1
|
Patel PN, Dombkowski KJ, Madden B, Raphael JL, Plegue M, Braun TM, Reeves SL. Patterns of primary and specialty care among children with sickle cell anemia. Pediatr Blood Cancer 2024; 71:e31048. [PMID: 38693643 DOI: 10.1002/pbc.31048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 03/28/2024] [Accepted: 04/17/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND AND OBJECTIVE National guidelines recommend that children with sickle cell anemia (SCA) be seen regularly by primary care providers (PCPs) as well as hematologists to receive comprehensive, multidisciplinary care. The objective is to characterize the patterns of primary and hematology care for children with SCA in Michigan. METHODS Using validated claims definitions, children ages 1-17 years with SCA were identified using Michigan Medicaid administrative claims from 2010 to 2018. We calculated the number of outpatient PCP and hematologist visits per person-year, as well as the proportion of children with at least one visit to a PCP, hematologist, or both a PCP and hematologist annually. Negative binomial regression was used to calculate annual rates of visits for each provider type. RESULTS A total of 875 children contributed 2889 person-years. Of the total 22,570 outpatient visits, 52% were with a PCP and 34% with a hematologist. Annually, 87%-93% of children had a visit with a PCP, and 63%-85% had a visit with a hematologist. Approximately 66% of total person-years had both visit types within a year. The annual rate ranged from 2.3 to 2.5 for hematologist visits and from 3.7 to 4.1 for PCP visits. CONCLUSIONS Substantial gaps exist in the receipt of annual hematology care. Given that the majority of children with SCA see a PCP annually, strategies to leverage primary care visits experienced by this population may be needed to increase receipt of SCA-specific services.
Collapse
Affiliation(s)
- Pooja N Patel
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Kevin J Dombkowski
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Brian Madden
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Jean L Raphael
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Center for Child Health Policy and Advocacy, Texas Children's Hospital, Houston, Texas, USA
| | - Melissa Plegue
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas M Braun
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah L Reeves
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
2
|
Payne T, Kevric J, Stelmach W, To H. The Use of Electronic Consultations in Outpatient Surgery Clinics: Synthesized Narrative Review. JMIR Perioper Med 2022; 5:e34661. [PMID: 35436223 PMCID: PMC9052035 DOI: 10.2196/34661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/20/2022] [Accepted: 03/18/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Electronic consultations (eConsults) are an increasingly used form of telemedicine that allows a nonspecialist clinician to seek specialist advice remotely without direct patient-specialist communication. Surgical clinics may see benefits from such forms of communication but face challenges with the need for intervention planning. OBJECTIVE We aimed to use the Quadruple Aim Framework to integrate published knowledge of surgical outpatient eConsults with regard to efficacy, safety, limitations, and evolving use in the era of COVID-19. METHODS We systematically searched for relevant studies across four databases (Ovid MEDLINE, Embase, Scopus, and Web of Science) on November 4, 2021, with the following inclusion criteria: English language, published in the past 10 years, and data on the outcomes of outpatient surgical eConsults. RESULTS A total of 363 studies were screened for eligibility, of which 33 (9.1%) were included. Most of the included studies were from the United States (23/33, 70%) and Canada (7/33, 21%), with a predominant multidisciplinary focus (9/33, 27%). Most were retrospective audits (16/33, 48%), with 15% (5/33) of the studies having a prospective component. CONCLUSIONS The surgical eConsult studies indicated a possible benefit for population health, promising safety results, enhanced patient and clinician experience, and cost savings compared with the traditional face-to-face surgical referral pathway. Their use appeared to be more favorable in some surgical subspecialties, and the overall efficacy was similar to that of medical subspecialties. Limited data on their long-term safety and use during the COVID-19 pandemic were identified, and this should be the focus of future research.
Collapse
Affiliation(s)
- Thomas Payne
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
- Department of Surgery, The Northern Hospital, Melbourne, Australia
| | - Jasmina Kevric
- Department of Surgery, The Northern Hospital, Melbourne, Australia
| | - Wanda Stelmach
- Department of Surgery, The Northern Hospital, Melbourne, Australia
| | - Henry To
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
- Department of Surgery, The Northern Hospital, Melbourne, Australia
- Department of Surgery, Werribee Mercy Hospital, Melbourne, Australia
| |
Collapse
|
3
|
Matiz LA, Kostacos C, Robbins-Milne L, Chang SJ, Rausch JC, Tariq A. Integrating Nurse Care Managers in the Medical Home of Children with Special Health Care needs to Improve their Care Coordination and Impact Health Care Utilization. J Pediatr Nurs 2021; 59:32-36. [PMID: 33454540 DOI: 10.1016/j.pedn.2020.12.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 12/30/2020] [Accepted: 12/30/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE There is a rising number of children with special health care needs (CSHCN) in the pediatric medical home and their care coordination is complicated and challenging. We aimed to integrate nurse care managers to coordinate care for such patients, and then evaluate, if this improved health care utilization. DESIGN AND METHODS This quality improvement project evaluated the impact on CSHCN of the integration of nurse care managers in the pediatric medical home. From October 2015 through February 2019, 673 children received longitudinal care coordination support from a care manager. Health care utilization for primary, subspecialty, emergency department (ED) and inpatient care was reviewed using pre and post design. RESULTS Three medical home-based nurse care managers were integrated into four pediatric hospital affiliated practices in a large, urban center. The number of ED visits and inpatient admissions were statistically significantly decreased post-intervention (p < 0.05).There was also a decrease in the number of subspecialty visits, but it was close to the threshold of significance (p = 0.054). There was no impact noted on primary care visits. CONCLUSION This quality improvement project demonstrates that nurse care managers who are integrated into the medical home of CSHCN can potentially decrease the utilization of ED visits and hospital admissions as well as subspecialty visits. PRACTICE IMPLICATIONS Nurse care managers can play a pivotal role in medical home redesign for the care of CSHCN.
Collapse
Affiliation(s)
- Luz Adriana Matiz
- Department of Pediatrics/Division of Child and Adolescent Health, Columbia University Irving Medical Center, NY, United States of America.
| | - Connie Kostacos
- Department of Pediatrics/Division of Child and Adolescent Health, Columbia University Irving Medical Center, NY, United States of America.
| | - Laura Robbins-Milne
- Department of Pediatrics/Division of Child and Adolescent Health, Columbia University Irving Medical Center, NY, United States of America.
| | - Steven J Chang
- Ambulatory Care Network, Division of Community and Population Health, NewYork Presbyterian, NY, United States of America.
| | - John C Rausch
- Department of Pediatrics/Division of Child and Adolescent Health, Columbia University Irving Medical Center, NY, United States of America.
| | - Abdul Tariq
- Ambulatory Care Network, Division of Community and Population Health, NewYork Presbyterian, NY, United States of America.
| |
Collapse
|
4
|
Grosse SD, Green NS, Reeves SL. Administrative data identify sickle cell disease: A critical review of approaches in U.S. health services research. Pediatr Blood Cancer 2020; 67:e28703. [PMID: 32939942 PMCID: PMC7606824 DOI: 10.1002/pbc.28703] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/27/2020] [Accepted: 08/28/2020] [Indexed: 12/20/2022]
Abstract
To identify people living with sickle cell disease (SCD) and study their healthcare utilization, researchers can either use clinical records linked to administrative data or use billing diagnosis codes in stand-alone administrative databases. Correct identification of individuals clinically managed for SCD using diagnosis codes in claims databases is limited by the accuracy of billing codes in outpatient encounters. In this critical review, we assess the strengths and limitations of claims-based SCD case-finding algorithms in stand-alone administrative databases that contain both inpatient and outpatient records. Validation studies conducted using clinical records and newborn screening for confirmation of SCD case status have found that algorithms that require three or more nonpharmacy claims or one inpatient claim plus two or more outpatient claims with SCD codes show acceptable accuracy (positive predictive value and sensitivity) in children and adolescents. Future studies might seek to assess the accuracy of case-finding algorithms over the lifespan.
Collapse
Affiliation(s)
- Scott D. Grosse
- Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities, Atlanta, Georgia
| | - Nancy S. Green
- Department of Pediatrics, Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Columbia University Medical Center, New York, New York
| | - Sarah L. Reeves
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, Michigan,School of Public Health, Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
5
|
Reeves SL, Madden B, Wu M, Miller LS, Anders D, Caggana M, Cogan LW, Kleyn M, Hurden I, Freed GL, Dombkowski KJ. Performance of ICD-10-CM diagnosis codes for identifying children with Sickle Cell Anemia. Health Serv Res 2020; 55:310-317. [PMID: 31916247 DOI: 10.1111/1475-6773.13257] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To develop, test, and validate the performance of ICD-10-CM claims-based case definitions for identifying children with sickle cell anemia (SCA). DATA SOURCES Medicaid administrative claims (2016) for children <18 years with potential SCA (any D57x diagnosis code) and newborn screening records from Michigan and New York State. STUDY DESIGN This study is a secondary data analysis. DATA COLLECTION/EXTRACTION METHODS Using specific SCA-related (D5700, D5701, and D5702) and nonspecific (D571) diagnosis codes, 23 SCA case definitions were applied to Michigan Medicaid claims (2016) to identify children with SCA. Measures of performance (sensitivity, specificity, area under the ROC curve) were calculated using newborn screening results as the gold standard. A parallel analysis was conducted using New York State Medicaid claims and newborn screening data. PRINCIPAL FINDINGS In Michigan Medicaid, 1597 children had ≥1 D57x claim; 280 (18 percent) were diagnosed with SCA. Measures of performance varied, with sensitivities from 0.02 to 0.97 and specificities from 0.88 to 1.0. The case definition of ≥1 outpatient visit with a SCA-related or D571 code had the highest area under the ROC curve, with a sensitivity of 95 percent and specificity of 92 percent. The same definition also had the highest performance in New York Medicaid (n = 2454), with a sensitivity of 94 percent and specificity of 86 percent. CONCLUSIONS Children with SCA can be accurately identified in administrative claims using this straightforward case definition. This methodology can be used to monitor trends and use of health services after transition to ICD-10-CM.
