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Alizadeh F, Gauvreau K, Mayourian J, Brown E, Barreto JA, Blossom J, Bucholz E, Newburger JW, Kheir J, Vitali S, Thiagarajan RR, Moynihan K. Social Drivers of Health and Pediatric Extracorporeal Membrane Oxygenation Outcomes. Pediatrics 2023; 152:e2023061305. [PMID: 37933403 DOI: 10.1542/peds.2023-061305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Relationships between social drivers of health (SDoH) and pediatric health outcomes are highly complex with substantial inconsistencies in studies examining SDoH and extracorporeal membrane oxygenation (ECMO) outcomes. To add to this literature with emerging novel SDoH measures, and to address calls for institutional accountability, we examined associations between SDoH and pediatric ECMO outcomes. METHODS This single-center retrospective cohort study included children (<18 years) supported on ECMO (2012-2021). SDoH included Child Opportunity Index (COI), race, ethnicity, payer, interpreter requirement, urbanicity, and travel-time to hospital. COI is a multidimensional estimation of SDoH incorporating traditional (eg, income) and novel (eg, healthy food access) neighborhood attributes ([range 0-100] higher indicates healthier child development). Outcomes included in-hospital mortality, ECMO run duration, and length of stay (LOS). RESULTS 540 children on ECMO (96%) had a calculable COI. In-hospital mortality was 44% with median run duration of 125 hours and ICU LOS 29 days. Overall, 334 (62%) had cardiac disease, 92 (17%) neonatal respiratory failure, 93 (17%) pediatric respiratory failure, and 21 (4%) sepsis. Median COI was 64 (interquartile range 32-81), 323 (60%) had public insurance, 174 (34%) were from underrepresented racial groups, 57 (11%) required interpreters, 270 (54%) had urban residence, and median travel-time was 89 minutes. SDoH including COI were not statistically associated with outcomes in univariate or multivariate analysis. CONCLUSIONS We observed no significant difference in pediatric ECMO outcomes according to SDoH. Further research is warranted to better understand drivers of inequitable health outcomes in children, and potential protective mechanisms.
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Affiliation(s)
| | | | | | | | | | - Jeff Blossom
- Center for Geographic Analysis, Harvard University, Cambridge, Massachusetts
| | | | | | - John Kheir
- Departments of Cardiology
- Departments of Pediatrics
| | - Sally Vitali
- Anesthesia, Critical Care, Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Anesthesia, Harvard Medical School, Boston, Massachusetts
| | | | - Katie Moynihan
- Departments of Cardiology
- Departments of Pediatrics
- Children's Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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2
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Rochlin DH, Rizk NM, Flores RL, Matros E, Sheckter CC. The Reality of Commercial Payer-Negotiated Rates in Cleft Lip and Palate Repair. Plast Reconstr Surg 2023; 152:476e-487e. [PMID: 36847669 DOI: 10.1097/prs.0000000000010329] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Commercial payer-negotiated rates for cleft lip and palate surgery have not been evaluated on a national scale. The aim of this study was to characterize commercial rates for cleft care, both in terms of nationwide variation and in relation to Medicaid rates. METHODS A cross-sectional analysis was performed of 2021 hospital pricing data from Turquoise Health, a data service platform that aggregates hospital price disclosures. The data were queried by CPT code to identify 20 cleft surgical services. Within- and across-hospital ratios were calculated per CPT code to quantify commercial rate variation. Generalized linear models were used to assess the relationship between median commercial rate and facility-level variables and between commercial and Medicaid rates. RESULTS There were 80,710 unique commercial rates from 792 hospitals. Within-hospital ratios for commercial rates ranged from 2.0 to 2.9 and across-hospital ratios ranged from 5.4 to 13.7. Median commercial rates per facility were higher than Medicaid rates for primary cleft lip and palate repair ($5492.20 versus $1739.00), secondary cleft lip and palate repair ($5429.10 versus $1917.00), and cleft rhinoplasty ($6001.00 versus $1917.00; P < 0.001). Lower commercial rates were associated with hospitals that were smaller ( P < 0.001), safety-net ( P < 0.001), and nonprofit ( P < 0.001). Medicaid rate was positively associated with commercial rate ( P < 0.001). CONCLUSIONS Commercial rates for cleft surgical care demonstrated marked variation within and across hospitals, and were lower for small, safety-net, or nonprofit hospitals. Lower Medicaid rates were not associated with higher commercial rates, suggesting that hospitals did not use cost-shifting to compensate for budget shortfalls resulting from poor Medicaid reimbursement.
