Reduction in racial and ethnic disparities after enrollment in the State Children's Health Insurance Program

Social Determinants of Outcomes Disparity among Pediatric Patients with Solid Tumor

BACKGROUND

Socioeconomic factors have a significant impact on healthcare outcomes. Metrics such as area deprivation index (ADI) are used to quantify the anticipated influence of these factors. Here, we sought to assess the impact of socioeconomic factors on clinical outcomes among pediatric patients with solid tumor in our region.

STUDY DESIGN

We identified 3,863 pediatric patients who were diagnosed with a malignant solid tumor in the Texas Cancer Registry between 1995 and 2019. ADI was used to quantify socioeconomic determinants of health. These outcome variables were determined: stage of disease at diagnosis, time between diagnosis and treatment initiation, and overall mortality. Statistical analysis was performed using logistic regression, linear regression, Cox proportional hazards regression, and Kaplan-Meier survival curves.

RESULTS

A total of 53.5% of patients were male and the average age at diagnosis was 4.5 years. Forty-seven percent of patients were White, 13.3% were Black, 36.2% were Hispanic, 1.7% were Asian, and other rare minority groups made up 1.8%. On multivariable analysis, increased risk of death was associated with Black race, rare minority race, residence in a border county, and increasing ADI score, with the risk of death at 5 years rising 4% with each increasing ADI point.

CONCLUSIONS

Social determinants of health are associated with disparate outcomes among pediatric patients with solid tumor. Our results suggest that patients who are part of racial minority groups and those who reside in socioeconomically disadvantaged neighborhoods or regions near the Texas-Mexico border are at an increased risk of death. This information may be useful in strategizing outreach and expanding resources to improve outcomes in at-risk communities.

Disparities in Racial, Ethnic, and Payer Groups for Pediatric Safety Events in US Hospitals

BACKGROUND AND OBJECTIVES

Health care disparities are pervasive, but little is known about disparities in pediatric safety. We analyzed a national sample of hospitalizations to identify disparities in safety events.

METHODS

In this population-based, retrospective cohort study of the 2019 Kids' Inpatient Database, independent variables were race, ethnicity, and payer. Outcomes were Agency for Healthcare Research and Quality pediatric safety indicators (PDIs). Risk-adjusted odds ratios were calculated using white and private payer reference groups. Differences by payer were evaluated by stratifying race and ethnicity.

RESULTS

Race and ethnicity of the 5 243 750 discharged patients were white, 46%; Hispanic, 19%; Black, 15%; missing, 8%; other race/multiracial, 7%, Asian American/Pacific Islander, 5%; and Native American, 1%. PDI rates (per 10 000 discharges) were 331.4 for neonatal blood stream infection, 267.5 for postoperative respiratory failure, 114.9 for postoperative sepsis, 29.5 for postoperative hemorrhage/hematoma, 5.6 for central-line blood stream infection, 3.5 for accidental puncture/laceration, and 0.7 for iatrogenic pneumothorax. Compared with white patients, Black and Hispanic patients had significantly greater odds in 5 of 7 PDIs; the largest disparities occurred in postoperative sepsis (adjusted odds ratio, 1.55 [1.38-1.73]) for Black patients and postoperative respiratory failure (adjusted odds ratio, 1.34 [1.21-1.49]) for Hispanic patients. Compared with privately insured patients, Medicaid-covered patients had significantly greater odds in 4 of 7 PDIs; the largest disparity occurred in postoperative sepsis (adjusted odds ratios, 1.45 [1.33-1.59]). Stratified analyses demonstrated persistent disparities by race and ethnicity, even among privately insured children.

CONCLUSIONS

Disparities in safety events were identified for Black and Hispanic children, indicating a need for targeted interventions to improve patient safety in the hospital.

Disparities in access to primary care, a key site for HIV prevention services, among gay and bisexual men in the United States

U.S. HIV diagnoses disproportionately affect Non-Hispanic Black (NHB) and Hispanic gay and bisexual men. Using data from the National Health Interview Survey (2013-2018), we examined race and ethnicity and primary care access, an HIV prevention resource, among gay and bisexual men. The explanatory variable was NHB, Hispanic or Non-Hispanic White (NHW). Outcomes were primary care-specific usual place of care (potential access) and saw general doctor <12 months (realized access). We used multivariable logistic regression, adjusting for individual sociodemographic characteristics, health status, and care barriers. In sensitivity analysis, we examined general access (any place/doctor) and subgroups (1) NHB (2) has usual place of care. The sample included 1,858 adult, gay and bisexual men (unweighted). Nearly one-third self-identified as NHB or Hispanic. Compared to NHW men, NHB and Hispanic men were younger, with lower household income, and more care barriers (p < 0.05). NHB and Hispanic men had lower realized access (aOR 0.7058, p = 0.030) than NHW men. Potential access was lower for NHB only (versus NHW) and, among those with any usual place of care, NHB and Hispanic men versus NHW men. Lower primary care access for NHB or Hispanic, rather than NHW, gay and bisexual men, may reduce HIV prevention access.

Failure to Complete Multidose Vaccine Series in Early Childhood

BACKGROUND

Most early childhood immunizations require 3 to 4 doses to achieve optimal protection. Our objective was to identify factors associated with starting but not completing multidose vaccine series.

METHODS

Using 2019 National Immunization Survey-Child data, US children ages 19 to 35 months were classified in 1 of 3 vaccination patterns: (1) completed the combined 7-vaccine series, (2) did not initiate ≥1 of the 7 vaccine series, or (3) initiated all series, but did not complete ≥1 multidose series. Associations between sociodemographic factors and vaccination pattern were evaluated using multivariable log-linked binomial regression. Analyses accounted for the survey's stratified design and complex weighting.

RESULTS

Among 16 365 children, 72.9% completed the combined 7-vaccine series, 9.9% did not initiate ≥1 series, and 17.2% initiated, but did not complete ≥1 multidose series. Approximately 8.4% of children needed only 1 additional vaccine dose from 1 of the 5 multidose series to complete the combined 7-vaccine series. The strongest associations with starting but not completing multidose vaccine series were moving across state lines (adjusted prevalence ratio [aPR] = 1.45, 95% confidence interval [CI]: 1.18-1.79), number of children in the household (2 to 3: aPR = 1.29, 95% CI: 1.05-1.58; 4 or more: aPR = 1.68, 95% CI: 1.30-2.18), and lack of insurance coverage (aPR = 2.03, 95% CI: 1.42-2.91).

CONCLUSIONS

More than 1 in 6 US children initiated but did not complete all doses in multidose vaccine series, suggesting children experienced structural barriers to vaccination. Increased focus on strategies to encourage multidose series completion is needed to optimize protection from preventable diseases and achieve vaccination coverage goals.

Predictors of Pediatric Frequent Emergency Department Use Among 7.6 million Pediatric Patients in New York

OBJECTIVE

This study examines the characteristics and factors associated with frequent emergency department (ED) utilization among the pediatric population.

METHODS

We conducted a pooled cross-sectional secondary analysis using the Healthcare Cost and Utilization Project State Emergency and Inpatient Databases on ED visits to all hospitals in New York from 2011 to 2016 by patients aged 0 to 21. We used multivariable logistic and negative binomial regressions to investigate the predictors of multiple ED visits in the pediatric population.