Collapse
Affiliation(s)
- Sarah L Reeves
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.,Department of Epidemiology, University of Michigan, Ann Arbor, Michigan
| | - Brian Madden
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Meng Wu
- New York State Department of Health, Office of Quality and Patient Safety, Albany, New York
| | - Lauren S Miller
- New York State Department of Health, Office of Quality and Patient Safety, Albany, New York
| | - David Anders
- New York State Department of Health, Office of Quality and Patient Safety, Albany, New York
| | - Michele Caggana
- New York State Department of Health, Office of Quality and Patient Safety, Albany, New York.,Wadsworth Center, New York State Department of Health, Albany, New York
| | - Lindsay W Cogan
- New York State Department of Health, Office of Quality and Patient Safety, Albany, New York.,Department of Health Policy Management & Behavior, School of Public Health, University at Albany, Albany, New York
| | - Mary Kleyn
- Michigan Department of Health and Human Services, Lansing, Michigan
| | - Isabel Hurden
- Michigan Department of Health and Human Services, Lansing, Michigan
| | - Gary L Freed
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Kevin J Dombkowski
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
6
|
Copley M, Jimenez N, Kroshus E, Chrisman SPD. Disparities in Use of Subspecialty Concussion Care Based on Ethnicity. J Racial Ethn Health Disparities 2020; 7:571-576. [PMID: 31898059 DOI: 10.1007/s40615-019-00686-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 12/04/2019] [Accepted: 12/19/2019] [Indexed: 11/26/2022]
Abstract
Concussion is common and subspecialty care can be essential to ensure recovery. However, barriers may exist to accessing care. This study aimed to assess disparities in subspecialty concussion care related to ethnicity, limited English proficiency (LEP), and insurance status. We utilized logistic regression to analyze 2010-2015 administrative data from four Sports Medicine clinics, comparing odds of being seen for concussion to odds of being seen for fracture by ethnicity, insurance type, and interpreter usage, controlling for demographic factors. ICD-9 codes were used to identify concussion and fracture. Our final sample contained 25,294 subjects: 5621 with concussion and 19,673 with fracture. In bivariate analysis, youth seen for concussion had 83% lower odds of being Hispanic compared with youth seen for fracture (95%CI: 75-92%). Due to interactions between ethnicity and interpreter use, we utilized a stratified multivariate model as our final model. Youth with concussion had 1.8× greater odds of having private insurance compared with youth with fracture (Hispanic OR 1.8, 95% CI 1.5-2.3; Non-Hispanic OR 1.8, 95% CI 1.7-2.0). Youth with concussion also had greater odds of not using an interpreter, though the strength of this association was weaker for Hispanic youth compared with non-Hispanic youth (Hispanic OR 1.68, 95% CI 1.30-2.17; Non-Hispanic OR 4.36, 95% CI 3.00-6.35). Age and sex were included as covariates. In conclusion, our analysis suggests disparities in subspecialty concussion care for Hispanic youth, as well as for individuals with LEP and non-private insurance. Further research should explore means for improving access to concussion care for all youth.
Collapse
Affiliation(s)
- M Copley
- University of Washington School of Medicine, Seattle, USA
| | - N Jimenez
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, PO Box 5371 CW 8/6, Seattle, WA, 98145, USA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
| | - E Kroshus
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, PO Box 5371 CW 8/6, Seattle, WA, 98145, USA
- Department of Pediatrics, University of Washington, Seattle, USA
| | - S P D Chrisman
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, PO Box 5371 CW 8/6, Seattle, WA, 98145, USA.
- Department of Pediatrics, University of Washington, Seattle, USA.
| |
Collapse
|
7
|
Shared Care for Adults with Sickle Cell Disease: An Analysis of Care from Eight Health Systems. J Clin Med 2019; 8:jcm8081154. [PMID: 31382365 PMCID: PMC6723540 DOI: 10.3390/jcm8081154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 11/17/2022] Open
Abstract
Adult sickle cell disease (SCD) patients frequently transition from pediatric hematology to adult primary care. We examined healthcare utilization for adult patients with SCD with shared care between hematologists and primary care providers (PCP). We analyzed the OneFlorida Data Trust, a centralized data repository of electronic medical record (EMR) data from eight different health systems in Florida. The number of included adults with SCD was 1147. We examined frequent hospitalizations and emergency department (ED) visits by whether the patient had shared care or single specialty care alone. Most patients were seen by a PCP only (30.4%), followed by both PCP and hematologist (27.5%), neither PCP nor hematologist (23.3%), and hematologist only (18.7%). For patients with shared care versus single specialist care other than hematologist, the shared care group had a lower likelihood of frequent hospitalizations (OR 0.63; 95% CI 0.43-0.90). Similarly, when compared to care from a hematologist only, the shared care group had a lower likelihood of frequent hospitalizations (OR 0.67; 95% CI 0.47-0.95). There was no significant relationship between shared care and ED use. When patients with SCD have both a PCP and hematologist involved in their care there is a benefit in decreased hospitalizations.
Collapse
|
8
|
Differences in Health Care Needs, Health Care Utilization, and Health Care Outcomes Among Children With Special Health Care Needs in Ohio: A Comparative Analysis Between Medicaid and Private Insurance. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2017; 23:e1-e9. [DOI: 10.1097/phh.0000000000000403] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
9
|
Ray KN, Kahn JM, Miller E, Mehrotra A. Use of Adult-Trained Medical Subspecialists by Children Seeking Medical Subspecialty Care. J Pediatr 2016; 176:173-181.e1. [PMID: 27344222 PMCID: PMC5003627 DOI: 10.1016/j.jpeds.2016.05.073] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 04/28/2016] [Accepted: 05/23/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To quantify the use of adult-trained medical subspecialists by children and to determine the association between geographic access to pediatric subspecialty care and the use of adult-trained subspecialists. Children with limited access to pediatric subspecialty care may seek care from adult-trained subspecialists, but data on this practice are limited. STUDY DESIGN We identified children aged <16 years in 2007-2012 Pennsylvania Medicaid claims. We categorized outpatient visits to 9 selected medical subspecialties as either pediatric or adult-trained subspecialty visits. We used multinomial logistic regression to examine the adjusted association between travel times to pediatric referral centers and use of pediatric vs adult-trained medical subspecialists for children with and without complex chronic conditions (CCCs). RESULTS Among 1.1 million children, 8% visited the examined medical subspecialists, with 10% of these children using adult-trained medical subspecialists. Compared with children with a ≤30-minute travel time to a pediatric referral center, children with a >90-minute travel time were more likely to use adult-trained subspecialists (without CCCs: relative risk ratio [RRR], 1.94, 95% CI, 1.79-2.11; with CCCs: RRR, 2.33; 95% CI, 2.10-2.59) and less likely to use pediatric subspecialists (without CCCs: RRR, 0.66; 95% CI, 0.63-0.68; with CCCs: RRR, 0.76, 95% CI, 0.73-0.79). CONCLUSION Among medical subspecialty fields with pediatric and adult-trained subspecialists, adult-trained subspecialists provided 10% of care to children overall and 18% of care to children living >90 minutes from pediatric referral centers. Future studies should examine consequences of adult-trained medical subspecialist use on pediatric health outcomes and identify strategies to increase access to pediatric subspecialists.
Collapse
Affiliation(s)
- Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA.
| | - Jeremy M Kahn
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Elizabeth Miller
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Ateev Mehrotra
- Department of Health Care Policy and Medicine, Harvard Medical School, Boston, MA; RAND Corporation, Boston, MA
| |
Collapse
|
10
|
Lunyera J, Jonassaint C, Jonassaint J, Shah N. Attitudes of Primary Care Physicians Toward Sickle Cell Disease Care, Guidelines, and Comanaging Hydroxyurea With a Specialist. J Prim Care Community Health 2016; 8:37-40. [PMID: 27506442 DOI: 10.1177/2150131916662969] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Sickle cell disease (SCD) is a complex chronic disease requiring multidisciplinary care that involves primary care physicians (PCPs) working with a hematologist or SCD specialists. However, PCPs often lack access to SCD specialists and are unaware of SCD guidelines or efficacious treatment. METHODS We partnered with Community Care of North Carolina (CCNC) to identify assigned PCPs for SCD patients with Medicaid across North Carolina. CCNC network administrators distributed a web-based questionnaire for completion. The questionnaire involved 12 self-reported items on a yes-no or a 1 to 5 Likert-type scale that assessed PCP attitudes toward SCD care, awareness of recent guidelines, and comanaging hydroxyurea. RESULTS Of the 53 PCPs who completed the electronic survey, 73% felt they were comfortable with the number of SCD patients in their practice. Most PCPs reported having infrequent communications with an SCD specialist (67%) and most were also not aware of the 2014 SCD guidelines (66%). Many reported that they would frequently use the new SCD guidelines if provided to them (76%). Furthermore, 51% of PCPs expressed comfort with using mobile apps to access SCD guidelines and provided email contact to receive further information. The majority also reported being comfortable comanaging hydroxyurea with an SCD specialist (65%). CONCLUSION Few PCPs in North Carolina were aware of the new SCD guidelines or had regular communication with an SCD specialist. The majority of PCPs, however, demonstrated a favorable attitude toward receiving the SCD guidelines and comanaging hydroxyurea with a specialist. In response to this gap in care, we have developed a mobile-based SCD toolbox specifically for PCPs to provide guidelines, algorithms, and a method to communicate with local SCD specialists. With the interest in receiving these guidelines, we are confident the toolbox will provide an easy to use platform to assist PCPs to utilize the SCD guidelines.
Collapse
Affiliation(s)
| | | | - Jude Jonassaint
- 2 University of Pittsburg Medical Center, Pittsburg, PA, USA
| | - Nirmish Shah
- 1 Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
11
|
Mayer ML, Slifkin RT, Skinner AC. The Effects of Rural Residence and Other Social Vulnerabilities on Subjective Measures of Unmet Need. Med Care Res Rev 2016; 62:617-28. [PMID: 16177461 DOI: 10.1177/1077558705279315] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To determine whether self-reports of unmet need are biased measures of access to health care, the authors examine the relationship between rural residence and perceived need for physician services. They perform logistic regression analyses to examine the likelihood of reporting a need for routine preventive care and/or specialty care using data from the National Survey of Children with Special Health Care Needs. Even after controlling for factors known to be associated with evaluated need, parents of rural children were less likely to report a need for routine or specialty services. Poor children, those whose mothers had less education, and those who were uninsured in the previous year were also less likely to perceive a need for physician services. Findings suggest that rural residence and other social vulnerabilities are associated with decreased perception of need, which may bias subjective measurements of unmet need for these populations.