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Affiliation(s)
- Danielle H Rochlin
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Nada M Rizk
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center
| | - Roberto L Flores
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine
| | - Evan Matros
- From the Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center
| | - Clifford C Sheckter
- Division of Plastic and Reconstructive Surgery, Stanford University Medical Center
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Kessel W, LaVallee CP. Conviction and Compassion Creates the Federal Children's Health Insurance Program. Matern Child Health J 2023:10.1007/s10995-023-03635-2. [PMID: 37022514 DOI: 10.1007/s10995-023-03635-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 04/07/2023]
Abstract
INTRODUCTION For a quarter century, the Children's Health Insurance Program (CHIP) has provided essential health care coverage for children and pregnant women in working families. Established as part of the Balanced Budget Act of 1997, CHIP provides critical coverage for children living in families with incomes falling between eligibility for Medicaid and employment-based coverage. Since its enactment, CHIP has markedly reduced the number of children who were uninsured in 2020 to approximately 3.7 million children (5.0%), an extraordinary 67% reduction. This article traces the history of the federal CHIP legislation based in large part upon the success of Pennsylvania's innovative efforts. METHODS Review of the literature. Personal Communications. RESULTS Since its enactment, CHIP has markedly reduced the number of children who were uninsured in 2020 to approximately 3.7 million children (5.0%), an extraordinary 67% reduction. DISCUSSION This article traces the history of the federal CHIP legislation based in large part upon the success of Pennsylvania's innovative efforts. The authors certify that the material presented in this article was prepared in accord with prevailing ethical principles.
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Affiliation(s)
- Woodie Kessel
- Koop Institute, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA.
- Geisel School of Medicine, Dartmouth College, Hanover, NH, USA.
- School of Public Health, University of Maryland, College Park, MD, USA.
| | - Charles P LaVallee
- Variety - the Children's Charity, Wexford, PA, USA
- Highmark Inc., Pittsburgh, PA, USA
- Highmark Caring Foundation, Pittsburgh, PA, USA
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Temkin AM, Uche UI, Evans S, Anderson KM, Perrone-Gray S, Campbell C, Naidenko OV. Racial and social disparities in Ventura County, California related to agricultural pesticide applications and toxicity. THE SCIENCE OF THE TOTAL ENVIRONMENT 2022; 853:158399. [PMID: 36063919 DOI: 10.1016/j.scitotenv.2022.158399] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 08/25/2022] [Accepted: 08/25/2022] [Indexed: 06/15/2023]
Abstract
Application of agricultural pesticides poses health concerns for farmworkers and for local communities due to pesticide drift from spraying or fumigation, pesticide volatilization into the air, contamination of household dust, as well as direct exposure for people who work in agriculture and their families. In this analysis of pesticide use records for Ventura County, California (USA) from 2016 to 2018, we identified the most prevalent toxicological effects of the pesticides applied. We also developed a cumulative toxicity index that incorporates specific toxicity endpoints for individual pesticides, the severity and strength of association for each endpoint, and the reliability of the data sources. Combining the toxicity index for each pesticide with the pounds applied within each square mile section in Ventura County, we calculated the total toxicity-weighted pesticide use and identified pesticides associated with higher potential risk to health. Analysis of U.S. Census data for Ventura County found a greater percentage of Hispanic/Latino, African American and Asian community members in township sections with a greater volume of pesticides applied and higher toxicity-weighted pesticide use. Similarly, areas with limited economic and social resources had elevated pesticide application overall and elevated toxicity-weighted pesticide use. The combination of toxicological and demographic analyses presented in this study provides information that can support the development of policies to protect public health from excessive exposure to pesticides and better environmental health protection for socially vulnerable populations.