RESULTS

Overall, our study included 7.6 million pediatric patients who accounted for more than 12 million ED visits. Of those, 6.2% of patients were frequent ED users (≥4 visits/year), accounting for 20.8% of all ED visits (5.4 ED visits/year on average). The strongest predictors of frequent ED use were having at least one ED visit related to asthma (aOR = 8.37 [95% CI: 6.34-11.04]), mental health disorders (aOR = 9.67 [95% CI: 8.60-10.89]), or multiple comorbidities compared to none. Larger shares of ED visits for not-emergent conditions were also associated with frequent ED use (aOR = 6.63 [95% CI = 5.08-8.65]). Being covered by Medicaid compared to private (aOR = 0.45 [95% CI: 0.42-0.47]) or no insurance (aOR = 0.41 [95% CI: 0.38-0.44]) were further associated with frequent ED use. The results from the negative binomial regression yielded consistent findings.

CONCLUSIONS

Pediatric patients who exhibit increased ED use are more medically complex and have increased healthcare needs that are inextricably tied to social determinants of health. Better integrated health systems should emphasize connecting vulnerable patients to appropriate social and primary care services outside of emergency settings.

Trends in Health Care Use Among Black and White Persons in the US, 1963-2019

IMPORTANCE

In the US, Black people receive less health care than White people. Data on long-term trends in these disparities, which provide historical context for interpreting contemporary inequalities, are lacking.

OBJECTIVE

To assess trends in Black-White disparities in health care use since 1963.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed 29 US surveys conducted between 1963 and 2019 of noninstitutionalized Black and non-Hispanic White civilians.

EXPOSURES

Self-reported race and ethnicity.

MAIN OUTCOMES AND MEASURES

Annual per capita visit rates (for ambulatory, dental, and emergency department care), inpatient hospitalization rates, and total per capita medical expenditures.

RESULTS

Data from 154 859 Black and 446 944 White (non-Hispanic) individuals surveyed from 1963 to 2019 were analyzed (316 503 [52.6%] female; mean [SD] age, 37.0 [23.3] years). Disparities narrowed in the 1970s in the wake of landmark civil rights legislation and the implementation of Medicare and Medicaid but subsequently widened. For instance, the White-Black gap in ambulatory care visits decreased from 1.2 (95% CI, 1.0-1.4) visits per year in 1963 to 0.8 (95% CI, 0.6-1.0) visits per year in the 1970s and then increased, reaching 3.2 (95% CI, 3.0-3.4) visits per year in 2014 to 2019. Even among privately insured adults aged 18 to 64 years, White individuals used far more ambulatory care (2.6 [95% CI, 2.4-2.8] more visits per year) than Black individuals in 2014 to 2019. Similarly, White peoples' overall health care use, measured in dollars per capita, exceeded that of Black people in every year. After narrowing from 1.96 in the 1960s to 1.26 in the 1970s, the White-Black expenditure ratio began widening in the 1980s, reaching 1.46 in the 1990s; it remained between 1.31 and 1.39 in subsequent periods.

CONCLUSIONS AND RELEVANCE

This study's findings indicate that racial inequities in care have persisted for 6 decades and widened in recent years, suggesting the persistence and even fortification of structural racism in health care access. Reform efforts should include training more Black health care professionals, investments in Black-serving health facilities, and implementing universal health coverage that eliminates cost barriers.

Demographic and socioeconomic disparities in pediatric cancer in the United States: Current knowledge, deepening understanding, and expanding intervention

While survival of pediatric cancer has improved greatly over the past 40 years, demographic and socioeconomic disparities have meant that some groups have not benefitted as much from these advances. We conducted a rapid review to summarize literature on demographic and socioeconomic disparities in outcomes of childhood cancer, starting in 2000. We find that unequal outcomes have been noted for many of these groups across hematologic malignancies, central nervous system tumors, and other solid tumors, although occasional studies have noted absence of disparities for particular at-risk groups and diseases, and gaps in understanding of disparities for some cancer subtypes and groups still exist. These include disparities in duration of overall survival, risk of death, more extensive disease at presentation, and differences/delays in treatment. Black race, Hispanic ethnicity, lack of private insurance, and adolescent/young adult age are most often associated with these poorer outcomes. We then delve into documented and theorized causes of these disparities, including impaired access to care and clinical trials, differences in cancer biology, treatment non-adherence, language barriers, and implicit racial bias. Here, it is clear that socioeconomic factors account for a large proportion of disparities seen, although not all, and that the causes of disparities are complex and interconnected and still need to be better understood. Finally, in an effort to shift emphasis to addressing disparities, we review interventions against disparities that have been studied in childhood cancer patients and other populations, including improving clinical trial representation, communication, health literacy, and family navigation. We suggest ways forward in disparity mitigation toward a goal of achieving equitable cancer outcomes for all children.

Disparities in Pediatric Rheumatic Diseases

Health and health care disparities in pediatric rheumatology are prevalent among socially disadvantaged and marginalized populations based on race/ethnicity, socioeconomic position, and geographic region. These groups are more likely to experience greater disease severity, morbidity, mortality, decreased quality of life, and poor mental health outcomes, which are in part due to persistent structural and institutional barriers, including decreased access to quality health care. Most of the research on health and health care disparities in pediatric rheumatology focuses on juvenile idiopathic arthritis and childhood-onset systemic lupus erythematosus; there are significant gaps in the literature assessing disparities associated with other pediatric rheumatic diseases. Understanding the underlying causes of health care disparities will ultimately inform the development and implementation of innovative policies and interventions on a federal, local, and individual level.

Lower Use of Biologics for the Treatment of Asthma in Publicly Insured Individuals

BACKGROUND

Despite bearing a disproportionate burden of poorly controlled asthma, publicly insured individuals are less likely to receive biologics.

OBJECTIVE

To assess biologic use by payer among individuals with asthma.

METHODS

We used IQVIA's National Disease and Therapeutic Index, a nationally representative, all-payer audit of ambulatory care in the United States, to describe the patterns of use by payer.

RESULTS

Asthma treatment visits in which a biologic product was reported increased from approximately 0.1% of asthma-related visits in 2003 to 1% in 2015 and doubled to 2% by 2019. Omalizumab use initially increased from 2003 to 2006 and plateaued till 2015 when its use declined modestly, coinciding with the release of additional biologic products. In 2019, omalizumab accounted for 37% of biologic treatment visits, mepolizumab 21%, benralizumab 27%, dupilumab 15%, and reslizumab <1%. Biologic treatment visits were higher for privately insured individuals (28.3 per 1000 visits) compared with publicly insured individuals (16.3 per 1000 visits). This difference persisted after accounting for age, sex, and race using nationally representative estimates. Whites accounted for a disproportionate amount of biologic treatment visits among the publicly insured (80%) despite accounting for only 60% of publicly insured asthma treatment visits. No biologic treatment visits were observed for individuals who were uninsured. Half of dupilumab visits were for publicly insured patients, compared with 22% of mepolizumab/benralizumab and 27% of omalizumab visits.

CONCLUSION

Biologics were uncommonly used among patients with asthma, and the basis for disproportionately lower use of biologics among the publicly insured, where the burden of uncontrolled asthma is greatest, merits further investigation.

Racial/Ethnic Disparities Among US Children and Adolescents in Use of Dental Care

Introduction

Dental care among children has increased over the past decade, and racial/ethnic disparities have narrowed for some groups. We measured changes in racial/ethnic disparities in annual dental care for children and adolescents aged 2 to 17 years and conducted multivariate analysis to study factors associated with changes in disparities over time.

