant and other psychotropic medications significantly improved persistence of index stimulant in all three stimulant classes.

CONCLUSIONS

LAS had comparatively longer persistence than other stimulants. An understanding of demographic and clinical characteristics that influence treatment continuation can help improve stimulant persistence rates in ADHD.

Health care expenditures for Medicaid-covered males with haemophilia in the United States, 2008

Although haemophilia is an expensive disorder, no studies have estimated health care costs for Americans with haemophilia enrolled in Medicaid as distinct from those with employer-sponsored insurance (ESI). The objective of this study is to provide information on health care utilization and expenditures for publicly insured people with haemophilia in the United States in comparison with people with haemophilia who have ESI. Data from the MarketScan Medicaid Multi-State, Commercial and Medicare Supplemental databases were used for the period 2004-2008 to identify cases of haemophilia and to estimate medical expenditures during 2008. A total of 511 Medicaid-enrolled males with haemophilia were identified, 435 of whom were enrolled in Medicaid for at least 11 months during 2008. Most people with haemophilia qualified for Medicaid based on 'disability'. Average Medicaid expenditures in 2008 were $142,987 [median, $46,737], similar to findings for people with ESI. Average costs for males with haemophilia A and an inhibitor were 3.6 times higher than those for individuals without an inhibitor. Average costs for 56 adult Medicaid enrollees with HCV or HIV infection were not statistically different from those for adults without the infection, but median costs were 1.6 times higher for those treated for blood-borne infections. Haemophilia treatment can lead to high costs for payers. Further research is needed to understand the effects of public health insurance on haemophilia care and expenditures, to evaluate treatment strategies and to implement strategies that may improve outcomes and reduce costs of care.

Validation of diabetes case definitions using administrative claims data

AIMS

  Our aim was to validate three diabetes case definitions for children and adolescents aged <20 years in Canada using administrative and clinical data in the province of British Columbia.

METHODS

  We identified potential cases of diabetes from physician claims, hospitalizations and prescription drug records between 1992/1993 and 2007/2008 using the three different case definitions, which included a national standard as well as two regionally developed case definitions. Each case definition used a different combination of administrative data; however, only one definition used prescription drug records. The sensitivity of each definition was calculated against the 'gold standard' of diagnosed cases recorded in British Columbia's Children's Hospital Endocrinology and Diabetes Unit clinical database.

RESULTS

  During this time period, 2611 patients were seen at the British Columbia's Children's Hospital. The sensitivities (95% CIs) of the national and two regional case definitions were 0.95 (0.941-0.958), 0.97 (0.964-0.977) and 0.82 (0.800-0.830), respectively.

CONCLUSIONS

  Our results highlight the benefit of regional case definitions that exploit the availability of different data sources, but also support that a nationally derived definition is sensitive among children and adolescents.

The effects of gatekeeping: a systematic review of the literature

OBJECTIVE

To assess the effects of physician-centred gatekeeping on health, health care utilization, and costs by conducting a systematic review of the literature.

METHODS

Systematic search in PubMed (MEDLINE and Pre-MEDLINE), EMBASE, and the Cochrane Library, from the databases' respective inception dates up to January 2010, using the search words "gatekeeping", "gatekeeper*", "first contact", and "self-referral". We included RCTs, CCTs, cohort studies, CBAs, and interrupted time-series. We included only studies in which the gatekeeper function was exercised by a physician and that reported health and patient-related outcomes including quality of life and satisfaction, quality of care, health care utilization, and/or economic outcomes (e.g. expenditures or efficiency). Selection was made independently by two reviewers and discrepancies were solved by consensus after discussion. Data on target population, intervention, additional interventions, study results, and methodological quality were extracted. Methodological quality was assessed independently by two reviewers following the previously defined criteria. Discrepancies were solved by consensus after discussion.

RESULTS

This review includes 26 studies in 32 publications. The majority of studies (62%) reported data from the United States and in most gatekeeping was associated with lower utilization of health services (up to -78%) and lower expenditures (up to -80%). However, there was great variability in the magnitude and direction of the differences.