Collapse
|
12
|
Bundy DG, Muschelli J, Clemens GD, Strouse JJ, Thompson RE, Casella JF, Miller MR. Preventive Care Delivery to Young Children With Sickle Cell Disease. J Pediatr Hematol Oncol 2016; 38:294-300. [PMID: 26950087 PMCID: PMC4842129 DOI: 10.1097/mph.0000000000000537] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Preventive services can reduce the morbidity of sickle cell disease (SCD) in children but are delivered unreliably. We conducted a retrospective cohort study of children aged 2 to 5 years with SCD, evaluating each child for 14 months and expecting that he/she should receive ≥75% of days covered by antibiotic prophylaxis, ≥1 influenza immunization, and ≥1 transcranial Doppler ultrasound (TCD). We used logistic regression to quantify the relationship between ambulatory generalist and hematologist visits and preventive services delivery. Of 266 children meeting the inclusion criteria, 30% consistently filled prophylactic antibiotic prescriptions. Having ≥2 generalist, non-well child care visits or ≥2 hematologist visits was associated with more reliable antibiotic prophylaxis. Forty-one percent of children received ≥1 influenza immunizations. Children with ≥2 hematologist visits were most likely to be immunized (62% vs. 35% among children without a hematologist visit). Only 25% of children received ≥1 TCD. Children most likely to receive a TCD (42%) were those with ≥2 hematologist visits. One in 20 children received all 3 preventive services. Preventive services delivery to young children with SCD was inconsistent but associated with multiple visits to ambulatory providers. Better connecting children with SCD to hematologists and strengthening preventive care delivery by generalists are both essential.
Collapse
Affiliation(s)
- David G. Bundy
- Division of General Pediatrics, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - John Muschelli
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Gwendolyn D. Clemens
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - John J. Strouse
- Division of Pediatric Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard E. Thompson
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - James F. Casella
- Division of Pediatric Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marlene R. Miller
- Division of Quality and Safety, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| |
Collapse
|
13
|
Parental Preferences Regarding Outpatient Management of Children with Congenital Heart Disease. Pediatr Cardiol 2016; 37:151-9. [PMID: 26342487 DOI: 10.1007/s00246-015-1257-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 08/24/2015] [Indexed: 10/23/2022]
Abstract
The objective of this study was to identify patterns of health care usage among children with congenital heart disease (CHD) and determine predictors for contacting cardiologists for routine care. Parents of children with CHD completed surveys, indicating which provider they would contact first for 12 concerns. Predictors for preference for cardiologist evaluation were identified by multivariable logistic regression. Surveys were completed by 307 of 925 (33.2%) parents. Median patient age was 9.4 years [interquartile range (IQR) 5.1-14.4 years] with a median of 1 cardiac surgery (IQR 1-3). Most parents agreed primary care physicians (PCPs) could identify problems related to CHD (70.0%) and when to refer to cardiologists (89.6%). More felt PCPs best understood their values (63.2 vs. 29.6%, P < 0.001) and were more accessible (63.5 vs. 33.6%, P < 0.001) than cardiologists. Parents preferred first evaluation by PCPs for 9 of 12 concerns. Preference for cardiology evaluation was independently associated with the number of cardiac catheterizations [adjusted odds ratio (AOR) for ≥2 catheterizations 2.4, 95% confidence interval (CI) 1.1-4.9], belief the cardiologist better knew the child's medical history (AOR 2.4, 95% CI 1.3-4.6), and provider accessibility (AOR 3.6, 95% CI 1.8-7.4). Parents of CHD patients reported close alignment with PCPs and would contact PCPs first for most routine care. However, some populations continue to contact cardiologists for routine care. Further study is needed to clarify best practices for clinician and parent education.
Collapse
|
14
|
Raphael JL, Rattler TL, Kowalkowski MA, Brousseau DC, Mueller BU, Giordano TP. Association of Care in a Medical Home and Health Care Utilization Among Children with Sickle Cell Disease. J Natl Med Assoc 2015. [DOI: 10.1016/s0027-9684(15)30008-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
15
|
Zuckerman KE, Mattox KM, Sinche BK, Blaschke GS, Bethell C. Racial, ethnic, and language disparities in early childhood developmental/behavioral evaluations: a narrative review. Clin Pediatr (Phila) 2014; 53:619-31. [PMID: 24027231 PMCID: PMC3955219 DOI: 10.1177/0009922813501378] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Katharine E. Zuckerman
- Oregon Health & Science University Division of General Pediatrics, Portland, OR,Child and Adolescent Health Measurement Initiative, Portland, OR
| | - Kimber M. Mattox
- Oregon Health & Science University Division of General Pediatrics, Portland, OR,Child and Adolescent Health Measurement Initiative, Portland, OR
| | | | - Gregory S. Blaschke
- Oregon Health & Science University Division of General Pediatrics, Portland, OR
| | | |
Collapse
|
16
|
Lafeuille MH, Gravel J, Figliomeni M, Zhang J, Lefebvre P. Burden of illness of patients with allergic asthma versus non-allergic asthma. J Asthma 2013; 50:900-7. [PMID: 23721416 DOI: 10.3109/02770903.2013.810244] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Allergic and non-allergic asthma share similar symptoms, but differ in that allergic asthma is triggered by inhaled allergens. This study compared healthcare resource utilization (HCRU) and costs between these groups using US employer-based claims data. METHODS Health insurance claims from Truven Marketscan database (2002Q1-2010Q2) were analyzed. Included patients had ≥2 asthma diagnoses and ≥1 year of eligibility prior to and following the date of first asthma diagnosis. Patients with ≥1 diagnosis for allergic asthma and ≥1 diagnosis for other allergic conditions formed the allergic asthma cohort whereas patients without any of these diagnoses formed the non-allergic asthma cohort. Allergic and non-allergic asthma patients were matched 1:1. HCRU and costs during the study period were compared between cohorts using incidence rate ratios (IRR) and bootstrap methods. RESULTS Sixty four thousand four hundred and seventy three allergic and non-allergic asthma patients were matched (mean age = 30; 57.1% female; mean CCI = 0.2), with 7.1% and 0.36% having received an allergy test during the baseline period, respectively. During the study period, allergic asthma patients had significantly more asthma-related pharmacy dispensings (IRR[95% CI] = 2.25[2.22-2.28], p < 0.001) and asthma-related outpatient visits (IRR[95% CI] = 2.29[2.27-2.32], p < 0.001). Allergic asthma patients incurred 39% greater per-patient-per-year all-cause costs (allergic: $4008; non-allergic: $2889, p < 0.001) and 79% greater asthma-related costs (allergic: $1063; non-allergic: $592, p < 0.001) than non-allergic asthma patients. CONCLUSIONS These results indicate, even in a relatively healthy population, allergic asthma is associated with greater HCRU and costs. Guideline-recommended IgE allergy tests should be employed in distinguishing the two forms of asthma, to optimize patient management and reduce costs.
Collapse
|
17
|
Reid RO, Ashwood JS, Friedberg MW, Weber ES, Setodji CM, Mehrotra A. Retail clinic visits and receipt of primary care. J Gen Intern Med 2013; 28:504-12. [PMID: 23070656 PMCID: PMC3599015 DOI: 10.1007/s11606-012-2243-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 08/15/2012] [Accepted: 09/18/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND An increasing number of patients are visiting retail clinics for simple acute conditions. Physicians worry that visits to retail clinics will interfere with primary care relationships. No prior study has evaluated the impact of retail clinics on receipt of primary care. OBJECTIVE To assess the association between retail clinic use and receipt of key primary care functions. DESIGN We performed a retrospective cohort analysis using commercial insurance claims from 2007 to 2009. PATIENTS We identified patients who had a visit for a simple acute condition in 2008, the "index visit". We divided these 127,358 patients into two cohorts according to the location of that index visit: primary care provider (PCP) versus retail clinic. MAIN MEASURES We evaluated three functions of primary care: (1) where patients first sought care for subsequent simple acute conditions; (2) continuity of care using the Bice-Boxerman index; and (3) preventive care and diabetes management. Using a difference-in-differences approach, we compared care received in the 365 days following the index visit to care received in the 365 days prior, using propensity score weights to account for selection bias. KEY RESULTS Visiting a retail clinic instead of a PCP for the index visit was associated with a 27.7 visits per 100 patients differential reduction (p < 0 .001) in subsequent PCP visits for new simple acute conditions. Visiting a retail clinic instead of a PCP was also associated with decreased subsequent continuity of care (10.9 percentage-point differential reduction in Bice-Boxerman index, p < 0 .001). There was no differential change between the cohorts in receipt of preventive care or diabetes management. CONCLUSIONS Retail clinics may disrupt two aspects of primary care: whether patients go to a PCP first for new conditions and continuity of care. However, they do not negatively impact preventive care or diabetes management.