Methods

We used Medical Expenditure Panel Survey data to obtain crude prevalence estimates of dental care use and calculated absolute disparities and changes in disparities for 3 racial/ethnic groups of children and adolescents compared with non-Hispanic white children and adolescents relative to fixed points in time (2001 and 2016). We pooled all single years of data into 3 data cycles (2001–2005, 2006–2010, and 2011–2016) and used multivariate regression to assess the relationship between dental care use and race/ethnicity, controlling for the covariates of age, sex, parents’ education, household income, insurance status, and data cycle (time).

Results

Use increased by 18% only in low-income children and adolescents. Low-income Hispanic (adjusted prevalence ratio [aPR] = 0.98; 95% CI, 0.94−1.02) and Asian (aPR = 0.92; 95% CI, 0.83−1.02) participants showed no difference in dental care use relative to non-Hispanic white participants, but non-Hispanic black participants had significantly lower use (aPR = 0.84; 95% CI, 0.81−0.88). Public and private insurance were associated with a doubling of use among low-income children.

Conclusion

We saw a modest increase in dental care use and a narrowing of disparities for some low-income children and adolescents. Use among low-income Hispanic and Asian participants “caught up” with use among Hispanic white participants but remained well below that of children and adolescents in families with middle and high incomes. Disparities persisted for non-Hispanic black participants at all income levels.

Does Universal Insurance and Access to Care Influence Disparities in Outcomes for Pediatric Patients with Osteomyelitis?

BACKGROUND

Healthcare disparities are an issue in the surgical management of orthopaedic conditions in children. Although insurance expansion efforts may mitigate racial disparities in surgical outcomes, prior studies have not examined these effects on differences in pediatric orthopaedic care. To assess for racial disparities in pediatric orthopaedic care that may persist despite insurance expansion, we performed a case-control study of the outcomes of children treated for osteomyelitis in the TRICARE system, the healthcare program of the United States Department of Defense and a model of universal insurance and healthcare access.

QUESTIONS/PURPOSES

We asked whether (1) the rates of surgical intervention and (2) 90-day outcomes (defined as emergency department visits, readmission, and complications) were different among TRICARE-insured pediatric patients with osteomyelitis when analyzed based on black versus white race and military rank-defined socioeconomic status.

METHODS

We analyzed TRICARE claims from 2005 to 2016. We identified 2906 pediatric patients, of whom 62% (1810) were white and 18% (520) were black. A surgical intervention was performed in 9% of the patients (253 of 2906 patients). The primary outcome was receipt of surgical intervention for osteomyelitis. Secondary outcomes included 90-day complications, readmissions, and returns to the emergency department. The primary predictor variables were race and sponsor rank. Military rank has been used as an indicator of socioeconomic status before and during enlistment, and enlisted service members, particularly junior enlisted service members, may be at risk of having the same medical conditions that affect civilian members of lower socioeconomic strata. Patient demographic information (age, sex, race, sponsor rank, beneficiary category [whether the patient is an insurance beneficiary from an active-duty or retired service member], and geographic region) and clinical information (prior comorbidities, environment of care [whether clinical care was provided in a civilian or military facility], treatment setting, and length of stay) were used as covariates in multivariable logistic regression analyses.

RESULTS

After controlling for demographic and clinical factors including age, sex, sponsor rank, beneficiary category, geographic region, Charlson comorbidity index (as a measure of baseline health), environment of care, and treatment setting (inpatient versus outpatient), we found that black children were more likely to undergo surgical interventions for osteomyelitis than white children (odds ratio 1.78; 95% confidence interval, 1.26-2.50; p = 0.001). When stratified by environment of care, this finding persisted only in the civilian healthcare setting (OR 1.85; 95% CI, 1.26-2.74; p = 0.002). Additionally, after controlling for demographic and clinical factors, lower socioeconomic status (junior enlisted personnel) was associated with a higher likelihood of 90-day emergency department use overall (OR 1.60; 95% CI, 1.02-2.51; p = 0.040).

CONCLUSIONS

We found that for pediatric patients with osteomyelitis in the universally insured TRICARE system, many of the historically reported disparities in care were absent, suggesting these patients benefitted from improved access to healthcare. However, despite universal coverage, racial disparities persisted in the civilian care environment, suggesting that no single intervention such as universal insurance sufficiently addresses differences in racial disparities in care. Future studies can address the pervasiveness of these disparities in other patient populations and the various mechanisms through which they exert their effects, as well as potential interventions to mitigate these disparities.

LEVEL OF EVIDENCE

Level III, prognostic study.

Americans' Health Mindsets: Content, Cultural Patterning, and Associations With Physical and Mental Health

BACKGROUND

Health mindsets are mental frameworks that help people recognize, organize, interpret, and respond to health-relevant information. Although mindsets shape health behaviors and outcomes, no study has examined the health mindsets of ethnically and socioeconomically diverse Americans.

PURPOSE

We explored the content, cultural patterning, and health correlates of diverse Americans' health mindsets.

METHODS

Two studies surveyed approximately equal numbers of African American, Asian American, European American, and Latinx American men and women of lower and higher socioeconomic status (SES). Study 1 (N = 334) used open-ended questions to elicit participants' mindsets about the definitions, causes, and benefits of health. Study 2 (N = 320) used Study 1's results to develop a closed-ended instrument.

RESULTS

In Study 1, open-ended questioning revealed six overarching mindset themes: behavioral, medical, physical, psychological, social, and spiritual. The most prevalent mindsets were psychological definitions, behavioral causes, and psychological benefits. Participants mentioned more cause themes than definition or benefit themes, and mindset theme mentions correlated with worse health. Older participants mentioned more themes than younger, women mentioned more definition themes than men, and low-SES participants mentioned more cause themes than high-SES participants. In Study 2, closed-ended scales uncovered more complex and positive health mindsets. Psychological and spiritual benefit mindsets correlated with good mental health. African Americans and women endorsed the widest array of mindsets, and the spiritual benefit mindset partially explained the superior mental health of African Americans.

CONCLUSIONS

Many Americans hold simplistic, illness-focused health mindsets. Cultivating more complex, benefit-focused, and culturally appropriate health mindsets could support health.

The effect of Medicaid waivers on ameliorating racial/ethnic disparities among children with autism

OBJECTIVE

To examine the effects of Medicaid Home and Community-based Services (HCBS) waivers on reducing racial/ethnic disparities in unmet need for services among families of children with autism spectrum disorder (ASD).

DATA SOURCES

Data from the 2003, 2007, and 2011 waves of the National Survey of Children's Health and the 2005 and 2010 waves of the National Survey of Children with Special Health Care Needs were used. Data on waiver characteristics were collected from source materials that were submitted in support of each state's waiver application. Waiver characteristics were combined to create a single waiver generosity variable.

STUDY DESIGN

Quasi-difference-in-difference-in-difference models were used to determine the effect of waiver generosity on racial/ethnic disparities in unmet need among children with ASD.

PRINCIPAL FINDINGS

Increased waiver generosity was associated with significantly reduced odds of having unmet need for black children with ASD compared with white children with ASD. Unmet needs among black children with ASD were roughly cut in half, a 13 percentage point decrease, with the implementation of an average generosity waiver. No significant differences were seen for Hispanic ethnicity.

CONCLUSION

These findings suggest that Medicaid HCBS waivers have the potential to ameliorate disparities in unmet need among children with ASD. Future policy development should focus on replicating the most effective characteristics of these waivers.