CONCLUSION

Overall, the evidence regarding the effects of gatekeeping is of limited quality. Many studies are available regarding the effects on health care utilisation and expenditures, whereas effects on health and patient-related outcomes have been studied only exceptionally and are inconclusive.

Administrative data sets and health services research on hemoglobinopathies: a review of the literature

CONTEXT

Large administrative healthcare data sets are an important source of data for health services research on sickle cell disease (SCD) and thalassemia. This paper identifies and describes major U.S. healthcare administrative databases and their use in published health services research on hemoglobinopathies.

EVIDENCE ACQUISITION

Publications that used U.S. administrative healthcare data sets to assess healthcare use or expenditures were identified through PubMed searches using key words for SCD and either costs, expenditures, or hospital discharges; no additional articles were identified by using thalassemia as a key word. Additional articles were identified through manual searches of related articles or reference lists.

EVIDENCE SYNTHESIS

A total of 26 original health services research articles were identified. The types of administrative data used for health services research on hemoglobinopathies included federal- and state-specific hospital discharge data sets and public and private health insurance claims databases. Gaps in recent health services research on hemoglobin disorders included a paucity of research related to thalassemia, few studies of adults with hemoglobinopathies, and few studies focusing on emergency department or outpatient clinic use.

CONCLUSIONS

Administrative data sets provide a unique means to study healthcare use among people with SCD or thalassemia because of the ability to examine large sample sizes at fairly low cost, resulting in greater generalizability than is the case with clinic-based data. Limitations of administrative data in general include potential misclassification, under-reporting, and lack of sociodemographic information.

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.

Timeliness of Primary Cleft Lip/Palate Surgery

Objective:

To examine the timeliness of primary cleft surgery, mean age at which surgery occurred, and factors associated with timely cleft surgery among children with orofacial clefts (OFCs).

Design:

Retrospective study of children with OFC using North Carolina vital statistics, birth defects registry, and Medicaid files.

Participants/Patients:

Medicaid-enrolled North Carolina resident children with OFC born from 1995 to 2002.

Main Outcome Measures:

Proportion of children who underwent primary cleft surgery within 18 months of life, mean age when surgery occurred, and factors associated with timely surgery.

Results:

406 children with OFC were continuously enrolled in Medicaid during the first 2 years of life. Overall, 78.1% of children had surgery within 18 months. About 90% of children with cleft lip (CL), 58.0% of children with cleft palate (CP), and 89.6% of children with cleft lip and palate (CLP) received timely cleft surgery; the mean age at which surgery occurred was 5 months. Children whose mothers received maternity care coordination, received prenatal care at a local health department, or lived in the southeastern or northeastern region of the state were more likely to receive timely cleft surgery.

Conclusion:

Most children with OFC in North Carolina born during this time period received primary cleft surgery within 18 months of life, but this varied by maternal demographics and other factors.

Changes in the health burden of a national sample of children with asthma

This paper focused on the extent to which factors that are modifiable by health policies or provider recommendations influenced the level and changes in the burden of childhood asthma. Demographic factors, access to health care services, and asthma control activities were posited to potentially influence the level and changes in health burden of children with asthma. The Medical Expenditure Panel Survey data from 1996-1999 on 3-11 year old U.S. children with asthma (N=784) were used. The findings of multilevel models of perceived burden indicated unfavorable trajectories among those families who had public health insurance. Asthma control activities were associated with favorable trajectories of both perceived and objectively measured burden. These findings emphasized the significance of asthma control and access to high quality and stable health care services as health policy targets.

Health care utilization and expenditures for privately and publicly insured children with sickle cell disease in the United States

BACKGROUND

There are no current national estimates on health care utilization and expenditures for US children with sickle cell disease (SCD).

PROCEDURE

We used the MarketScan Medicaid Database and the MarketScan Commercial Claims and Encounters Database for 2005 to estimate health services use and expenditures. The final samples consisted of 2,428 Medicaid-enrolled and 621 privately insured children with SCD.