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Affiliation(s)
- Alexis M Temkin
- Environmental Working Group, 1250 I street NW Suite 1000, Washington, DC 20005, USA.
| | - Uloma Igara Uche
- Environmental Working Group, 1250 I street NW Suite 1000, Washington, DC 20005, USA
| | - Sydney Evans
- Environmental Working Group, 1250 I street NW Suite 1000, Washington, DC 20005, USA
| | - Kayla M Anderson
- Peabody College, Vanderbilt University, Nashville, TN 37203, USA
| | | | - Chris Campbell
- Environmental Working Group, 1250 I street NW Suite 1000, Washington, DC 20005, USA
| | - Olga V Naidenko
- Environmental Working Group, 1250 I street NW Suite 1000, Washington, DC 20005, USA
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Sindhu KK, Alker JC, Adashi EY. The Children's Health Insurance Program at 25: The Road Ahead. JAMA 2022; 327:2185-2186. [PMID: 35587863 DOI: 10.1001/jama.2022.8291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kunal K Sindhu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joan C Alker
- Center for Children and Families, McCourt School of Public Policy, Georgetown University, Washington, DC
| | - Eli Y Adashi
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island
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Goel K, Vasudevan L. Disparities in healthcare access and utilization and human papillomavirus (HPV) vaccine initiation in the United States. Hum Vaccin Immunother 2021; 17:5390-5396. [PMID: 34736353 DOI: 10.1080/21645515.2021.1989919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Currently in the United States, Human Papillomavirus (HPV) vaccination coverage among eligible individuals is lower compared to coverage goals of 80% set by the HealthyPeople 2030 initiative. In this study, we used the National Health and Nutrition Examination Survey (NHANES) 2015-2016 and 2017-2018 datasets to determine the association between HPV vaccine initiation among individuals of ages 9 to 26 years and their patterns of healthcare access and utilization. In particular, we examined the following healthcare characteristics: 1) having a routine place of healthcare, 2) having health insurance coverage, 3) frequency of healthcare visits per year, and 4) type of routine place of healthcare (outpatient primary care vs. ED, etc.). We fit independent multivariable logistic regression models for each NHANES dataset and controlled for sociodemographic characteristics and interactions with healthcare access and utilization characteristics. Our findings suggest that HPV vaccine initiation is positively associated with having a routine place of healthcare (2015-2016: aOR 1.92, 95% CI 1.25-2.95; 2017-2018: aOR 1.99, 95% CI 1.07-3.68). Relatedly, HPV vaccine initiation is negatively associated with never having received healthcare in the past year (2015-2016: aOR 0.61, 95% CI 0.41-0.90; 2017-2018: aOR 0.45, 95% CI 0.27-0.75). The results of this study suggest that interventions to promote HPV vaccination should include strategies that promote access to and utilization of routine health care services. Our findings are particularly salient in light of the drop in HPV vaccine initiation and healthcare access and utilization among adolescents during the COVID-19 pandemic.
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Affiliation(s)
- Kunal Goel
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Lavanya Vasudevan
- Department of Family Medicine and Community Health, Duke University, Durham, North Carolina, USA
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Racial disparities in survival outcomes following pediatric in-hospital cardiac arrest. Resuscitation 2021; 159:117-125. [PMID: 33400929 DOI: 10.1016/j.resuscitation.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] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/13/2020] [Accepted: 12/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Among adults with in-hospital cardiac arrest (IHCA), overall survival is lower in black patients compared to white patients. Data regarding racial differences in survival for pediatric IHCA are unknown. METHODS Using 2000-2017 data from the American Heart Association Get With the Guidelines-Resuscitation® registry, we identified children >24 h and <18 years of age with IHCA due to an initial pulseless rhythm. We used generalized estimation equation to examine the association of black race with survival to hospital discharge, return of spontaneous circulation (ROSC), and favorable neurologic outcome at discharge. RESULTS Overall, 2940 pediatric patients (898 black, 2042 white) at 224 hospitals with IHCA were included. The mean age was 3.0 years, 57% were male and 16% had an initial shockable rhythm. Age, sex, interventions in place at the time of arrest and cardiac arrest characteristics did not differ significantly by race. The overall survival to discharge was 36.9%, return of spontaneous circulation (ROSC) was 73%, and favorable neurologic survival was 20.8%. Although black race was associated with lower rates of ROSC compared to white patients (69.5% in blacks vs. 74.6% in whites; risk-adjusted OR 0.79, 95% CI 0.67-0.94, P = 0.016), black race was not associated with survival to discharge (34.7% in blacks vs. 37.8% in whites; risk-adjusted OR 0.96, 95% CI 0.80-1.15, P = 0.68) or favorable neurologic outcome (18.7% in blacks vs. 21.8% in whites, risk-adjusted OR 0.98, 95% CI 0.80-1.20, p = 0.85). CONCLUSIONS In contrast to adults, we did not find evidence for racial differences in survival outcomes following IHCA among children.