Exploring national trends of patient- and family-centered care among US children

We explored national trends in the receipt of high-quality patient-physician communication and patient empowerment through behavioral health counseling among children in the United States. We used data from the Medical Expenditure Panel Survey from 2010 to 2014. We employed two measures of patient- and family-centered care (PFCC): (1) a composite measure of high-quality patient-physician communication ( n = 34,629) and (2) patient empowerment through behavioral health counseling about healthy eating ( n = 36,527) and exercise ( n = 38,318). We used multivariate logistic regression models to estimate the variation of receiving PFCC by social determinants of health over time. Rates of receiving behavioral health counseling about healthy eating (53-60%) and exercise (37-42%) were lower than the rate of receiving high-quality physician-patient communication (92-93%). Parents were significantly more likely to report receiving high-quality physician-patient communication in 2014 than in 2010 (odds ratio 1.37, confidence interval 1.08-1.67); however, no association was found for empowerment through behavioral health counseling. Low income and parental educational attainment, and lack of insurance were associated with lower odds of receiving behavioral health counseling. Results showed significant variation of physician-patient communication and empowerment by social and demographic factors. The results suggest more providers need to empower parents and their children to self-care through behavioral health counseling.

Racial, Ethnic, and Socioeconomic Disparities in Patient Safety Events for Hospitalized Children

OBJECTIVES

Previous studies have revealed racial/ethnic and socioeconomic disparities in quality of care and patient safety. However, these disparities have not been examined in a pediatric inpatient environment by using a measure of clinically confirmed adverse events (AEs). In this study, we do so using the Global Assessment of Pediatric Patient Safety (GAPPS) Trigger Tool.

METHODS

GAPPS was applied to medical records of randomly selected pediatric patients discharged from 16 hospitals in the Pediatric Research in Inpatient Settings Network across 4 US regions from January 2007 to December 2012. Disparities in AEs for hospitalized children were identified on the basis of patient race/ethnicity (black, Latino, white, or other; N = 17 336 patient days) and insurance status (public, private, or self-pay/no insurance; N = 19 030 patient days).

RESULTS

Compared with hospitalized non-Latino white children, hospitalized Latino children experienced higher rates of all AEs (Latino: 30.1 AEs per 1000 patient days versus white: 16.9 AEs per 1000 patient days; P ≤ .001), preventable AEs (Latino: 15.9 AEs per 1000 patient days versus white: 8.9 AEs per 1000 patient days; P = .002), and high-severity AEs (Latino: 12.6 AEs per 1000 patient days versus white: 7.7 AEs per 1000 patient days; P = .02). Compared with privately insured children, publicly insured children experienced higher rates of preventable AEs (public: 12.1 AEs per 1000 patient days versus private: 8.5 AEs per 1000 patient days; P = .02). No significant differences were observed among other groups.

CONCLUSIONS

The GAPPS analysis revealed racial and/or ethnic and socioeconomic disparities in rates of AEs experienced by hospitalized children across a broad range of geographic and hospital settings. Further investigation may reveal underlying mechanisms of these disparities and could help hospitals reduce harm.

Universal Health Insurance and its association with long term outcomes in Pediatric Trauma Patients

BACKGROUND

Racial disparities in mortality exist among pediatric trauma patients; however, little is known about disparities in outcomes following discharge.

METHODS

We conducted a longitudinal cohort study of children admitted for moderate to severe trauma, covered by TRICARE from 2006 to 2014. Patients were followed up to 90days after discharge. All children <18 years with a primary trauma diagnosis, an Injury Severity Score >9 and 90days of follow-up after discharge were included. Complications, readmissions and utilization of healthcare services up to 90days after discharge were compared between Black and White patients.

RESULTS

Of the 5192 children included, majority were White (74.6%, n=3871), with 15.4% Black (n=800) and 10.0% Other (n=521). Most common injuries involved the extremities or the pelvic girdle followed by the head or neck. Complication and readmission rates were 3.6% and 8.9% within 30days of discharge respectively and 4.4% and 9.3% within 90days of discharge. 99.0% of children had at least one outpatient visit by 90days. After adjusting for patient and injury characteristics no significant differences were detected between Black and White children in outcomes after discharge.

CONCLUSIONS

Universal insurance may help mitigate disparities in post discharge care in pediatric trauma populations by increasing access to outpatient services overall and within each racial group. Further studies are required to determine the appropriate timing and frequency of follow up care in order to achieve maximum reduction in use of acute care services after discharge.

Characteristics of Children Enrolled in Medicaid With High-Frequency Emergency Department Use

BACKGROUND AND OBJECTIVES

Some children repeatedly use the emergency department (ED) at high levels. Among Medicaid-insured children with high-frequency ED use in 1 year, we sought to describe the characteristics of children who sustain high-frequency ED use over the following 2 years.

METHODS

Retrospective longitudinal cohort study of 470 449 Medicaid-insured children appearing in the MarketScan Medicaid database, aged 1-16 years, with ≥1 ED discharges in 2012. Children with high ED use in 2012 (≥4 ED discharges) were followed through 2014 to identify characteristics associated with sustained high ED use (≥8 ED discharges in 2013-2014 combined). A generalized linear model was used to identify patient characteristics associated with sustained high ED use.

RESULTS

A total of 39 945 children (8.5%) experienced high ED use in 2012, accounting for 25% of total ED visits in 2012. Sixteen percent of these children experienced sustained high ED use in the following 2 years. Adolescents (adjusted odds ratio [aOR]: 1.4 [95% confidence interval: 1.3-1.5]), disabled children (aOR: 1.3 [95% confidence interval: 1.1-1.5]), and children with 3 or more chronic conditions (aOR: 2.1, [95% confidence interval: 1.9-2.3]) experienced the highest likelihood for sustaining high ED use.

CONCLUSIONS

One in 6 Medicaid-insured children with high ED use in a single year experienced sustained high levels of ED use over the next 2 years. Adolescents and individuals with multiple chronic conditions were most likely to have sustained high rates of ED use. Targeted interventions may be indicated to help reduce ED use among children at high risk.

Impact of geographic accessibility on utilization of the annual health check-ups by income level in Japan: A multilevel analysis

Although both geographic accessibility and socioeconomic status have been indicated as being important factors for the utilization of health care services, their combined effect has not been evaluated. The aim of this study was to reveal whether an income-dependent difference in the impact of geographic accessibility on the utilization of government-led annual health check-ups exists. Existing data collected and provided by Chiba City Hall were employed and analyzed as a retrospective cohort study. The subjects were 166,966 beneficiaries of National Health Insurance in Chiba City, Japan, aged 40 to 74 years. Of all subjects, 54,748 (32.8%) had an annual health check-up in fiscal year 2012. As an optimal index of geographic accessibility has not been established, five measures were calculated: travel time to the nearest health care facility, density of health care facilities (number facilities within a 30-min walking distance from the district of residence), and three indices based on the two-step floating catchment area method. Three-level logistic regression modeling with random intercepts for household and district of residence was performed. Of the five measures, density of health care facilities was the most compatible according to Akaike's information criterion. Both low density and low income were associated with decreased utilization of the health check-ups. Furthermore, a linear relationship was observed between the density of facilities and utilization of the health check-ups in all income groups and its slope was significantly steeper among subjects with an equivalent income of 0.00 yen than among those with equivalent income of 1.01-2.00 million yen (p = 0.028) or 2.01 million yen or more (p = 0.040). This result indicated that subjects with lower incomes were more susceptible to the effects of geographic accessibility than were those with higher incomes. Thus, better geographic accessibility could increase the health check-up utilization and also decrease the income-related disparity of utilization.