RESULTS

The percentage of children with SCD enrolled in Medicaid with an inpatient admission was higher compared to those privately insured (43% vs. 38%), yet mean expenditures per admission were 35% lower ($6,469 vs. $10,013). The mean number of emergency department (ED) visits was 49% higher for Medicaid-enrolled children compared to those with private insurance (1.36 vs. 0.91), but mean expenditures per ED visit were 28% lower. The mean number of non-ED outpatient visits was similar (12.6 vs. 11.5) but mean expenditures were 40% lower for the Medicaid-enrolled children ($3,557 vs. $5,908). The mean expenditures on drug claims were higher among those with Medicaid than private insurance ($1,049 vs. $531). Mean total expenditures for children with SCD enrolled in Medicaid were 25% lower than for privately insured children ($11,075 vs. $14,722). The samples were comparable with respect to SCD-related inpatient discharge diagnoses and use of outpatient blood transfusions.

CONCLUSIONS

Children with SCD enrolled in Medicaid had lower expenditures than privately insured children, despite higher utilization of medical care, which indicates lower average reimbursements. Research is needed to assess the quality of care delivered to Medicaid-enrolled children with SCD and its relation to health outcomes.

The cost of health care for children and adults with sickle cell disease

Although sickle cell disease (SCD) is marked by high utilization of medical resources, the full cost of care for patients with SCD, including care not directly related to SCD, is unknown. The purpose of this study was to estimate the total cost of medical care for a population of children and adults with SCD. We used data from individuals diagnosed with SCD enrolled in the Florida Medicaid program during 2001-2005 to estimate total, SCD-related, and non-SCD-related cost per patient-month based on patient age at the time of health care use. Across the 4,294 patient samples, total health care costs generally rose with age, from $892 to $2,562 per patient-month in the 0-9- and 50-64-year age groups, respectively. Average cost per patient-month was $1,389. Overall, 51.8% of care was directly related to SCD, the majority of which (80.5%) was associated with inpatient hospitalizations. Notably, non-SCD-related costs were substantially higher than those reported for the general US population. These results suggest a discounted (3% discount rate) lifetime cost of care averaging $460,151 per patient with SCD. Interventions designed to prevent SCD complications and avoid hospitalizations may reduce the significant economic burden of the disease.

Revisiting predictors of parental health care-seeking behaviors for nonurgent conditions at one inner-city hospital

INTRODUCTION

To determine important predictors of why parents seek care for their children at a pediatric emergency department (ED) compared to their child's primary care provider's (PCP's) walk-in clinic.

DESIGN

Cross-sectional study.

SETTING

An inner-city hospital located in New York City, from April 2003 to January 2004.

PARTICIPANTS

A convenience sample of 170 parents with children younger than 18 years, Medicaid beneficiaries, had a PCP, and presented with a nonurgent medical problem either at the pediatric ED or walk-in clinic.

MAIN OUTCOME MEASURE

The main outcome measure was the setting in which parents sought care for their child; odds ratios (ORs) were calculated for parents seeking care in the pediatric ED compared to those seeking care at the walk-in clinic, adjusting for predisposing, enabling, and need-related factors.

RESULTS

Of the 170 parent-child visits, 87 (51%) were seeking care at the ED and 83 (49%) at their child's walk-in clinic. In logistic regression, single parenting was the strongest predictor for seeking care in the ED (OR, 5.54; 95% confidence interval [CI], 1.4-26.9), followed by Hispanic ethnicity (OR, 4.96; 95% CI, 1.43-17.2), low parental perceptions of their child's physical health (OR, 0.90; 95% CI, 0.82-0.99), controlling for number of chronic conditions, parental working status, and satisfaction with their PCP.

CONCLUSIONS

Single parenting, Hispanic ethnicity, and perceptions of health are associated with health care-seeking behaviors in high cost settings among Medicaid beneficiaries. Targeted education programs could be used to influence future site of care.

Correlates of therapy use and expenditures in children in the United States

INTRODUCTION

This paper describes correlates of use and expenditures for therapies (physical, occupational, speech or home health services) among children in the US.

METHODS

It is data from the Medical Expenditure Panel Survey, a nationally-representative US sample. The Characteristics of users and describe patterns of expenditures were examined.