Collapse
Affiliation(s)
- Rachel O. Reid
- />University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - J. Scott Ashwood
- />RAND Corporation, Pittsburgh, PA USA
- />H. John Heinz School of Public Policy and Management, Carnegie Mellon University, Pittsburgh, PA USA
| | - Mark W. Friedberg
- />RAND Corporation, Boston, MA USA
- />Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA USA
- />Harvard Medical School, Boston, MA USA
| | - Ellerie S. Weber
- />University of Pittsburgh School of Medicine, Pittsburgh, PA USA
- />RAND Corporation, Pittsburgh, PA USA
- />H. John Heinz School of Public Policy and Management, Carnegie Mellon University, Pittsburgh, PA USA
| | | | - Ateev Mehrotra
- />University of Pittsburgh School of Medicine, Pittsburgh, PA USA
- />RAND Corporation, Pittsburgh, PA USA
- />RAND Corporation, Boston, MA USA
- />University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA 15213 USA
| |
Collapse
|
18
|
Perez FD, Xie J, Sin A, Tsai R, Sanders L, Cox K, Haberland CA, Park KT. Characteristics and direct costs of academic pediatric subspecialty outpatient no-show events. J Healthc Qual 2013; 36:32-42. [PMID: 23551280 DOI: 10.1111/jhq.12007] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clinic no shows (NS) create a lost opportunity for provider-patient interaction and impose a financial burden to the healthcare system and on society. We aimed to: (1) to determine the clinical and demographic factors associated with increased NS rates at a children's hospital's subsubspecialty clinics and (2) to estimate the direct institutional financial costs associated with NS events. METHODS A comprehensive database was generated from all clinic encounters for 15 subspecialty outpatient clinics (five surgical and 10 medical) between September 12, 2005 and December 30, 2010. Multivariate logistic regressions were performed to identify the variables associated with NS events. Direct costs of NS events were estimated using annual revenue for each clinic. RESULTS A total of 284,275 encounters and 17,024 NS events were available for analysis. Public insurance coverage (Medicaid and Title V), compared to private insurance or self-pay status, was associated with an increased likelihood NS (OR 2.19, 95% CI 2.10-2.28, p < 0.0005 for Medicaid; OR 1.56, 95% CI 1.50-1.62, p < 0.0005 for Title V). Compared to patients 21-30 years of age, patients <12 years (OR 2.08, 95% CI 1.77-2.45, p < 0.0005) had increased likelihood of NS. Scheduled visits with medical subspecialists were more likely than surgical subspecialty visits to result in a NS (OR 1.69, 95% CI 1.63-1.75, p < 0.0005). The predicted annualized lost revenue associated with NS visits was estimated at $730,000 from the 15 clinics analyzed, approximately $210 per NS event. CONCLUSION Pediatric subspecialty NS events are common, costly, and potentially preventable.
Collapse
|
19
|
Zuckerman KE, Perrin JM, Hobrecker K, Donelan K. Barriers to specialty care and specialty referral completion in the community health center setting. J Pediatr 2013; 162:409-14.e1. [PMID: 22929162 PMCID: PMC3752985 DOI: 10.1016/j.jpeds.2012.07.022] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Revised: 05/24/2012] [Accepted: 07/12/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To assess the frequency of barriers to specialty care and to assess which barriers are associated with an incomplete specialty referral (not attending a specialty visit when referred by a primary care provider) among children seen in community health centers. STUDY DESIGN Two months after their child's specialty referral, 341 parents completed telephone surveys assessing whether a specialty visit was completed and whether they experienced any of 10 barriers to care. Family/community barriers included difficulty leaving work, obtaining childcare, obtaining transportation, and inadequate insurance. Health care system barriers included getting appointments quickly, understanding doctors and nurses, communicating with doctors' offices, locating offices, accessing interpreters, and inconvenient office hours. We calculated barrier frequency and total barriers experienced. Using logistic regression, we assessed which barriers were associated with incomplete referral, and whether experiencing ≥ 4 barriers was associated with incomplete referral. RESULTS A total of 22.9% of families experienced incomplete referral. 42.0% of families encountered 1 or more barriers. The most frequent barriers were difficulty leaving work, obtaining childcare, and obtaining transportation. On multivariate analysis, difficulty getting appointments quickly, difficulty finding doctors' offices, and inconvenient office hours were associated with incomplete referral. Families experiencing ≥ 4 barriers were more likely than those experiencing ≤ 3 barriers to have incomplete referral. CONCLUSION Barriers to specialty care were common and associated with incomplete referral. Families experiencing many barriers had greater risk of incomplete referral. Improving family/community factors may increase satisfaction with specialty care; however, improving health system factors may be the best way to reduce incomplete referrals.
Collapse
Affiliation(s)
- Katharine E Zuckerman
- Division of General Pediatrics, Child and Adolescent Health Measurement Initiative, Oregon Health and Science University, Portland, OR 97239, USA.
| | | | | | | |
Collapse
|
20
|
Raphael JL, Rattler TL, Kowalkowski MA, Mueller BU, Giordano TP. The medical home experience among children with sickle cell disease. Pediatr Blood Cancer 2013; 60:275-80. [PMID: 22522496 PMCID: PMC3427710 DOI: 10.1002/pbc.24184] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 04/02/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND While a large body of research documents acute care services for children with sickle cell disease (SCD), little is known about the primary care experiences of this population. The goal of this study was to determine to what extent children with SCD experienced care consistent with a patient-centered medical home (PCMH). PROCEDURE We collected and analyzed data from 150 children, ages 1-17 years, who received care within a large children's hospital. The primary dependent variable was access to a PCMH or its four individual components (regular provider, comprehensive care, family-centered care, and coordinated care) as determined by parental report. Multivariate logistic regression was conducted to investigate associations between socio-demographic variables and having access to a PCMH. RESULTS Only 11% (16/150) of children qualified as having a PCMH, achieving the required thresholds in all four components. Approximately half of children had access to two or fewer components. Over 90% of children were reported to have a personal provider. Two-thirds of children had access to comprehensive care. Almost 60% of children were reported to receive family-centered care. Only 20% of children had access to coordinated care. No consistent associations were found between socio-demographic variables and having access to a PCMH or its individual components. CONCLUSIONS Within our study sample, children with SCD experienced multiple deficiencies in having access to a PCMH, particularly with respect to care coordination. However, further studies with larger samples are needed to determine associations between socio-demographic variables and having a PCMH.
Collapse
Affiliation(s)
- Jean L. Raphael
- Department of Pediatrics, Baylor College of Medicine, Hematology/Oncology, Houston, TX
| | - Tiffany L. Rattler
- Department of Pediatrics, Baylor College of Medicine, Hematology/Oncology, Houston, TX
| | | | - Brigitta U. Mueller
- Department of Pediatrics, Baylor College of Medicine, Hematology/Oncology, Houston, TX
| | | |
Collapse
|
21
|
Park KT, Bensen R, Lu B, Nanda P, Esquivel C, Cox K. Geographical rural status and health outcomes in pediatric liver transplantation: an analysis of 6 years of national United Network of Organ Sharing Data. J Pediatr 2013; 162:313-8.e1. [PMID: 22914224 DOI: 10.1016/j.jpeds.2012.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 06/11/2012] [Accepted: 07/10/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To determine whether children in rural areas have worse health than children in urban areas after liver transplantation (LT). STUDY DESIGN We used urban influence codes published by the US Department of Agriculture to categorize 3307 pediatric patients undergoing LT in the United Network of Organ Sharing database between 2004 and 2009 as urban or rural. Allograft rejection, patient death, and graft failure were used as primary outcome measures of post-LT health. Pediatric end-stage liver disease/model of end-stage liver disease scores >20 was used to measure worse pre-LT health. RESULTS In a multivariate analysis, we found greater rates of allograft rejection within 6 months of LT (OR 1.27; 95% CI 1.05-1.53) and a lower occurrence of posttransplantation lymphoproliferative disorder (OR 0.64; 95% CI 0.41-0.99) in patients in rural areas. The difference in allograft rejection was eliminated at 1 year of LT (OR 1.18; 95% CI 0.98-1.42). Rural location did not impact other outcome measures. CONCLUSION We conclude that rural location makes a negative impact on patient health within the first 6 months of LT by increasing the risk for allograft rejection, although patients in rural areas may have lower rates of developing posttransplantation lymphoproliferative disorder. Long-term adverse health effects were not seen.
Collapse
Affiliation(s)
- K T Park
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Lucile Packard Children's Hospital at Stanford, Palo Alto, CA 94304, USA.
| | | | | | | | | | | |
Collapse
|
22
|
Raphael JL, Rattler TL, Kowalkowski MA, Brousseau DC, Mueller BU, Giordano TP. Association of care in a medical home and health care utilization among children with sickle cell disease. J Natl Med Assoc 2013; 105:157-65. [PMID: 24079216 PMCID: PMC3834259 DOI: 10.1016/s0027-9684(15)30109-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Sickle cell disease (SCD) is marked by high utilization of medical services. The aim of this study was to determine whether having a patient-centered medical home (PCMH) is associated with a reduction in emergency care (ED) utilization or hospitalizations among children with SCD. METHODS We collected and analyzed data from parents of 150 children, ages 1 to 17 years, who received care within a large children's hospital. The primary dependent variables were rates of parent-reported ED visits and hospitalizations. The principal independent variable was parent-reported experience with an overall PCMH or its four individual components (regular provider, comprehensive care, family-centered care, and coordinated care). Multivariate negative binomial regression, yielding incident rate ratios (IRR), was used for analysis. RESULTS Children who received comprehensive care had half the rate of ED visits (IRR 0.51, 95% confidence interval, 0.33-0.78) and nearly half the rate of hospitalizations (IRR 0.56, 95% confidence interval, 0.33-0.93) compared to children without comprehensive care. No other component of the PCMH was significantly associated with ED visits or hospitalizations. Children reported to have excellent/very good/good health status had lower odds of ED visits and hospitalizations compared to those reported to be in fair/poor condition. CONCLUSIONS Children with SCD reported to experience comprehensive care had lower rates of ED encounters and hospitalizations after controlling for demographics and health status. The overall findings highlight that the provision of comprehensive care--having a usual source of care and no problems with referrals--may provide a strategy for improving pediatric SCD care.