Inequities in health care needs for children with medical complexity

Children with special health care needs are believed to be susceptible to inequities in health and health care access. Within the group with special needs, there is a smaller group of children with medical complexity: children who require medical services beyond what is typically required by children with special health care needs. We describe health care inequities for the children with medical complexity compared to children with special health care needs but without medical complexity, based on a secondary analysis of data from the 2005-06 and 2009-10 National Survey of Children with Special Health Care Needs. The survey examines the prevalence, health care service use, and needs of children and youth with special care needs, as reported by their families. The inequities we examined were those based on race/ethnicity, primary language in the household, insurance type, and poverty status. We found that children with medical complexity were twice as likely to have at least one unmet need, compared to children without medical complexity. Among the children with medical complexity, unmet need was not associated with primary language, income level, or having Medicaid. We conclude that medical complexity itself can be a primary determinant of unmet needs.

Implementing the Florida Kidcare Open Enrollment Communications Campaign: A Framework for Mobilizing Community Partners to Reduce the Number of Uninsured Children

Florida ranks third among states with the lowest children's insurance coverage, due to constraints such as language barriers, multiple programs, documentation requirements, limited outreach, and short enrollment periods. In November 2004, Florida announced a 30-day children's health insurance enrollment period for January 2005 following an 18-month closure. This article describes the development, implementation, and evaluation of a communication plan creating coalitions between community partners, government agencies, and child advocacy groups to inform families. Over 96,000 families applied, almost five times any previous monthly enrollment. This campaign serves as a template for implementing strategies and engaging community partners to reduce the number of uninsured children.

Fathers' Roles in the Care and Development of Their Children: The Role of Pediatricians

Fathers' involvement in and influence on the health and development of their children have increased in a myriad of ways in the past 10 years and have been widely studied. The role of pediatricians in working with fathers has correspondingly increased in importance. This report reviews new studies of the epidemiology of father involvement, including nonresidential as well as residential fathers. The effects of father involvement on child outcomes are discussed within each phase of a child's development. Particular emphasis is placed on (1) fathers' involvement across childhood ages and (2) the influence of fathers' physical and mental health on their children. Implications and advice for all child health providers to encourage and support father involvement are outlined.

Questioning Children: Interactional Evidence of Implicit Bias in Medical Interviews

Social psychologists have shown experimentally that implicit race bias can influence an individual's behavior. Implicit bias has been suggested to be more subtle and less subject to cognitive control than more explicit forms of racial prejudice. Little is known about how implicit bias is manifest in naturally occurring social interaction. This study examines the factors associated with physicians selecting children rather than parents to answer questions in pediatric interviews about routine childhood illnesses. Analysis of the data using a Generalized Linear Latent and Mixed Model demonstrates a significant effect of parent race and education on whether physicians select children to answer questions. Black children and Latino children of low-education parents are less likely to be selected to answer questions than their same aged white peers irrespective of education. One way that implicit bias manifests itself in naturally occurring interaction may be through the process of speaker selection during questioning.

An Essential Role for Pediatricians: Becoming Child Poverty Change Agents for a Lifetime

Poverty has profound and enduring effects on the health and well-being of children, as well as their subsequent adult health and success. It is essential for pediatricians to work to reduce child poverty and to ameliorate its effects on children. Pediatricians have important and needed tools to do this work: authority/power as physicians, understanding of science and evidence-based approaches, and first-hand, real-life knowledge and love of children and families. These tools need to be applied in partnership with community-based organizations/leaders, educators, human service providers, business leaders, philanthropists, and policymakers. Examples of the effects of pediatricians on the issue of child poverty are seen in Ferguson, Missouri; Denver, Colorado; and Rochester, New York. In addition, national models exist such as the American Academy of Pediatrics Community Pediatrics Training Initiative, which engages numerous pediatric faculty to learn and work together to make changes for children and families who live in poverty and to teach these skills to pediatric trainees. Some key themes/lessons for a pediatrician working to make changes in a community are to bear witness to and recognize injustice for children and families; identify an area of passion; review the evidence and gain expertise on the issue; build relationships and partnerships with community leaders and organizations; and advocate for effective solutions.

Explaining racial disparities in infant health in Brazil

OBJECTIVES

We sought to quantify how socioeconomic, health care, demographic, and geographic effects explain racial disparities in low birth weight (LBW) and preterm birth (PTB) rates in Brazil.

METHODS

We employed a sample of 8949 infants born between 1995 and 2009 in 15 cities and 7 provinces in Brazil. We focused on disparities in LBW (< 2500 g) and PTB (< 37 gestational weeks) prevalence between infants of African ancestry alone or African mixed with other ancestries, and European ancestry alone. We used a decomposition model to quantify the contributions of conceptually relevant factors to these disparities.

RESULTS

The model explained 45% to 94% of LBW and 64% to 94% of PTB disparities between the African ancestry groups and European ancestry. Differences in prenatal care use and geographic location were the most important contributors, followed by socioeconomic differences. The model explained the majority of the disparities for mixed African ancestry and part of the disparity for African ancestry alone.

CONCLUSIONS

Public policies to improve children's health should target prenatal care and geographic location differences to reduce health disparities between infants of African and European ancestries in Brazil.

Coverage for low-income immigrant children increased 24.5 percent in states that expanded CHIPRA eligibility

The Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009 provided states with the option of expanding eligibility for federally funded public insurance to low-income immigrant children within their first five years of legal residence in the United States. By 2011 twenty states and the District of Columbia had adopted that option. Using cross-sectional data from the 2003, 2007, and 2011-12 National Survey of Children's Health, we compared trends in coverage and access to care among immigrant children in states that did expand eligibility to children in states that did not. Compared to immigrant children in states that did not expand eligibility, children in states expanding eligibility experienced a 24.5 percent increase in insurance coverage, largely due to greater enrollment in public insurance. Immigrant children in states that expanded eligibility also experienced significant reductions in unmet health care needs, compared to their counterparts in nonexpansion states. Disparities relative to children in nonimmigrant families were substantially reduced in states that expanded eligibility, compared to states that did not. Expanding eligibility for federally funded public insurance to immigrant children within their first five years of legal residence in other states could improve coverage for immigrant children and might also increase access to care.

The Children's Health Insurance Program Reauthorization Act Evaluation Findings on Children's Health Insurance Coverage in an Evolving Health Care Landscape

The Children's Health Insurance Program (CHIP) Reauthorization Act (CHIPRA) reauthorized CHIP through federal fiscal year 2019 and, together with provisions in the Affordable Care Act, federal funding for the program was extended through federal fiscal year 2015. Congressional action is required or federal funding for the program will end in September 2015. This supplement to Academic Pediatrics is intended to inform discussions about CHIP's future. Most of the new research presented comes from a large evaluation of CHIP mandated by Congress in the CHIPRA. Since CHIP started in 1997, millions of lower-income children have secured health insurance coverage and needed care, reducing the financial burdens and stress on their families. States made substantial progress in simplifying enrollment and retention. When implemented optimally, Express Lane Eligibility has the potential to help cover more of the millions of eligible children who remain uninsured. Children move frequently between Medicaid and CHIP, and many experienced a gap in coverage with this transition. CHIP enrollees had good access to care. For nearly every health care access, use, care, and cost measure examined, CHIP enrollees fared better than uninsured children. Access in CHIP was similar to private coverage for most measures, but financial burdens were substantially lower and access to weekend and nighttime care was not as good. The Affordable Care Act coverage options have the potential to reduce uninsured rates among children, but complex transition issues must first be resolved to ensure families have access to affordable coverage, leading many stakeholders to recommend funding for CHIP be continued.