RESULTS

Use is quite low, only 3.8% of children use services or 4.3% once the use that occurs in the special education system is included. Children more likely to use therapy include those with presumably greater need: children with chronic conditions, functional limitations and/or a history of hospitalizations or injuries. There is significant interaction of minority status and having a functional limitation. Expenditures are low when examined across the child population. Among a small proportion of higher users, therapy expenditures account for a larger proportion of overall health expenditures.

CONCLUSIONS

The educational system adds only slightly to the overall rate of use. In general use appears to be related to the need for such services. Some children, likely including racial/ethnic minority children, may under-use services. Lack of insurance is not related to less use, perhaps because there are other ways to get some services (family care or services provided through the public health system) or because not all insurers cover therapy services. Therapy expenditures account for high proportion of overall expenditures among the high user of therapy whereas, for the entire child populations, therapy expenditures account for a very small part of overall health expenditures.

Utilization of pharmacologic treatment in youths with attention deficit/hyperactivity disorder in Medicaid database

BACKGROUND

Little is known about longitudinal changes in drug utilization in attention-deficit/hyperactivity disorder (ADHD).

OBJECTIVE

To describe longitudinal trends in ADHD drug utilization and explore demographic differences among youths eligible for a large Southern state Medicaid program.

METHODS

A cross-sectional and longitudinal analysis of 10 years of claims data for all Medicaid beneficiaries younger than 20 years of age with 6 months or more of continuous insurance (N = 2,131,953) was conducted. Annual prevalence, incidence, and persistence in ADHD medication use (stimulants and atomoxetine) were estimated based on pharmacy claims and clinician-reported ADHD diagnosis.

RESULTS

ADHD prevalence increased 1.70-fold (95% CI 1.67 to 1.73) from 3.10% (21,904 of 705,573 beneficiaries) in fiscal year 1995-1996 to 5.27% (41,681 of 790,338) in 2003-2004, paralleled by a 1.84-fold (95% CI 1.81 to 1.87) increase in drug use to 4.63%. In 2003-2004, 0.89% of youths were diagnosed and newly started on drugs, reflecting a 1.38-fold (95% CI 1.33 to 1.43) increase over 1995-1996. One in five white males between the ages of 10 and 14 years (19.24%; 95% CI 18.81 to 19.67) received ADHD medication in 2003-2004. Males continued to be more likely diagnosed and treated than females (prevalence ratio [PR] in 2003-2004 = 2.96; 95% CI 2.90 to 3.03 vs 3.82; 95% CI 3.69 to 3.96 in 1995-1996), as were whites when compared with Hispanics (PR in 2003-2004 = 2.65; 95% CI 2.57 to 2.73 vs 3.78; 95% CI 3.57 to 3.99 in 1995-1996) and blacks (PR in 2003-2004 = 1.81; 95% CI 1.76 to 1.85 vs 2.00; 95% CI 1.93 to 2.07 in 1995-1996). The most common starting age throughout the study period was 5-9 years, with 2.45% (95% CI 2.37 to 2.52) new ADHD drug users in 2003-2004, but largest increases in prevalence were observed in adolescents 15-19 years of age, with 2.47% (95% CI 2.38 to 2.55) in 2003-2004 compared with 0.45% (95% CI 0.41 to 0.49) in 1995-1996. Medication persistence varied, with only 49.9% (95% CI 49.4 to 50.5) of new users receiving drugs after 1 year, with yet another 17.2% (95% CI 16.4 to 18.0) continuing for 5 years or more.

CONCLUSIONS

ADHD drug utilization continues to increase due to steady increases in diagnosis and chronic use of the drugs over several years. While racial, ethnic, and sex differences persist, the age distribution of drug users has shifted toward older children. These findings emphasize the need for studies that analyze determinants of treatment as well as outcomes, both benefits and risks, associated with long-term medication use.

Who cares for patients with attention-deficit/hyperactivity disorder (ADHD)? Insights from Nordbaden (Germany) on administrative prevalence and physician involvement in health care provision

OBJECTIVE

To determine age and gender specific administrative prevalence of ADHD (hyperkinetic disorder, HKD, and hyperkinetic conduct disorder, HKCD, according to ICD-10-based coding) in Germany in 2003, and to assess physician involvement in medical care.

