Planning the next wave of SCHIP research

Increase in federal match associated with significant gains in coverage for children through Medicaid and CHIP

As the number of children living in poverty has increased steadily over the past decade, Medicaid and the Children's Health Insurance Program (CHIP) have enrolled millions of additional youths. Federal and state governments jointly finance both programs, with the federal portion determined by the Federal Medical Assistance Percentage, commonly known as the "federal match." The federal government has used intermittent increases in the federal match as a way to provide fiscal relief to states during economic downturns. The most recent broad increase ended in June 2011, but the precise impact on Medicaid and CHIP enrollment for children is not known. No previous study has evaluated the association of the federal match with children's enrollment in state Medicaid or CHIP programs in the context of other state factors. To shed light on the degree to which public coverage for children varies with differences in the federal match, we examined publicly available data from all fifty states from 1999 to 2009. We found that a ten-percentage-point increase in the federal match was associated with a 1.9 percent increase in Medicaid and CHIP enrollment, equivalent to approximately 500,000 children. This association persisted when adjusted for multiple state-level factors, including the proportion of children living in poverty. This analysis underscores the central role of the federal match in supporting expansion of Medicaid and CHIP coverage for children.

Does a prehospital Glasgow Coma Scale score predict pediatric outcomes?

BACKGROUND

Although the Glasgow Coma Scale (GCS) score is widely used by medical professionals to evaluate and predict neurological outcomes, studies using the prehospital (P) GCS score to predict neurological outcomes in children are few.

OBJECTIVE

The objective of this study was to determine the agreement between the P GCS score and the emergency department (ED) GCS score, and the association between P GCS score and outcomes at hospital discharge in pediatric patients 5 to 18 years of age.

METHODS

Medical record review of children 5 to 18 years old with traumatic brain injury (TBI) was conducted. Children with documented P and ED GCS scores were eligible for enrollment. The hospital records of each enrolled child were reviewed, and the Glasgow outcome score and the disability rating scale scores were calculated. Agreement between the P and ED GCS scores was calculated using χ (κ statistic).

RESULTS

One hundred eighty-five subjects were included. There was strong agreement between P and ED GCS scores (κ = +0.69; confidence interval, 0.57-0.81). The Glasgow outcome score category improved with improving GCS category. The median disability rating scale score was also similar for P and ED GCS scores and was higher with decreasing GCS.

CONCLUSIONS

Our data showed strong agreement between P and ED GCS scores. Also, there was strong association between P GCS scores and short-term outcomes in children with TBI. The results support the use of GCS in prehospital transport destination guidelines for children with TBI.

Improving children's healthcare through state health insurance programs: an emerging need

OBJECTIVES

State Children's Health Insurance Program (SCHIP) in the USA plays a critical role in healthcare service utilization. This study assesses children's needs for healthcare services among the variations of SCHIP.

METHODS

This study applies the PRECEDE-PROCEED behavioral model to analyze the behavior of children with healthcare needs and unmet healthcare needs by using the National Survey of Children with Special Healthcare Needs of the USA.

RESULTS

Children who were previously under a Medicaid program are apt to enroll in SCHIP programs. SCHIP children with healthcare needs are more likely than comparable non-SCHIP children to use hospital outpatient departments instead of using doctors' offices and health centers. Children under the SCHIP single and SCHIP combination programs are more likely to use doctors' offices and health centers than those in the Medicaid expansion program. SCHIP combination or SCHIP Medicaid expansion states are significantly less likely to have unmet healthcare needs than children in SCHIP single states.

CONCLUSIONS

Medicaid has a significant impact on the SCHIP program. There is a substitution of healthcare service facilities between hospital outpatient departments and either the doctors' offices or health centers.

Pediatric blunt splenic trauma: a comprehensive review

Abdominal trauma is a leading cause of death in children older than 1 year of age. The spleen is the most common organ injured following blunt abdominal trauma. Pediatric trauma patients present unique clinical challenges as compared to adults, including different mechanisms of injury, physiologic responses, and indications for operative versus nonoperative management. Splenic salvage techniques and nonoperative approaches are preferred to splenectomy in order to decrease perioperative risks, transfusion needs, duration/cost of hospitalization, and risk of overwhelming postsplenectomy infection. Early and accurate detection of splenic injury is critical in both adults and children; however, while imaging findings guide management in adults, hemodynamic stability is the primary determinant in pediatric patients. After initial diagnosis, the primary role of imaging in pediatric patients is to determine the level and duration of care. We present a comprehensive literature review regarding the mechanism of injury, imaging, management, and complications of traumatic splenic injury in pediatric patients. Multiple patients are presented with an emphasis on the American Association for the Surgery of Trauma organ injury grading system. Clinical practice guidelines from the American Pediatric Surgical Association are discussed and compared with our experience at a large community hospital, with recommendations for future practice guidelines.

Community-based strategies to reduce childhood immunization disparities

This study demonstrates how community-based immunization promotion reduced immunization disparities. In 2002 to 2004, the coalition enrolled 3,748 children younger than 5, with 1,502 aged 19 to 35 months in April 2004. Disparity reduction was assessed by comparing coalition immunization coverage rates (4:3:1:3:3) to the National Immunization Survey 2003 rates. Logistic regression was used to assess factors contributing to up-to-date immunizations. Coverage increased from 46.0% at enrollment to 80.5%, matching nationwide rates for all (t = 0.87) or White (t = 1.99) children. The 78% for African Americans was higher than 73% for U.S. African American children (t = 2.90); 84% for Latinos was higher than 77% for U.S. Latinos (t = 2.32). Being current with age-appropriate immunizations at enrollment (OR = 9.8), being Latino (OR = 1.6), and participating through child health insurance enrollment (OR = 4.9), Women, Infants, and Children (OR = 3.1), or child care or parenting (OR = 1.9) programs increased immunization coverage. Embedding immunization promotion into existing community programs was successful in eliminating immunization disparities. Most effective programs were those with direct linkages to health care systems or that targeted young children.