Sociocultural issues in african american and Hispanic minorities seeking care for attention-deficit/hyperactivity disorder

OBJECTIVE

To review the sociocultural factors that may affect the diagnosis and management of attention-deficit/hyperactivity disorder (ADHD) in African American and Hispanic minorities seen in the primary care setting in the United States.

DATA SOURCES

Searches on MEDLINE and PubMed were conducted in April and September 2012 on ADHD and its related problems and disabilities. A general search was conducted using the terms (attention deficit hyperactivity disorder OR attention deficit/hyperactivity disorder OR ADHD OR AD/HD) AND (ethnicity OR cultural OR culture). Issues of particular relevance to racial and ethnic minorities utilizing health care services were researched using the string (black OR African OR Hispanic OR Latino OR minority OR racial) combined with terms relating to access, insurance, comorbidity, high-risk behavior, treatment compliance, and nonpharmacologic modalities. Searches were limited to English-language citations, and no date parameters were used. References identified as pertinent to this review were selected for citation.

STUDY SELECTION/DATA EXTRACTION

Information revealing contrasts between minorities and the US non-Hispanic white population was organized in distinct categories, such as access to medical care and insurance, cultural attitudes, and the effects of stigmatization. The authors also provide perspectives for the primary care physician from their own clinical experience.

DATA SYNTHESIS

Rates of diagnosis of in the United States are higher for non-Hispanic whites than for minorities, yet true prevalence is probably similar across racial-ethnic groups. When the stigma of mental illness is added to the challenges faced by racial/ethnic minorities or immigrant status, patients may be especially sensitive. Underuse of clinical services may reflect economic limitations on access to care, cultural attitudes toward mental illness, and the effects of real or perceived prejudice and stigmatization.

CONCLUSIONS

Primary care clinicians in the United States should seek to become more aware of cultural factors that could interfere with the recognition and management of ADHD.

Children's Health Insurance Program (CHIP): accomplishments, challenges, and policy recommendations

Sixteen years ago, the 105th Congress, responding to the needs of 10 million children in the United States who lacked health insurance, created the State Children's Health Insurance Program (SCHIP) as part of the Balanced Budget Act of 1997. Enacted as Title XXI of the Social Security Act, the Children's Health Insurance Program (CHIP; or SCHIP as it has been known at some points) provided states with federal assistance to create programs specifically designed for children from families with incomes that exceeded Medicaid thresholds but that were insufficient to enable them to afford private health insurance. Congress provided $40 billion in block grants over 10 years for states to expand their existing Medicaid programs to cover the intended populations, to erect new stand-alone SCHIP programs for these children, or to effect some combination of both options. Congress reauthorized CHIP once in 2009 under the Children's Health Insurance Program Reauthorization Act and extended its life further within provisions of the Patient Protection and Affordable Care Act of 2010. The purpose of this statement is to review the features of CHIP as it has evolved over the 16 years of its existence; to summarize what is known about the effects that the program has had on coverage, access, health status, and disparities among participants; to identify challenges that remain with respect to insuring this group of vulnerable children, including the impact that provisions of the new Affordable Care Act will have on the issue of health insurance coverage for near-poor children after 2015; and to offer recommendations on how to expand and strengthen the national commitment to provide health insurance to all children regardless of means.

Socioeconomic factors are associated with frequency of repeat emergency department visits for pediatric closed fractures

BACKGROUND

Previous research has demonstrated both greater difficulty in obtaining follow-up appointments and increased likelihood of return visits to the emergency department (ED) for patients with government-funded insurance plans. The purpose of the current study is to determine whether socioeconomic factors, such as race and insurance type, are associated with the frequency of repeat ED visits in pediatric patients with closed fractures.

METHODS

A review of ED visit data over a 2-year period from a statewide hospital discharge database in New York was conducted. Discharges for patients with a unique person identifier in the database age 17 years and younger were examined for an ICD-9 diagnosis of closed upper or lower extremity fracture. Age, sex, race, and insurance type for patients with a return ED visit within 8 weeks for the same fracture diagnosis were compared with those without a return visit using standard univariate statistical tests and logistic regression analyses.

RESULTS

Of the 68,236 visits reviewed, the revisit rate was 0.85%. Patients of nonwhite or unidentified race were significantly more likely to have a revisit than white patients (OR, 1.27; P=0.006). Patients with government-funded insurance were significantly more likely to have a revisit than those without government-funded insurance (OR, 1.55; P<0.001). Patients with private insurance were significantly less likely to have a revisit than those without private insurance (OR, 0.72; P=0.001).

CONCLUSIONS

Our analysis revealed that nonwhite patients are more likely to return to the ED within 8 weeks for the same fracture diagnosis. Patients with government insurance are 55% more likely to have a revisit, whereas patients with private insurance are 28% less likely to have a revisit. Our results suggest that socioeconomic disparities exist in access to orthopaedic care for closed fractures in a pediatric population. Physicians and policy makers should be mindful of these health care disparities when striving to improve access to care among patients and resource utilization in the ED.

LEVEL OF EVIDENCE

Prognostic level II.

Continuity of Public Insurance Coverage

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

Disparities in health insurance among children with same-sex parents

OBJECTIVES

The objectives of this study were to examine disparities in health insurance coverage for children with same-sex parents and to investigate how statewide policies such as same-sex marriage and second-parent adoptions affect children's private insurance coverage.

METHODS

We used data from the 2008-2010 American Community Survey to identify children (aged 0-17 years) with same-sex parents (n = 5081), married opposite-sex parents (n = 1369789), and unmarried opposite-sex parents (n = 101678). We conducted multinomial logistic regression models to estimate the relationship between family type and type of health insurance coverage for all children and then stratified by each child's state policy environment.

RESULTS

Although 77.5% of children with married opposite-sex parents had private health insurance, only 63.3% of children with dual fathers and 67.5% with dual mothers were covered by private health plans. Children with same-sex parents had fewer odds of private insurance after controlling for demographic characteristics but not to the extent of children with unmarried opposite-sex parents. Differences in private insurance diminished for children with dual mothers after stratifying children in states with legal same-sex marriage or civil unions. Living in a state that allowed second-parent adoptions also predicted narrower disparities in private insurance coverage for children with dual fathers or dual mothers.

CONCLUSIONS

Disparities in private health insurance for children with same-sex parents diminish when they live in states that secure their legal relationship to both parents. This study provides supporting evidence in favor of recent policy statements by the American Academy of Pediatricians endorsing same-sex marriage and second-parent adoptions.

Language and immigrant status effects on disparities in Hispanic children's health status and access to health care

The objective of this study is to estimate Hispanic/non-Hispanic (nH)-white health disparities and assess the extent to which disparities can be explained by immigrant status and household primary language. The 2007 National Survey of Children's Health was funded by the Maternal and Child Health Bureau, and conducted by Centers for Disease Control and Prevention's National Center for Health Statistics as a module of the State and Local Area Integrated Telephone Survey. We calculated disparities for various health indicators between Hispanic and nH-white children, and used logistic regression to adjust them for socio-economic and demographic characteristics, primary language spoken in the household, and the child's immigrant status. Controlling for language and immigrant status greatly reduces health disparities, although it does not completely eliminate all disparities showing poorer outcomes for Hispanic children. English-speaking and nonimmigrant Hispanic children are more similar to nH-white children than are Hispanic children in non-English speaking households or immigrant children. Hispanic/nH-white health disparities among children are largely driven by that portion of the Hispanic population that is either newly-arrived to this country or does not speak primarily English in the household.