METHOD

Retrospective claims database analysis covering the insured population of Nordbaden, Germany (n = 2.238 million).

RESULTS

A total of 11,875 subjects with a diagnosis of HKD/HKCD were identified (overall 12-month prevalence rate 0.53%). Prevalence was highest among children age 7-12 years (5.0%; boys, 7.2%; girls, 2.7%). Among adults age 20 years and higher, prevalence was 0.04% (males, 0.04%; females, 0.03%). 36.0% (13.0%) of children and adolescents and 33.5% (12.5%) of adults with a diagnosis of ADHD were seen by a specialized physician at least once (four times) during the year. Physician involvement by discipline was highly skewed.

CONCLUSION

Diagnosis rates in children and adolescents exceeded those expected according to ICD-10 criteria, but matched DSM-IV-based estimates. In the adult population, ADHD was rarely detected. Most patients were not seen by a mental health specialist, and physician involvement was highly concentrated. Potential policy implications include a high need for expertise among pediatricians and general practitioners. The data indicate an urgent need for further research into health care utilization and quality.

Psychotherapeutic medication prevalence in Medicaid-insured preschoolers

OBJECTIVE

To update knowledge of the prevalence of the use of psychotherapeutic medications in preschoolers with Medicaid insurance as requested by the Best Pharmaceuticals for Children Act of 2002 (BPCA).

METHOD

Prescription, enrollment, and outpatient visit data from 7 state Medicaid programs were used to identify 274,518 youths continuously enrolled in 2001 and aged 2 to 4 on January 1, 2001. Annual prevalence of use was defined as one or more dispensed prescriptions for a psychotherapeutic medication and adjusted for anticonvulsant and anxiolytic/sedative/hypnotic use according to ICD-9 diagnostic groupings. Prevalence ratios adjusted for age, race/ethnicity, and gender were estimated.

RESULTS

2.30% (CI = 2.24, 2.36) of preschoolers received one or more dispensings for a psychotherapeutic medication in 2001, approximately doubling the usage of comparable youth from 2 other state Medicaid programs studied in 1995. Boys were 2.4 times more likely than girls to receive psychotherapeutic medication. Whites were 4 times more likely than Hispanics and twice as likely as Blacks to receive medication for psychiatric or behavioral conditions. Since the mid-1990s, usage increased, especially for atypical antipsychotics and antidepressants. The prominent use of anticonvulsants (78.8%) and anxiolytic/sedative/hypnotic drugs (91.4%) in those with no psychiatric diagnosis, but with other medical diagnoses, shows that much use therein reflects treatment for seizures, rather than mood stabilization, and for minor medical conditions, rather than psychiatric disorders.

CONCLUSION

Preschool psychotherapeutic medication use increased across ages 2 to 4 for stimulants, antipsychotics, and antidepressants, reflecting use for psychiatric/behavioral disorders. However, the use of anxiolytic/sedative/hypnotics and anticonvulsants was more stable across these years, suggesting medical usage. Additional research to assess the benefits and risks of psychotherapeutic drugs is needed, particularly when such usage is off-label for both psychiatric and nonpsychiatric conditions.

Medicaid expenditures for children with autistic spectrum disorders: 1994 to 1999

This study used data from 1994 to 1999 from one large county in Pennsylvania to estimate the Medicaid expenditures of children diagnosed with autism spectrum disorders (ASD) and to compare these expenditures with those of other Medicaid-eligible children. On average, children diagnosed with ASD had expenditures 10 times those of other children. Differences in expenditures were driven in large part by inpatient psychiatric care. Further research is required to determine whether hospitalized children could be served in less restrictive and less expensive settings. Lack of differences in ambulatory care expenditures suggests that children with ASD are not receiving additional primary care services that would be indicative of appropriately coordinated services as suggested by the medical home model.