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Abstract
OBJECTIVE This systematic review and meta-analysis aims to systematically analyse the association of overweight and obesity with health service utilisation during childhood. DATA SOURCES PubMed, MEDLINE, CINAHL, EMBASE and Web of Science. METHODS Observational studies published up to May 2020 that assessed the impact of overweight and obesity on healthcare utilisation in children and adolescents were included. Studies were eligible for inclusion if the included participants were ≤19 years of age. Findings from all included studies were summarised narratively. In addition, rate ratios (RRs) and 95% CIs were calculated in a meta-analysis on a subgroup of eligible studies. OUTCOME MEASURES Included studies reported association of weight status with healthcare utilisation measures of outpatient visits, emergency department (ED) visits, general practitioner visits, hospital admissions and hospital length of stay. RESULTS Thirty-three studies were included in the review. When synthesising the findings from all studies narratively, obesity and overweight were found to be positively associated with increased healthcare utilisation in children for all the outcome measures. Six studies reported sufficient data to meta-analyse association of weight with outpatient visits. Five studies were included in a separate meta-analysis for the outcome measure of ED visits. In comparison with normal-weight children, rates of ED (RR 1.34, 95% CI 1.07 to 1.68) and outpatient visits (RR 1.11, 95% CI 1.02 to 1.20) were significantly higher in obese children. The rates of ED and outpatient visits by overweight children were only slightly higher and non-significant compared with normal-weight children. CONCLUSIONS Obesity in children is associated with increased healthcare utilisation. Future research should assess the impact of ethnicity and obesity-associated health conditions on increased healthcare utilisation in children with overweight and obesity. PROSPERO REGISTRATION NUMBER CRD42018091752.
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Affiliation(s)
- Taimoor Hasan
- Department of Health Sciences, University of York, York, North Yorkshire, UK
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Tom S Ainscough
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Jane West
- Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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Keim-Malpass J, Croson E, Allen M, Deagle C, DeGuzman P. Towards translational health policy: Findings from a state evaluation of programs targeting children with special health care needs. J SPEC PEDIATR NURS 2019; 24:e12240. [PMID: 30896893 DOI: 10.1111/jspn.12240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/29/2018] [Accepted: 02/22/2019] [Indexed: 01/26/2023]
Abstract
PURPOSE Current evidence-based research suggests that early evaluation, comprehensive care plans, and appropriate referrals for childhood and adolescent behavioral and development needs is critical for successful family-centered outcomes. The overall purpose of this study was to conduct an assessment of a state public health program that offers diagnostic evaluation and coordination for children with behavioral and developmental disorders in the state of Virginia (Child Development Center programs, or CDC). A secondary purpose was to provide translational policy and advocacy targets based on key findings. DESIGN AND METHOD The evaluation of the scope of services of the CDC programs was done using qualitative interviews with a focus group interview (n = 23), interviews from representatives from individual centers ( n = 5 centers), and descriptive quantitative data elements for the fiscal year 2015. RESULTS After conducting the state public health evaluation, several translational health policy priorities emerged, including: (a) the need for integrated data standards, (b) Lack of developmental pediatric workforce, particularly in rural sectors of the state, and (c) Need for enhanced program support for care coordination. CONCLUSION Academic nurse and public health partnerships can aid in translation from research to policy among vulnerable populations and assist in communication to key stakeholders and legislators for iterative action and reassessment.