Race does not impact pancreatic cancer treatment and survival in an equal access federal health care system

BACKGROUND

Black patients with pancreatic adenocarcinoma (PDAC) have been reported to undergo surgical resection less frequently and to have a shorter overall survival duration than white patients. We sought to determine whether disparities in clinical management and overall survival exist between black and white patients with PDAC treated in an equal access health care system.

METHODS

Using the Department of Defense (DoD) tumor registry database from 1993 to 2007, patient, tumor, and treatment factors were analyzed to compare rates of therapy and survival between black and white patients.

RESULTS

Of 1,008 patients with PDAC, 157 were black (15 %). Thirty-six percent of black and 37 % of white patients presented with locoregional disease (p = 0.85). Among those with locoregional cancers, the odds of black patients having received surgical resection (odds ratio [OR] 1.06, 95 % confidence interval [CI] 0.60-1.89), chemotherapy (OR 0.92, 95 % CI 0.49-1.73) and radiotherapy (OR 1.14, 95 % CI 0.61-2.10) were not different from those of whites. Among those with distant disease, the odds of having received palliative chemotherapy were also similar (OR 0.91, 95 % CI 0.55-1.51). Black and white patients with PDAC had a similar median overall survival. In a multivariate analysis, as compared to whites, black race was not associated with shorter overall survival.

CONCLUSIONS

We observed no disparities in either management or survival between white and black patients with PDAC treated in the DoD's equal access health care system. These data suggest that improving the access of minorities with PDAC to health care may reduce disparities in their oncologic outcomes.

Racial disparities in ordering laboratory and radiology tests for pediatric patients in the emergency department

OBJECTIVE

The objective of this study was to examine the association of race and language on laboratory and radiological testing in the pediatric emergency department (ED).

METHODS

This retrospective, case-cohort study examined laboratory and radiological testing among patients discharged home from 2 urban, pediatric EDs between March 2, 2009, and March 31, 2010.

RESULTS

There were 75,254 visits among 49,164 unique patients, of whom 31.0% had laboratory and 30.5% had radiological testing. African American (adjusted odds ratio [aOR], 0.93; confidence interval [CI], 0.89-0.98; P = 0.004) and biracial racial categories (aOR, 0.91; CI, 0.86-0.98; P = 0.007) were associated with decreased odds of laboratory testing compared with non-Hispanic whites. Similarly, Native American (aOR, 0.82; CI, 0.73-0.94), African American (aOR0.81; CI, 0.72-0.81), biracial (aOR, 0.82; CI, 0.77-0.88), Hispanic (aOR.76; CI, 0.72-0.81), and "other" (aOR, 0.84; CI, 0.73-0.97) racial categories were each associated with lower odds of radiological testing compared with non-Hispanic whites. Subgroup analysis of visits with a final diagnosis of fever and upper respiratory tract infection, conditions for which there were few treatment protocols, confirmed the racial differences. Subgroup analysis in visits for head injury, for which there is an established evaluation protocol, did not find a lower odds of laboratory or radiological testing by race compared with non-Hispanic whites.

CONCLUSIONS

Racial disparities in laboratory and radiological testing were present in pediatric ED visits. No racial differences were seen in the radiological and laboratory charges in the head injury subgroup, suggesting that evaluation algorithms can ameliorate racial disparities in pediatric ED care.

Time to Pediatric Epilepsy Surgery Is Longer and Developmental Outcomes Lower for Government Compared With Private Insurance

BACKGROUND:

It is unclear if socioeconomic factors like type of insurance influence time to referral and developmental outcomes for pediatric patients undergoing epilepsy surgery.

OBJECTIVE:

This study determined whether private compared with state government insurance was associated with shorter intervals of seizure onset to surgery and better developmental quotients for pediatric patients undergoing epilepsy surgery.

METHODS:

A consecutive cohort (n = 420) of pediatric patients undergoing epilepsy surgery were retrospectively categorized into those with Medicaid (California Children's Services; n = 91) or private (Preferred Provider Organization, Health Maintenance Organization, Indemnity; n = 329) insurance. Intervals from seizure onset to referral and surgery and Vineland developmental assessments were compared by insurance type with the use of log-rank tests.

RESULTS:

Compared with private insurance, children with Medicaid had longer intervals from seizure onset to referral for evaluation (log-rank test, P = .034), and from seizure onset to surgery (P = .017). In a subset (25%) that had Vineland assessments, children with Medicaid compared with private insurance had lower Vineland scores presurgery (P = .042) and postsurgery (P = .003). Type of insurance was not associated with seizure severity, types of operations, etiology, postsurgical seizure-free outcomes, and complication rate.

CONCLUSION:

Compared with Medicaid, children with private insurance had shorter intervals from seizure onset to referral and to epilepsy surgery, and this was associated with lower Vineland scores before surgery. These findings may reflect delayed access for uninsured children who eventually obtained state insurance. Reasons for the delay and whether longer intervals before epilepsy surgery affect long-term cognitive and developmental outcomes warrant further prospective investigations.

Explaining racial disparities in infant health in Brazil

OBJECTIVES

We sought to quantify how socioeconomic, health care, demographic, and geographic effects explain racial disparities in low birth weight (LBW) and preterm birth (PTB) rates in Brazil.

METHODS

We employed a sample of 8949 infants born between 1995 and 2009 in 15 cities and 7 provinces in Brazil. We focused on disparities in LBW (< 2500 g) and PTB (< 37 gestational weeks) prevalence between infants of African ancestry alone or African mixed with other ancestries, and European ancestry alone. We used a decomposition model to quantify the contributions of conceptually relevant factors to these disparities.

RESULTS

The model explained 45% to 94% of LBW and 64% to 94% of PTB disparities between the African ancestry groups and European ancestry. Differences in prenatal care use and geographic location were the most important contributors, followed by socioeconomic differences. The model explained the majority of the disparities for mixed African ancestry and part of the disparity for African ancestry alone.

CONCLUSIONS

Public policies to improve children's health should target prenatal care and geographic location differences to reduce health disparities between infants of African and European ancestries in Brazil.

Development of educational materials to improve rates of early eye care for Hispanic children

The purpose of this study was to develop targeted materials to encourage Hispanic parents to seek eye care for their children. Hispanic children present with high rates of eye problems such as astigmatism, strabismus, and amblyopia. Related vision impairment can be prevented with timely detection and treatment. After failing a vision screening, a child must obtain professional eye care to take care of the suspected problem. We involved Hispanic community members and health care experts in Alabama to develop educational materials to encourage Hispanic parents to seek eye care for their children. There were six stages in the development of the educational materials: (a) focus groups with Hispanic parents, (b) development of preliminary materials (c) panel with Hispanic health experts (d) panel with members of the target population (e) final production of materials (f) pilot testing of materials. The parents and health experts suggested the information should be provided in the form of radio announcements, brochures, and newspaper advertisements. They also noted the content should stress the importance of seeking vision care for children even when there were no visible problems. Materials developed through this project included messages designed to overcome specific barriers identified by Hispanic parents and to educate them on the importance of comprehensive eye care for all children, regardless of the presence of visible symptoms.