Role of insurance for children with special health care needs: a synthesis of the evidence

OBJECTIVE

Children with special health care needs constitute a particularly vulnerable subpopulation of children. Health insurance coverage has the potential to enhance access to care and improve the quality of life for these children while protecting their families from financially burdensome health care expenses. The purpose of this review is to assess and synthesize recent research in the peer-reviewed literature pertaining to the role of insurance for children with special health care needs. A marked increase in the volume of research on this topic makes this an opportune time to summarize these contributions and begin the process of formalizing an evidence base that can inform health policy decisions. Our intention is to further the evidence base by providing a literature-driven assessment of the role of health insurance in influencing access, utilization, satisfaction, quality, expenditures, and health outcomes for children with special health care needs.

METHODS

A systematic literature review was conducted on the effects of insurance status, insurance type, and insurance features on access, utilization, satisfaction, quality, expenditures, and health status.

RESULTS

The strongest evidence emerged for the positive effects of insurance on access and utilization. Limited evidence on the effect of insurance on satisfaction with care showed improved satisfaction ratings for the insured. The studies with findings relevant to out-of-pocket expenditures for insured versus uninsured children with special health care needs all found significantly higher out-of-pocket burden and financial problems among the uninsured. Evidence was mixed for the effects of insurance type (public or private) and insurance characteristics (eg, managed care or fee-for-service payment mechanisms) on outcomes. None of the studies that we reviewed attempted to assess the impact of health insurance on health outcomes.

CONCLUSIONS

Our review of the literature found plentiful evidence demonstrating the positive and substantial impact of insurance on access and utilization. There also is clear evidence that insurance protects families against financially burdensome expenses. The evidence is less conclusive for satisfaction and quality and is nonexistent for health status. These latter outcomes should be the focus of future studies.

The influence of chronic health conditions on susceptibility to severe acute illness of children treated in PICU

OBJECTIVES

Our study aimed to assess differences in the susceptibility to severe acute illness in children with and without chronic health conditions treated in a pediatric intensive care unit (PICU).

PATIENTS AND METHODS

Data on age, gender, need for ventilator support, length of stay, as well as other parameters for the Paediatric Index of Mortality (PIM2) score were collected. Data were analyzed and compared across three patient groups: those with a neurodevelopmental disability, those with a chronic condition other than a neurodevelopmental disability, and those with no chronic condition. Reasons for admission of patients were classified according to the Australia and New Zealand Paediatric Intensive Care Registry (ANZPIC Registry) diagnostic codes. In the multidisciplinary, seven-bed, level I PICU of the Split University Hospital, the admission data were collected prospectively for 591 consecutively admitted patients aged<or=18 years.

RESULTS

Patients with a neurodevelopmental disability had a significantly higher rate of respiratory-related admissions compared to patients with other chronic health conditions and those with no chronic condition (chi2=33.72, P<0.001). There was a significant difference in the age at admission (f=6.04, P=0.003), median length of stay (f=7.94, P<0.001), need for ventilation during the first hour of admission (chi2=14.74, P<0.001) and PICU mortality (chi2=9.91, P=0.007) of patients with neurodevelopmental disabilities, compared to the other two groups of patients.

CONCLUSION

Children with neurodevelopmental disabilities are more susceptible to acute illness compared to children with other chronic health conditions and those with no chronic condition.

Disparities in use of and unmet need for therapeutic and supportive services among school-age children with functional limitations: a comparison across settings

OBJECTIVES

To determine whether family resources predict use of therapeutic and supportive services and unmet needs in medical versus educational settings.

DATA SOURCE

Children 5-17 years of age with at least one functional limitation (n=3,434) from the 1994 to 1995 Disability Supplement to the U.S. National Health Interview Survey.

STUDY DESIGN

Family resources included the child's type of health insurance, household education level, and poverty status. Therapeutic services included audiology; social work; occupational, physical, or speech therapy. Supportive services included special equipment, personal care assistance, respite care, transportation, or environmental modifications. Need was controlled by child health status and the severity and type of functional limitation(s). Age, gender, race/ethnicity, family size, and structure were covariates. DATA ANALYSIS METHODS: Logistic regression provided estimates of associations between-family resources and use of or unmet need for therapeutic and supportive services. Multinomial methods were used to determine therapeutic service outcomes in medical versus educational settings.