Collapse
|
23
|
Bundy DG, Muschelli J, Clemens GD, Strouse JJ, Thompson RE, Casella JF, Miller MR. Ambulatory care connections of Medicaid-insured children with sickle cell disease. Pediatr Blood Cancer 2012; 59:888-94. [PMID: 22422739 DOI: 10.1002/pbc.24129] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Accepted: 02/10/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND Sickle cell disease (SCD) requires coordinated ambulatory care from generalists and hematologists. We examined when children with SCD establish ambulatory care connections, whether these connections are maintained, and how these connections are used before and after hospitalizations. PROCEDURE We conducted a retrospective cohort study of Medicaid-insured Maryland children with SCD from 2002 to 2008. For children enrolled from birth, time to first, second, and third generalist and first hematologist visits was plotted. For all children, we analyzed ambulatory visits by age group, by emergency department (ED) and hospital use, and before and after hospitalizations. RESULTS The overall study cohort comprised 851 children; 178 provided data from birth. Ambulatory care connections to generalists were made rapidly; connections to hematologists occurred more slowly, if at all (38% of children had not seen a hematologist by age 2 years). Visits with generalists decreased as patients aged, as did visits with hematologists (54% of children in the 12-17 year age group had no hematology visits in 2 years). Children with higher numbers of ED visits or hospitalizations also had higher numbers of ambulatory visits (generalist and hematologist). Most children had visits with neither generalists nor hematologists in the 30 days before and after hospitalizations. CONCLUSIONS Medicaid-insured children with SCD rapidly connect with generalists after birth; connections to hematologists occur more slowly. The observation that connections to generalists and hematologists diminish with time and are infrequently used around hospitalizations suggests that the ambulatory care of many Medicaid-insured children with SCD may be inadequate.
Collapse
Affiliation(s)
- David G Bundy
- Division of Quality and Safety, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
| | | | | | | | | | | | | |
Collapse
|
24
|
Abstract
Sickle cell disease (SCD), the most common genetic disease screened for in the newborn period, occurs in ~1 in 2400 newborns in the general population and 1 in 400 individuals of African descent in the United States. Despite the relative high prevalence and low pediatric mortality rate of SCD when compared with other genetic diseases or chronic diseases in pediatrics, few evidence-based guidelines have been developed to facilitate the transition from pediatrics to an internal medicine or family practice environment. As with any pediatric transition program, common educational, social, and health systems themes exist to prepare for the next phase of health care; however, unique features characterizing the experience of adolescents with SCD must also be addressed. These challenges include, but are not limited to, a higher proportion of SCD adolescents receiving public health insurance when compared with any other pediatric genetic or chronic diseases; the high proportion of overt strokes or silent cerebral infarcts (~30%) affecting cognition; risk of low high school graduation; and a high rate of comorbid disease, including asthma. Young adults with SCD are living longer; consequently, the importance of transitioning from a pediatric primary care provider to adult primary care physician has become a critical step in the health care management plan. We identify how the primary care physicians in tandem with the pediatric specialist can enhance transition interventions for children and adolescents with SCD.
Collapse
Affiliation(s)
- Michael R DeBaun
- Department of Pediatrics, Vanderbilt University School of Medicine and Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee 37232-9000, USA.
| | | |
Collapse
|
25
|
Guh S, Grosse SD, McAlister S, Kessler CM, Soucie JM. Health care expenditures for Medicaid-covered males with haemophilia in the United States, 2008. Haemophilia 2012; 18:276-83. [PMID: 22188641 PMCID: PMC4684173 DOI: 10.1111/j.1365-2516.2011.02713.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
Collapse
Affiliation(s)
- S Guh
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | | | | | | |
Collapse
|
26
|
Leschke J, Panepinto JA, Nimmer M, Hoffmann RG, Yan K, Brousseau DC. Outpatient follow-up and rehospitalizations for sickle cell disease patients. Pediatr Blood Cancer 2012; 58:406-9. [PMID: 21495162 DOI: 10.1002/pbc.23140] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 03/02/2011] [Indexed: 11/06/2022]
Abstract
BACKGROUND Rehospitalization rates are increasingly used as quality indicators for a variety of illnesses, including sickle cell disease. While one small, single center study suggested outpatient follow-up with a pediatric hematologist was associated with fewer rehospitalizations, no study has examined the effect of post-discharge outpatient follow-up on rehospitalization rates across ages and beyond a single site. PROCEDURE This is a retrospective cohort study using Wisconsin Medicaid claims data for hospitalized children and adults with sickle cell disease from 2003 to 2007. The primary outcomes were rehospitalization at both 14 and 30 days after an index hospitalization for sickle cell pain crisis (ICD-9-CM codes 28242, 28262, 28264, 28269). Univariate survival analyses were performed based on outpatient visit, severe disease, asthma, and age. The Cox proportional hazards model was used for multivariate analyses yielding hazard ratios for the association between outpatient visits and subsequent rehospitalization rates. RESULTS Of the 408 patients included, 42 (10.2%) patients were rehospitalized within 14 days and 70 (17.1%) were rehospitalized within 30 days. Multivariate analysis showed that an outpatient visit is associated with lower rates of both 30-day rehospitalization (Hazard Ratio (HR) 0.442; 95%CI: 0.330-0.593) and 14-day rehospitalization (HR 0.226; 95%CI: 0.124-0.412), with the majority of 30-day rehospitalizations occurring within 14 days. CONCLUSIONS For sickle cell disease, post-discharge planning should emphasize early follow-up to prevent subsequent hospitalization and improve care quality. Pediatr Blood Cancer 2012; 58: 406-409. © 2011 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- John Leschke
- Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | | | | | | | | | | |
Collapse
|
27
|
Wolfson JA, Schrager SM, Khanna R, Coates TD, Kipke MD. Sickle cell disease in California: sociodemographic predictors of emergency department utilization. Pediatr Blood Cancer 2012; 58:66-73. [PMID: 21360655 PMCID: PMC3272000 DOI: 10.1002/pbc.22979] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 11/22/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Patients with sickle cell disease (SCD) visit emergency departments (EDs) in rates leading to a significant health system burden. However, limited comprehensive evaluations of utilization patterns have been published using data connecting visits to patients across facilities. This study aims to examine sociodemographic predictors of ED utilization in SCD. PROCEDURE This retrospective cohort study employed 2007 data from the California Office of Statewide Health Planning and Development (OSHPD). Data included all ED encounters from California hospitals; identifiers connected each visit to an individual patient, across all facilities in the state. Multivariate regression techniques evaluated sociodemographic predictors of utilization while adjusting for confounding variables. RESULTS In 2007, 2,920 California patients with SCD made 16,364 ED visits. Adults ≥ 21 years of age had higher ED visit rates than children and were more likely to both be in the highest tier of users and visit multiple facilities. Patients living further from a self-identified provider of comprehensive SCD care had higher rates of ED visits and a lower likelihood of hospitalization from the ED. Publicly insured patients had higher rates of ED visits and were more likely to be in the highest tier of users than were the privately insured or uninsured. CONCLUSIONS Adulthood ≥ 21 years of age, distance from comprehensive SCD care, and insurance status are significant predictors of ED utilization in SCD. As a routine source of care decreases ED utilization, these findings prompt concern that these factors act as barriers to accessing comprehensive SCD care.
Collapse
Affiliation(s)
- Julie A. Wolfson
- Division of Pediatrics, City of Hope National Medical Center, Duarte, California
| | - Sheree M. Schrager
- Community, Health Outcomes, and Intervention Research Program, The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, California
| | - Rachna Khanna
- Division of Cancer Prevention and Control, School of Public Health and Jonsson Comprehensive Cancer Center, UCLA, Los Angeles California
| | - Thomas D. Coates
- Division of Hematology-Oncology, Children’s Hospital Los Angeles, Los Angeles, California,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California,Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michele D. Kipke
- Community, Health Outcomes, and Intervention Research Program, The Saban Research Institute, Children’s Hospital Los Angeles, Los Angeles, California,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California,Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| |
Collapse
|
28
|
Yusuf HR, Lloyd-Puryear MA, Grant AM, Parker CS, Creary MS, Atrash HK. Sickle cell disease: the need for a public health agenda. Am J Prev Med 2011; 41:S376-83. [PMID: 22099361 DOI: 10.1016/j.amepre.2011.09.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 08/13/2011] [Accepted: 09/07/2011] [Indexed: 12/01/2022]
Abstract
Sickle cell disease (SCD) is a collection of inherited blood disorders that affect a substantial number of people in the U.S., particularly African Americans. People with SCD have an abnormal type of hemoglobin, Hb S, which polymerizes when deoxygenated, causing the red blood cells to become misshapen and rigid. Individuals with SCD are at higher risk of morbidity and mortality from infections, vaso-occlusive pain crises, acute chest syndrome, and other complications. Addressing the public health needs related to SCD is an important step toward improving outcomes and maintaining health for those affected by the disorder. The objective of this study was to review public health activities focusing on SCD and define the need to address it more comprehensively from a public health perspective. We found that there has been some progress in the development of SCD-related public health activities. Such activities include establishing newborn screening (NBS) for SCD with all states currently having universal NBS programs. However, additional areas needing focus include strengthening surveillance and monitoring of disease occurrence and health outcomes, enhancing adherence to health maintenance guidelines, increasing knowledge and awareness among those affected, and improving healthcare access and utilization. These and other activities discussed in this paper can help strengthen public health efforts to address SCD.
Collapse
Affiliation(s)
- Hussain R Yusuf
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia 30333, USA.
| | | | | | | | | | | |
Collapse
|
29
|
Zuckerman KE, Nelson K, Bryant TK, Hobrecker K, Perrin JM, Donelan K. Specialty referral communication and completion in the community health center setting. Acad Pediatr 2011; 11:288-96. [PMID: 21622041 DOI: 10.1016/j.acap.2011.03.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 03/03/2011] [Accepted: 03/03/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Parent and provider disagreement about children's care at the time of specialty referral may lead to incomplete referral, ie, not attending a specialty visit when referred. This study's objectives were first to assess parent-provider correlation in perspectives on referral necessity, seriousness of child's health problem, and parental understanding of referral among children referred to pediatric specialists, and second to assess whether these perspectives are associated with incomplete referral. METHODS Two months after specialty referral, parents and primary care providers completed a survey rating referral necessity, seriousness of problem, and parental understanding on a 4-part scale ("definitely yes" to "definitely no"). Parents were surveyed by telephone; providers completed one self-administered survey per referral. Using z tests and Pearson correlation coefficients, we summarized parent-provider agreement about referral necessity, seriousness of problem, and parent understanding. We applied logistic regression to test associations of parent and provider ratings for each variable with incomplete referral. RESULTS A total of 299 (60.0%) of 498 matched parent and provider surveys were included in the analysis. Parents had low correlation with providers in perspectives of referral necessity and seriousness of problem. Parents reported that referral was necessary more often than providers, and providers underestimated parents' self-reported understanding of the referral. Nearly 1 in 3 children had incomplete referral, and both parent and provider reports of lower necessity were associated with incomplete referral. CONCLUSIONS Parents and providers hold divergent perspectives on referral necessity and seriousness of children's health problems; these perspectives may impact rates of incomplete referral. Improving communication around specialty referral might reduce incomplete referral.