Are pediatric quality care measures too stringent?

INTRODUCTION

We aimed to demonstrate the application of national pediatric quality measures, derived from claims-based data, for use with electronic medical record data, and determine the extent to which rates differ if specifications were modified to allow for flexibility in measuring receipt of care.

METHODS

We reviewed electronic medical record data for all patients up to 15 years of age with ≥1 office visit to a safety net family medicine clinic in 2010 (n = 1544). We assessed rates of appropriate well-child visits, immunizations, and body mass index (BMI) documentation, defined strictly by national guidelines versus by guidelines with clinically relevant modifications.

RESULTS

Among children aged <3 years, 52.4% attended ≥6 well-child visits by the age of 15 months; 60.8% had ≥6 visits by age 2 years. Less than 10% completed 10 vaccination series before their second birthday; with modifications, 36% were up to date. Among children aged 3 to 15 years, 63% had a BMI percentile recorded; 91% had BMI recorded within 36 months of the measurement year.

CONCLUSIONS

Applying relevant modifications to national quality measure definitions captured a substantial number of additional services. Strict adherence to measure definitions might miss the true quality of care provided, especially among populations that may have sporadic patterns of care utilization.

Racial and ethnic disparities in quality of health care among children with autism and other developmental disabilities

We examined racial and ethnic disparities in quality of care for children with autism and other developmental disabilities and whether disparities varied for children with autism compared to children with other developmental disabilities. Analyzing data from the National Survey of Children with Special Health Care Needs (N  =  4,414), we compared Black and Latino children to White children. We found racial and ethnic disparities on 5 of 6 quality outcomes. The interaction between race and disability status indicated that disparities in quality indicators were exacerbated among families of children with autism. These analyses suggest that children with autism, particularly those who are Latino and Black, face greater challenges in receiving high-quality health care.

Understanding the Gap in Primary Care Access and Use Between Teens and Younger Children

Primary health care use among teenagers falls short of clinical recommendations and consistently lags behind that of younger children. Using the Medical Expenditure Panel Survey, the authors explore three explanations for this age-related gap: family composition, parental awareness of children’s health care needs, and the relative role of predisposing, enabling, and need-based factors for teens and younger children. Teenagers are 64% more likely to have no usual source of care and 25% more likely to have had no health care visit in the prior year relative to younger children. The gap narrows in families with children from both age-groups and among children with special health care needs. The largest disparity in primary care access exists between teens in families with no younger sibling(s) and younger children in families with no teen(s). A resolution to the age-related access gap will likely require understanding of, and intervention into, family-level determinants of poor access.

Generational status, health insurance, and public benefit participation among low-income Latino children

The objectives of this study were to (1) measure health insurance coverage and continuity across generational subgroups of Latino children, and (2) determine if participation in public benefit programs is associated with increased health insurance coverage and continuity. We analyzed data on 25,388 children income-eligible for public insurance from the 2003 to 2004 National Survey of Children's Health and stratified Latinos by generational status. First- and second-generation Latino children were more likely to be uninsured (58 and 19%, respectively) than third-generation children (9.5%). Second-generation Latino children were similarly likely to be currently insured by public insurance as third-generation children (61 and 62%, respectively), but less likely to have private insurance (19 and 29%, respectively). Second-generation Latino children were slightly more likely than third-generation children to have discontinuous insurance during the year (19 and 15%, respectively). Compared with children in families where English was the primary home language, children in families where English was not the primary home language had higher odds of being uninsured versus having continuous insurance coverage (OR: 2.19; 95% CI [1.33-3.62]). Among second-generation Latino children, participation in the Food Stamp (OR 0.26; 95% CI [0.14-0.48]) or Women, Infants, and Children (OR 0.40; 95% CI [0.25-0.66]) programs was associated with reduced odds of being uninsured. Insurance disparities are concentrated among first- and second-generation Latino children. For second-generation Latino children, connection to other public benefit programs may promote enrollment in public insurance.

Assessing barriers to health insurance and threats to equity in comparative perspective: the Health Insurance Access Database

BACKGROUND

Typologies traditionally used for international comparisons of health systems often conflate many system characteristics. To capture policy changes over time and by service in health systems regulation of public and private insurance, we propose a database containing explicit, standardized indicators of policy instruments.

METHODS

The Health Insurance Access Database (HIAD) will collect policy information for ten OECD countries, over a range of eight health services, from 1990-2010. Policy indicators were selected through a comprehensive literature review which identified policy instruments most likely to constitute barriers to health insurance, thus potentially posing a threat to equity. As data collection is still underway, we present here the theoretical bases and methodology adopted, with a focus on the rationale underpinning the study instruments.

RESULTS

These harmonized data will allow the capture of policy changes in health systems regulation of public and private insurance over time and by service. The standardization process will permit international comparisons of systems' performance with regards to health insurance access and equity.

CONCLUSION

This research will inform and feed the current debate on the future of health care in developed countries and on the role of the private sector in these changes.

Why are Low-Income Teens More Likely to Lack Health Insurance Than Their Younger Peers?

Low-income teenagers are more likely to lack health insurance than younger children. Using data from the 2006, 2007, and 2008 rounds of the National Health Interview Survey, we examine whether differences between teens and younger children in socioeconomic factors, public health insurance eligibility, and observable family characteristics explain this apparent age-related coverage gap. Somewhat surprisingly, they do not. We find a highly robust age-coverage gradient among poor and near-poor children. Our results suggest the need to examine teen-specific insurance enrollment dynamics, particularly in families with no younger siblings, to optimize the effect of the newly enacted Patient Protection and Affordable Care Act on teens' insurance coverage.

Measuring and reporting quality of health care for children: CHIPRA and beyond

BACKGROUND AND PURPOSE

The coming years could be a watershed period for children and health care as the nation implements the most significant federal health care legislation in 50 years: the Accountable Care Act (ACA). A year earlier, the American Recovery and Reinvestment Act (ARRA) set up a framework and road map for the eventual universal adoption of health information technology in its Health Information Technology for Economic and Clinical Health (HITECH) provisions, and the Children's Health Insurance Program Reauthorization Act (CHIPRA) legislation articulated a new and compelling vision for quality measurement in child health services. Each of these landmark advances in federal health policy contains relevant provisions for the measurement and improvement of the performance of the health system. Less clear is the extent to which the child specific framework articulated in CHIPRA will be preserved and built upon. Here, we set forth recommendations for ensuring that measurement and reporting efforts under CHIPRA, ARRA, and ACA are aligned for children.

POLICY THEMES AND RECOMMENDATIONS

Our findings around problems and recommendations are grouped into 2 broad areas: those that deal with helping states report and use current measures, and those that deal with expanding the current measures. Recommendations include 5 aimed at focusing efforts on measure reporting and use: 1) help states build a measurement infrastructure; 2) provide specific technical assistance and support to states on how to collect, report, and use measures; 3) establish a national office for quality monitoring; 4) make available nationally data from states; and 5) ensure specific focus on child health in HITECH initiatives. Recommendations also include 3 aimed at extending what is being measured: 1) continue emphasis on insurance stability; 2) ensure that disparities can be measured and monitored; and 3) build measures that focus on system accountability and outcomes.

CONCLUSIONS

National health care reform provides the opportunity to extend coverage and dramatically restructure systems of care. It will be important to ensure that focus on health care quality for children be maintained and that the advances made under CHIPRA reinforce and are not diluted or overtaken by broader reform efforts.