PRINCIPAL FINDINGS

Children with public insurance were two to three times more likely to use services than children with private or no insurance regardless of type of service. Household education and public insurance were associated with supportive and therapeutic service use, but for therapeutic services only among children receiving services beyond the school setting. Household education predicted unmet need for both types of services and therapeutic services across settings. Findings should be interpreted cautiously, given the survey's dependence on respondent report to define the need for services and the potential for overrepresentation of children with more severe needs in the public insurance category.

CONCLUSIONS

Disparities in the use of services by household education level and by type of health insurance across service settings suggests inequitable access among the U.S. policies and programs serving children with functional limitations. Family income and education appear to give families an advantage in obtaining services and in identifying a child's unmet need.

Health care access after injury by insurance type in a pediatric population

OBJECTIVES

Previous studies demonstrate discrepancies in health care access by insurance status for routine, discretionary care. It is unknown whether these discrepancies in health care utilization by insurance status persist in urgent/emergent circumstances. We used injury as a sentinel event to represent urgent/emergent medical conditions to examine the relationship with insurance type.

METHODS

Using the 2000, 2001, and 2002 National Health Interview Survey, we examined medical care sought after 1847 injuries among children younger than 18 years. We performed univariate analyses to explore the relationship of insurance type and demographic variables with medical care sought. We then conducted multivariate logistical regression analysis to assess the association of insurance type with only making a telephone call and with being hospitalized while controlling for confounding variables. There was no direct measure in injury severity in these data.

RESULTS

Although uninsured children had the lowest percentage of head injuries, there was no significant difference in body part injured by insurance type. While controlling for potentially confounding variables, there were no significant differences for making only a telephone call after an injury by insurance type [OR (95% CI): 1.29 (0.45-3.72) for private insurance; 1.13 (0.28-4.62) for other insurance types; 0.69 (0.08-6.33) for uninsured; Medicaid as the reference]. However, uninsured children had a significantly increased likelihood of being hospitalized after an injury [OR (95% CI): 4.07 (1.13-14.66) compared with 2.21 (0.73-6.63) for privately insured; 1.61 (0.47-5.55) for other insurance types; Medicaid as the reference].

CONCLUSIONS

While controlling for potentially confounding variables, there was no relationship between type of insurance and only making a telephone call after an injury. However, uninsured children were significantly more likely to be hospitalized after an injury than insured children. This latter relationship differs from overall patterns of health care utilization by insurance type.

Pediatric prescription pick-up rates after ED visits

OBJECTIVE

To determine the compliance rate in filling outpatient medication prescriptions written upon discharge from the emergency department (ED).

METHODS

Emergency department records of children during a 3-month period were examined along with pharmacy claim data obtained in cooperation with the largest insurance carrier in the community (private and Medicaid). Pharmacy claim data were used to validate the prescription pick-up date.

RESULTS

Overall, 65% of high-urgency prescriptions were filled. The prescription pick-up rate in the 0-to 3-year age group (75%) was significantly higher than in the rest of the cohort (55%) ( P < .001). Children with private insurance were more likely to fill their prescriptions (68%) compared to children with Medicaid insurance (57%) ( P = .03).

CONCLUSION

This study demonstrates that filling a prescription after discharge from an ED represents a substantial barrier to medication compliance.

Physical and behavioral health of Medicaid children in two southern states

OBJECTIVES

As the primary insurer of children in the United States, Medicaid covers at least one in four US children. Information on the health and behavioral health needs of this group of children is critical to plan, deliver, and monitor services accordingly.

METHODS

Parent interview data from a representative sample of Medicaid children in two Southern states were used to generate information from standardized questionnaires on physical health status, chronic illnesses, physical functioning, emotional and behavioral symptoms, and psychosocial functioning.

RESULTS

The levels of physical and behavioral health and co-occurring problems were higher than other estimates available on the general population.

CONCLUSIONS

The high levels of health problems among Medicaid-enrolled children need attention in the current struggles over Medicaid reform. Support for improving screening, referral, and integration of services is discussed, as well as the importance of monitoring service system performance in this era of managed care.

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

OBJECTIVE

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

METHODS

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

RESULTS

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