Collapse
|
30
|
Pineda N, Chamberlain LJ, Chan J, Cidon MJ, Wise PH. Access to pediatric subspecialty care: A population study of pediatric rheumatology inpatients in California. Arthritis Care Res (Hoboken) 2011; 63:998-1005. [DOI: 10.1002/acr.20458] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
31
|
Witt WP, Litzelman K, Mandic CG, Wisk LE, Hampton JM, Creswell PD, Gottlieb CA, Gangnon RE. Healthcare-Related Financial Burden among Families in the U.S.: The Role of Childhood Activity Limitations and Income. JOURNAL OF FAMILY AND ECONOMIC ISSUES 2011; 32:308-326. [PMID: 21552342 PMCID: PMC3088430 DOI: 10.1007/s10834-011-9253-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This study examined the impact of childhood activity limitations on family financial burden in the U.S. We used ten complete panels (1996-2006) of the Medical Expenditure Panel Survey (MEPS) to evaluate the burden of out-of-pocket healthcare expenditures for 17,857 families with children aged 0-17 years. Multivariate generalized linear models were used to examine the relationship between childhood activity limitation status and both absolute and relative financial burden. Families of children with limitations had higher absolute out-of-pocket healthcare expenditures than families of children without limitations ($594.36 higher; p<0.05), and were 54% more likely to experience relative burden (p<0.05). Substantial socioeconomic disparities in financial burden were observed. Policies are needed to enable these families to access appropriate and affordable healthcare services.
Collapse
Affiliation(s)
- Whitney P Witt
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Wolfson JA, Schrager SM, Coates TD, Kipke MD. Sickle-cell disease in California: a population-based description of emergency department utilization. Pediatr Blood Cancer 2011; 56:413-9. [PMID: 21225920 PMCID: PMC3286652 DOI: 10.1002/pbc.22792] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2010] [Accepted: 07/20/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Acute and chronic clinical manifestations of sickle-cell disease (SCD) lead to significant healthcare utilization, especially of the emergency department (ED). Limited population-level data are available in SCD with the ability to connect patients to visits, leaving us with minimal description of utilization patterns. PROCEDURE Using ED discharge data with links between patients and visits, we sought to describe the California SCD population and its ED utilization patterns across facilities. Non-public California Office of Statewide Health Planning and Development data employ unique patient identifiers, linking patients, and visits. RESULTS SCD patients of all ages are heavily reliant on Medicaid (46%). The majority of SCD Californians visit an ED more than once during a year (69%), but only a minority use more than one facility during a year (34%). However, adults with SCD have multiple visits and utilize multiple EDs in higher proportions than do children (72% vs. 60% and 40% vs. 21%, respectively). A higher proportion of visits to the ED are made by SCD adults, but a higher proportion of visits by children result in hospital admission. Uninsured adults outnumber uninsured children (16% vs. 5%). CONCLUSIONS ED utilization by the California SCD population is described on a population level. Utilization patterns by adults point towards increased utilization in the population no longer eligible for Title V pediatric coverage for their disease. Further investigation using population-level socioeconomic and geographic correlates is warranted to evaluate the factors leading to ED utilization in SCD.
Collapse
Affiliation(s)
- Julie A. Wolfson
- Division of Pediatric Hematology-Oncology, Childrens Hospital Los Angeles
| | - Sheree M. Schrager
- Community, Health Outcomes, and Intervention Research Program, The Saban Research Institute, Childrens Hospital Los Angeles
| | - Thomas D. Coates
- Division of Pediatric Hematology-Oncology, Childrens Hospital Los Angeles,Department of Pediatrics, Keck School of Medicine, University of Southern California,Department of Pathology, Keck School of Medicine, University of Southern California
| | - Michele D. Kipke
- Community, Health Outcomes, and Intervention Research Program, The Saban Research Institute, Childrens Hospital Los Angeles,Department of Pediatrics, Keck School of Medicine, University of Southern California,Department of Preventive Medicine, Keck School of Medicine, University of Southern California
| |
Collapse
|
33
|
Zuckerman KE, Cai X, Perrin JM, Donelan K. Incomplete specialty referral among children in community health centers. J Pediatr 2011; 158:24-30. [PMID: 20801461 DOI: 10.1016/j.jpeds.2010.07.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Revised: 05/19/2010] [Accepted: 07/09/2010] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess rates of incomplete specialty referral (referral not resulting in a specialist visit) and risk factors for incomplete referral in pediatric community health care centers. STUDY DESIGN In this cross-sectional study, we used referral records and electronic health records to calculate rate of incomplete referral in 577 children referred from two health care centers in underserved communities to any of 19 pediatric specialties at an affiliated tertiary care center, over 7 months in 2008-2009. We used logistic regression to test the association of incomplete referral with child/family sociodemographic and health care system factors. RESULTS Of the children, 30.2% had an incomplete referral. Incomplete referral rates were similar at the two health care centers, but varied from 10% to 73% according to specialty clinic type. In multivariate analysis, sociodemographic factors of older child age, public insurance status, and no chronic health conditions correlated with incomplete referral, as did health care system factors of surgical specialty clinic type, low patient volume, longer wait for visit, and appointment rescheduling. CONCLUSION Almost one-third of children referred to specialists were unable to complete the referral in a timely manner. To improve specialty access, health care organizations and policymakers should target support to families with high-risk children and remediate problematic health care system features.
Collapse
Affiliation(s)
- Katharine E Zuckerman
- Child and Adolescent Health Measurement Initiative, Oregon Health and Sciences University, Portland, OR 97239-2998, USA.
| | | | | | | |
Collapse
|
34
|
Zickafoose JS, Gebremariam A, Clark SJ, Davis MM. Medical home disparities between children with public and private insurance. Acad Pediatr 2011; 11:305-10. [PMID: 21640680 PMCID: PMC3139004 DOI: 10.1016/j.acap.2011.03.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Revised: 03/21/2011] [Accepted: 03/25/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare the prevalence of a medical home for children with public versus private insurance and identify components of the medical home that contribute to any differences. METHODS We performed a secondary data analysis of the 2007 National Survey of Children's Health. A medical home was defined as meeting each of 5 components: 1) usual source of care; 2) personal doctor/nurse; 3) family-centered care; 4) care coordination, if needed; and 5) no problems getting a referral, if needed. We estimated the national prevalence of the medical home and its components for children with public versus private insurance. Comparisons were made using logistic regression, unadjusted and adjusted for sociodemographic factors. RESULTS A total of 67% of privately insured children met all 5 components of the medical home, compared with only 45% of publicly insured children (P < .001). The gap in medical home prevalence between public and private groups remained significant after controlling for sociodemographic characteristics (public vs private adjusted odds ratio [AOR] 0.82; 95% confidence interval [95% CI] 0.73-0.92). Over 90% of children in both groups reported having a usual source of care and a personal doctor/nurse. Only 58% of publicly insured children reported family-centered care, compared with 76% of privately insured children (P < .001). This difference was significant after adjustment for sociodemographic characteristics (public vs private AOR 0.87; 95% CI 0.77-0.99). CONCLUSIONS Significant medical home disparities exist between publicly and privately insured children, driven primarily by disparities in family-centered care. Efforts to promote the medical home must recognize and address determinants of family-centered care.
Collapse
Affiliation(s)
- Joseph S Zickafoose
- Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, Mich., USA.
| | | | | | | |
Collapse
|
35
|
Yusuf HR, Atrash HK, Grosse SD, Parker CS, Grant AM. Emergency department visits made by patients with sickle cell disease: a descriptive study, 1999-2007. Am J Prev Med 2010; 38:S536-41. [PMID: 20331955 PMCID: PMC4521762 DOI: 10.1016/j.amepre.2010.01.001] [Citation(s) in RCA: 158] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 12/16/2009] [Accepted: 01/02/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients with sickle cell disease (SCD) often use emergency department services to obtain medical care. Limited information is available about emergency department use among patients with SCD. PURPOSE This study assessed characteristics of emergency department visits made nationally by patients with SCD. METHODS Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for the years 1999-2007 were analyzed. The NHAMCS is a survey of hospital emergency department and outpatient visits. Emergency department visits by patients with SCD were identified using ICD-9-CM codes, and nationally weighted estimates were calculated. RESULTS On average, approximately 197,333 emergency department visits were estimated to have occurred each year between 1999 and 2007 with SCD as one of the diagnoses listed. The expected source of payment was private insurance for 14%, Medicaid/State Children's Health Insurance Program for 58%, Medicare for 14%, and other/unknown for 15%. Approximately 29% of visits resulted in hospital admission; this was 37% among patients aged 0-19 years, and 26% among patients aged >/=20 years. The episode of care was indicated as a follow-up visit for 23% of the visits. Patient-cited reasons for the emergency department visit included chest pain (11%); other pain or unspecified pain (67%); fever/infection (6%); and shortness of breath/breathing problem/cough (5%), among other reasons. CONCLUSIONS Substantial numbers of emergency department visits occur among people with SCD. The most common reason for the emergency department visits is pain symptoms. The findings of this study can help to improve health services delivery and utilization among patients with SCD.
Collapse
Affiliation(s)
- Hussain R Yusuf
- Division of Blood Disorders, National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia 30333, USA.
| | | | | | | | | |
Collapse
|
36
|
Grosse SD, Boulet SL, Amendah DD, Oyeku SO. Administrative data sets and health services research on hemoglobinopathies: a review of the literature. Am J Prev Med 2010; 38:S557-67. [PMID: 20331958 DOI: 10.1016/j.amepre.2009.12.015] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 12/07/2009] [Accepted: 12/21/2009] [Indexed: 11/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, CDC, Atlanta, Georgia 30333, USA.
| | | | | | | |
Collapse
|
37
|
Case AP, Canfield MA. Methods for developing useful estimates of the costs associated with birth defects. ACTA ACUST UNITED AC 2010; 85:920-4. [PMID: 19830852 DOI: 10.1002/bdra.20637] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cost estimates for birth defects are useful to policy makers in deciding the best use of resources to prevent these conditions. Much of the effort in this area has focused on spina bifida, in part because cost savings can be estimated from folic acid-preventable cases. However, comprehensive cost-of-illness estimates for this condition may be too outdated, too general, or not applicable to individual states' environments. METHODS Using the live birth prevalence for spina bifida in Texas, we applied recent spina bifida cost estimates to approximate total lifetime medical and other costs for an average live birth cohort of spina bifida cases in Texas. In addition, we queried various government programs that provide services for persons with spina bifida to provide program-specific annual costs for this condition. RESULTS Applying a recently published average lifetime medical cost of $635,000 per case of spina bifida to the average annual birth cohort of 120 Texas cases, an estimated $76 million in direct and indirect medical and other costs will be incurred in Texas over the life span of that cohort. Examples of estimated medical costs for one year are $5 million for infants using actual employer-paid insurance claims data and $6 million combined for children in two public sector programs. DISCUSSION Stakeholders and state policy makers may look to state birth defects registries for useful cost data. Although comprehensive state-specific figures are not available, applying prevalence data to existing estimates and obtaining actual claims and program expenditures may help close this information gap.
Collapse
Affiliation(s)
- Amy P Case
- Texas Department of State Health Services, Birth Defects Epidemiology and Surveillance Branch, Mail Code 1964, P.O. Box 149347, Austin, TX 78714-9347, USA.
| | | |
Collapse
|
38
|
Valderas JM, Starfield B, Forrest CB, Rajmil L, Roland M, Sibbald B. Routine care provided by specialists to children and adolescents in the United States (2002-2006). BMC Health Serv Res 2009; 9:221. [PMID: 19961581 PMCID: PMC2797004 DOI: 10.1186/1472-6963-9-221] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Accepted: 12/04/2009] [Indexed: 11/17/2022] Open
Abstract
Background Specialist physicians provide a large share of outpatient health care for children and adolescents in the United States, but little is known about the nature and content of these services in the ambulatory setting. Our objective was to quantify and characterize routine and co-managed pediatric healthcare as provided by specialists in community settings. Methods Nationally representative data were obtained from the National Ambulatory Medical Care Survey for the years 2002-2006. We included office based physicians (excluding family physicians, general internists and general pediatricians), and a representative sample of their patients aged 18 or less. Visits were classified into mutually exclusive categories based on the major reason for the visit, previous knowledge of the health problem, and whether the visit was the result of a referral. Primary diagnoses were classified using Expanded Diagnostic Clusters. Physician report of sharing care for the patient with another physician and frequency of reappointments were also collected. Results Overall, 41.3% out of about 174 million visits were for routine follow up and preventive care of patients already known to the specialist. Psychiatry, immunology and allergy, and dermatology accounted for 54.5% of all routine and preventive care visits. Attention deficit disorder, allergic rhinitis and disorders of the sebaceous glands accounted for about a third of these visits. Overall, 73.2% of all visits resulted in a return appointment with the same physician, in half of all cases as a result of a routine or preventive care visit. Conclusion Ambulatory office-based pediatric care provided by specialists includes a large share of non referred routine and preventive care for common problems for patients already known to the physician. It is likely that many of these services could be managed in primary care settings, lessening demand for specialists and improving coordination of care.
Collapse
Affiliation(s)
- Jose M Valderas
- National Primary Care Research and Development Centre, The University of Manchester, UK.
| | | | | | | | | | | |
Collapse
|
39
|
Ouyang L, Grosse SD, Amendah DD, Schechter MS. Healthcare expenditures for privately insured people with cystic fibrosis. Pediatr Pulmonol 2009; 44:989-96. [PMID: 19768806 DOI: 10.1002/ppul.21090] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
With improved survival and new therapies for people with cystic fibrosis (CF), updated information on medical care expenditures for those individuals is needed. We estimated medical care expenditures, including both insurance reimbursements and patient out-of-pocket expenses, for privately insured people with CF and investigated how those expenditures varied with certain complications of CF. From a private insurance claims database of people covered by health plans associated with large corporate employers, we identified people with CF who were currently receiving medical care for the disorder and characterized their medical expenditures during the period 2004-2006. We selected a matching group of people who did not have CF based on age, sex, and geographic area, and calculated incremental expenditures associated with CF. We also examined the effect of age and certain complications of CF on these expenditures. The annual medical care expenditure for a person with actively managed CF averaged $48,098 in 2006 dollars, which was 22 times higher than for a person without CF. This ratio is high relative to other chronic disorders. Outpatient prescription medications made up the largest component of total expenditures for people with CF (39%). Those who were recorded in claims data as having a liver or lung transplant, malnutrition, diabetes, or a chronic Pseudomonas aeruginosa pulmonary infection incurred much higher expenditures than people without these conditions. People with CF will incur high medical expenditures throughout their lifespan. These findings will assist in the development of economic evaluations of future CF screening and management initiatives.
Collapse
Affiliation(s)
- Lijing Ouyang
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
| | | | | | | |
Collapse
|
40
|
Mvundura M, Amendah D, Kavanagh PL, Sprinz PG, Grosse SD. Health care utilization and expenditures for privately and publicly insured children with sickle cell disease in the United States. Pediatr Blood Cancer 2009; 53:642-6. [PMID: 19492318 DOI: 10.1002/pbc.22069] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
Collapse
Affiliation(s)
- Mercy Mvundura
- National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
| | | | | | | | | |
Collapse
|
41
|
Pless IB, Stein REK, Walker DK. Research Consortium on Children with Chronic Conditions (RCCCC): a vehicle for interdisciplinary collaborative research. Matern Child Health J 2009; 14:9-19. [PMID: 19701701 DOI: 10.1007/s10995-009-0484-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 06/05/2009] [Indexed: 10/20/2022]
Abstract
To describe the evolution, accomplishments, and limitations of a research consortium after 25 years of existence. A narrative historical account supplemented by data documenting citations to all group papers. In 1980 the Research Consortium on Children with Chronic Conditions was established. Since then, we have met 2-3 times a year to discuss issues related to research and policies for children with special health care needs. We describe the origin of the Consortium, its operation, and some of its accomplishments, as well as the difficulties it encountered. Our interactions helped promote and sustain research on an emerging topic and did so in an interdisciplinary manner. We include a citation analysis suggesting that group papers published by Consortium members are reasonably well cited by others. We believe our work has been of value in developing influencing research, clinical practice, and policy. This paper is intended to serve as a guide for others who believe that this type of interaction can do much to promote an emerging field. However, it also highlights some of the difficulties in forging and maintaining a productive, research-focused relationship over an extended period of time. The most important lesson learned is that a small group of committed individuals able to meet on a regular basis can accelerate movement in a new field. However, unless stable funding can be secured, maintaining a consortium is truly challenging.
Collapse
Affiliation(s)
- I B Pless
- Department of Pediatrics, Epidemiology and Biostatistics, McGill University, Montreal, Canada
| | | | | |
Collapse
|
42
|
Children with chronic conditions in pediatric intensive care units located in predominantly French-speaking regions: Prevalence and implications on rehabilitation care need and utilization. Crit Care Med 2009; 37:1456-62. [PMID: 19242335 DOI: 10.1097/ccm.0b013e31819cef0c] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To estimate the prevalence of chronic conditions and/or disability in intensive care units admitting children (Pediatric Intensive Care Unit [PICU]) or both neonates and children (Neonatal and Pediatric Intensive Care Unit [NPICU]) and to describe available rehabilitation resources. DESIGN A cross-sectional study on two separate days, using a web questionnaire. SETTING NPICU/PICUs affiliated to the Groupe Francophone de Réanimation et Urgences Pédiatriques and the Réseau Mère-Enfant de la Francophonie. PATIENTS Children >1 month of gestationally corrected age. MEASUREMENTS AND MAIN RESULTS Disability was defined as a Pediatric Overall Performance Category >or=3 before admission and chronic conditions as hospitalization since birth or the presence before admission of any condition requiring ongoing pediatric subspecialty care that was expected to last >or=12 months. Intensivists indicated what rehabilitation services they would have ideally prescribed ("perceived needs") and those provided. Of 45 affiliated units, 8 PICUs and 15 NPICUs participated. Staff included or had access to a psychologist (11 and 5, respectively), a social worker (10 and 3), a physiotherapist (11 and 12), a "psychomotrician" (2 and 8), a child educator (1 and 6), and a speech-language pathologist (0 and 6). Among 289 recorded intensive care unit-days, 236 were analyzed (excluding those for children admitted after surgery): 57 concerned children hospitalized since birth and 179 children admitted from home. Among these 179 recorded intensive care unit-days, 107 concerned children with chronic conditions (including 50 concerning disabled children) and 72 previously healthy children. Thus, prevalence of chronic conditions, including children hospitalized since birth, was 67%. Rehabilitation services included respiratory physical therapy (552 visits), musculoskeletal physical therapy (71), neurologic physical therapy (37), rehabilitation for swallowing (11), and for speech-language disorders (1), representing 79% of perceived needs. CONCLUSIONS Prevalence of chronic conditions in NPICU/PICU was 67%. More attention must be paid to the rehabilitation care needs of patients during their NPICU/PICU stay and after discharge.
Collapse
|
43
|
Mayer ML, Skinner AC, Freed GL. Interspecialty differences in the care of children with chronic or serious acute conditions: a review of the literature. J Pediatr 2009; 154:164-8. [PMID: 19150672 PMCID: PMC3733246 DOI: 10.1016/j.jpeds.2008.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2008] [Revised: 09/22/2008] [Accepted: 11/03/2008] [Indexed: 01/15/2023]
Affiliation(s)
- Michelle L Mayer
- Cecil G. Sheps Center for Health Services Research and Department of Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | |
Collapse
|
44
|
Grosse SD, Schechter MS, Kulkarni R, Lloyd-Puryear MA, Strickland B, Trevathan E. Models of comprehensive multidisciplinary care for individuals in the United States with genetic disorders. Pediatrics 2009; 123:407-12. [PMID: 19117908 DOI: 10.1542/peds.2007-2875] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Approaches to providing comprehensive coordinated care for individuals with complex diseases include the medical home approach, the chronic care model in primary care, and disease-specific, multidisciplinary specialty clinics. There is uneven availability and utilization of multidisciplinary specialty clinics for different genetic diseases. For 2 disorders (ie, hemophilia and cystic fibrosis), effective national networks of specialty clinics exist and reach large proportions of the target populations. For other disorders, notably, sickle cell disease, fewer such centers are available, centers are less likely to be networked, and centers are used less widely. Models of comanagement are essential for promoting ongoing communication and coordination between primary care and subspecialty services, particularly during the transition from pediatric care to adult care. Evaluation of the effectiveness of different models in improving outcomes for individuals with genetic diseases is essential.
Collapse
Affiliation(s)
- Scott D Grosse
- National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | | | | | | | | | | |
Collapse
|
45
|
Abstract
OBJECTIVE I tested the hypothesis that, for vulnerable children with asthma, barriers to care (pragmatics, skills, knowledge and beliefs, expectations of care, and marginalization) affect primary care experiences, after accounting for financial, potential, and realized access to care, demographic features, and asthma severity. METHODS Patients, recruited primarily from urban, federally qualified health centers, were between 3 and 12 years of age and had been diagnosed as having asthma. Bilingual, bicultural interviewers administered surveys in participants' homes. Validated instruments were used to measure barriers to care (Barriers to Care Questionnaire) and primary care experiences (Parent's Perceptions of Primary Care measure). RESULTS Of 252 families recruited, 56.6% of parents were monolingual Spanish speakers, 73.6% of mothers had not graduated from high school, and 24.5% of children were uninsured. Asthma severity was 27% mild persistent, 40.5% moderate persistent, and 32.5% severe persistent. In bivariate analyses, better access to care (being insured and having a regular provider) was related to better primary care experiences. Consistent with the hypothesis, multivariate regression analyses showed that fewer barriers (Barriers to Care Questionnaire scores) predicted better primary care (Parent's Perceptions of Primary Care total and subscale scores), after controlling for access to care, demographic features, and asthma severity (a 1-point change in Barriers to Care Questionnaire scores was associated with a 0.59-point change in Parent's Perceptions of Primary Care total scale scores). Having a regular doctor and not having experienced foregone care were also significant predictors of Parent's Perceptions of Primary Care scores in the multivariate analysis. CONCLUSION For vulnerable children with asthma, barriers to care explain variance in primary care characteristics beyond that explained by access, demographic factors, and disease severity.
Collapse
Affiliation(s)
- Michael Seid
- Divisions of Pulmonary Medicine and Health Policy and Clinical Effectiveness, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039, USA.
| |
Collapse
|
46
|
Schmidt S, Thyen U, Chaplin J, Mueller-Godeffroy E, Bullinger M. Healthcare needs and healthcare satisfaction from the perspective of parents of children with chronic conditions: the DISABKIDS approach towards instrument development. Child Care Health Dev 2008; 34:355-66. [PMID: 18410641 DOI: 10.1111/j.1365-2214.2008.00815.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM Increasingly, families' perspectives are taken into account in the appraisal of health services. The objective of this study was to cross-culturally analyse concepts related to healthcare needs, healthcare utilization and the appraisal and satisfaction with care of parents of children with chronic conditions with the aim of developing a cross-cultural measure. METHODS Several approaches were employed in the study: (i) a deductive approach integrating existing measurements; and (ii) an inductive approach based on focus groups. Focus groups were conducted in seven countries with mothers and fathers as well as their children with seven different chronic conditions, and qualitatively analysed. RESULTS As a result of an evaluation of the different existing methodological approaches, the basic structural components were identified: healthcare needs, the receipt of services, problems with receiving services as well as the appraisal of and satisfaction with the quality of care. While items referring to existing healthcare services were primarily derived by the work of an expert group, items related to quality of care and satisfaction with services mainly evolved from the focus group work. From the focus groups, 367 statements were extracted, which were further processed in a Q-sort rating by a multinational expert group in order to identify domains and salient items. The draft questionnaire to be pilot tested cross-nationally consisted of 101 items which were reduced on the basis of psychometric findings. CONCLUSION On the basis of results of focus groups and existing evidence, a comprehensive measure should be employed in paediatric health services research including structural, process and outcome parameters of care from the perspective of parents.
Collapse
Affiliation(s)
- S Schmidt
- Department of Medical Psychology, University Hospital of Hamburg Eppendorf, Hamburg, Germany.
| | | | | | | | | | | |
Collapse
|
47
|
Shankar SM, Arbogast PG, Mitchel E, Ding H, Wang WC, Griffin MR. Impact of proximity to comprehensive sickle cell center on utilization of healthcare services among children with sickle cell disease. Pediatr Blood Cancer 2008; 50:66-71. [PMID: 16998856 DOI: 10.1002/pbc.21066] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The impact of comprehensive care on utilization of healthcare services by children with sickle cell disease (SCD) has not been fully evaluated. We compared the medical care utilization and mortality in children less than 20 years of age with SCD in four regions in the state of Tennessee with and without a comprehensive sickle cell center (CSCC). METHODS Rates of hospitalizations, outpatient and emergency department (ED) visits, and deaths were measured in a cohort of children aged <20 years with SCD, enrolled in TennCare, from January 1995 to December 2002. TennCare data linked to Tennessee vital records were used to define the population and identify the outcomes. The patients were classified into one of four regions based on their residential address on the day of their hospitalization or outpatient visit. RESULTS The cohort consisted of 1,214 children with 6,393 person-years of follow-up. Fifty-six percent of patients resided in the region with the CSCC. This region had the highest overall rates of hospitalization for all children (P < 0.001), while ED and outpatient visits were higher in other areas. The death rates ranged from 1.8 to 4.3 per 1,000 person-years in the four regions and did not represent statistically significant differences. CONCLUSION No clear pattern of improved utilization of medical care services were identified in relation to proximity of residence to a CSCC. This cohort was not large enough to detect small differences in death rates. In addition, other outcomes that incorporate quality of life measures may be more sensitive to differences in medical care.
Collapse
Affiliation(s)
- Sadhna M Shankar
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
| | | | | | | | | | | |
Collapse
|
48
|
Skinner AC, Mayer ML. Effects of insurance status on children's access to specialty care: a systematic review of the literature. BMC Health Serv Res 2007; 7:194. [PMID: 18045482 PMCID: PMC2222624 DOI: 10.1186/1472-6963-7-194] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2006] [Accepted: 11/28/2007] [Indexed: 11/23/2022] Open
Abstract
Background The current climate of rising health care costs has led many health insurance programs to limit benefits, which may be problematic for children needing specialty care. Findings from pediatric primary care may not transfer to pediatric specialty care because pediatric specialists are often located in academic medical centers where institutional rules determine accepted insurance. Furthermore, coverage for pediatric specialty care may vary more widely due to systematic differences in inclusion on preferred provider lists, lack of availability in staff model HMOs, and requirements for referral. Our objective was to review the literature on the effects of insurance status on children's access to specialty care. Methods We conducted a systematic review of original research published between January 1, 1992 and July 31, 2006. Searches were performed using Pubmed. Results Of 30 articles identified, the majority use number of specialty visits or referrals to measure access. Uninsured children have poorer access to specialty care than insured children. Children with public coverage have better access to specialty care than uninsured children, but poorer access compared to privately insured children. Findings on the effects of managed care are mixed. Conclusion Insurance coverage is clearly an important factor in children's access to specialty care. However, we cannot determine the structure of insurance that leads to the best use of appropriate, quality care by children. Research about specific characteristics of health plans and effects on health outcomes is needed to determine a structure of insurance coverage that provides optimal access to specialty care for children.
Collapse
Affiliation(s)
- Asheley Cockrell Skinner
- Department of Health Policy and Administration, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | | |
Collapse
|
49
|
Smith K, Siddarth P, Zima B, Sankar R, Mitchell W, Gowrinathan R, Shewmon A, Caplan R. Unmet mental health needs in pediatric epilepsy: insights from providers. Epilepsy Behav 2007; 11:401-8. [PMID: 17870672 DOI: 10.1016/j.yebeh.2007.05.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2007] [Revised: 05/12/2007] [Accepted: 05/23/2007] [Indexed: 10/22/2022]
Abstract
Eighteen pediatric neurologists and 18 pediatricians completed a 5-point Likert scale questionnaire on their knowledge of, attitudes toward, and management of the behavioral, cognitive, and psychosocial aspects of pediatric epilepsy, before and after a lecture on this topic. They also responded to questions about possible barriers to mental health care of children with epilepsy. The brief educational intervention modified the knowledge/attitudes of pediatricians compared with pediatric neurologists on the impact of epilepsy on behavior and cognition in children with epilepsy. However, there were no between-group differences in how providers perceived their competence to assess behavioral and cognitive comorbid conditions in pediatric epilepsy. Responses to open-ended questions suggested insufficient mental health coverage for and expertise on pediatric epilepsy, resistance of mental health clinicians to treat children with epilepsy, and the stigma of mental health as possible barriers to mental health care in children with epilepsy. In addition to the need for provider education about the behavioral and cognitive comorbid conditions of pediatric epilepsy, these findings emphasize the importance of examining alternative routes to increasing mental health care for children with epilepsy.
Collapse
Affiliation(s)
- Kimberly Smith
- Department of Psychiatry, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | | | | | | | | | | | | | | |
Collapse
|
50
|
Abstract
The United States has been and continues to be a multicultural society. Many children are born into two cultures, sharing a different one with each parent. Children with intellectual and developmental disabilities (I/DD) may belong to a minority culture, the additional culture of disability, and the culture of poverty. After an introduction to culture and its characteristics, the focus of this article is on strategies pediatric nurses can use to assess and intervene with minority children with I/DD and their families in a culturally sensitive manner. Suggestions for future research are provided.
Collapse
Affiliation(s)
- Wendy M Nehring
- College of Nursing, Rutgers, The State University of New Jersey, Newark, NJ 07102, USA.
| |
Collapse
|