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Affiliation(s)
- Jessica Keim-Malpass
- School of Nursing, University of Virginia, Charlottesville, Virginia.,Department of Pediatrics, School of Medicine, University of Virginia, Charlottesville, Virginia
| | - Elizabeth Croson
- School of Nursing, University of Virginia, Charlottesville, Virginia
| | - Marcus Allen
- Virginia Department of Health, Richmond, Virginia
| | | | - Pamela DeGuzman
- School of Nursing, University of Virginia, Charlottesville, Virginia
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Miyawaki A, Kobayashi Y. Effect of a medical subsidy on health service utilization among schoolchildren: A community-based natural experiment in Japan. Health Policy 2019; 123:353-359. [PMID: 30791987 DOI: 10.1016/j.healthpol.2019.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/09/2019] [Accepted: 02/04/2019] [Indexed: 11/29/2022]
Abstract
Reducing out-of-pocket medical payments for children can reduce financial barriers to healthcare, but may increase health service expenditure. Efficient schemes of patient cost-sharing are needed to address this. We explored the impacts of a medical subsidy for children (MSC), which contained two schemes for cost-sharing of medical expenditure and health service utilization. The first is a monthly stop-loss policy, or caps on out-of-pocket payments, for outpatient/inpatient services; this reduces out-of-pocket payments for those who use greater amounts of health services. The second is a free prescription policy, which eliminates out-of-pocket payments regardless of the amount of drug expenditure. Expansion of the MSC was used as a natural experiment in a Japanese prefecture. We analyzed Japanese National Health Insurance claims data covering April 2013 to January 2017, and found no significant effect of the stop-loss policy on outpatient/inpatient service expenditures, regardless of the children's baseline health status. The free prescription policy, however, significantly increased prescription drug expenditure to 116% in the total sample and 121% among children with good health status, but not among children with poor health status. Increased health expenditure among healthy, low-volume users was found to cause increased overall expenditure. The stop-loss policy for children is potentially efficient because it selectively reduced out-of-pocket payments in high-volume users and did not increase overall expenditure.
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Affiliation(s)
- Atsushi Miyawaki
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Japan.
| | - Yasuki Kobayashi
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Japan
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Chung CY, Alson MD, Duszak R, Degnan AJ. From imaging to reimbursement: what the pediatric radiologist needs to know about health care payers, documentation, coding and billing. Pediatr Radiol 2018; 48:904-914. [PMID: 29552707 DOI: 10.1007/s00247-018-4104-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 01/15/2018] [Accepted: 02/20/2018] [Indexed: 10/17/2022]
Abstract
Medical coding and billing processes in the United States are complex, cumbersome and poorly understood by radiologists. Despite the direct implications of radiology documentation on reimbursement, trainees and practicing radiologists typically receive limited relevant training. This article summarizes the payer structure including the state-based Children's Health Insurance Programs, discusses the essential processes by which radiologists request and receive reimbursement, details the mechanisms of coding diagnoses using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and imaging services using Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, and explores reimbursement and coding-related issues specific to pediatric radiology. Appropriate documentation, informed by knowledge of coding, billing and reimbursement fundamentals, facilitates appropriate payment for clinically relevant services provided by pediatric radiologists.
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Affiliation(s)
- Chul Y Chung
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Richard Duszak
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Andrew J Degnan
- Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
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Jones RE, Gee KM, Burkhalter LS, Beres AL. Correlation of payor status and pediatric transfer for acute appendicitis. J Surg Res 2018; 229:216-222. [PMID: 29936993 DOI: 10.1016/j.jss.2018.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 03/15/2018] [Accepted: 04/03/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Tertiary referral centers provide specialty and critical care for patients presenting to hospitals that lack these resources. There is a notion among tertiary centers that outside hospitals are more likely to transfer uninsured or underinsured patients. We examined funding status of patients transferred to our tertiary pediatric hospital for surgical management of appendicitis, hypothesizing that transferred patients were more likely to have unfavorable coverage. MATERIALS AND METHODS The electronic medical record was queried for all cases of laparoscopic appendectomy at our hospital between 2011 and 2015. Insurance was grouped into three categories: commercial, Medicaid/Children's Health Insurance Plan, or none. Transferred patients were compared to patients who presented directly. RESULTS A total of 5758 patients underwent laparoscopic appendectomy during the study period, of which 1683 (29.2%) were transfer patients. Transfer patients were more likely to be older, with a median age of 10.5 y versus 9.8 y in nontransferred patients (P ≤ 0.0001), and were more likely to be identified as non-Hispanic (50.0% versus 36.5%; P ≤ 0.0001). Insurance coverage was similar between groups. However, subgroup analysis of the hospitals that most frequently used our transfer services revealed a trend to transfer a higher proportion of Medicaid/Children's Health Insurance Plan patients. CONCLUSIONS Overall, pediatric patients transferred for laparoscopic appendectomy had similar insurance coverage to patients admitted directly, but subgroup analysis shows that not all centers follow this trend. Transfer patients were more frequently older and non-Hispanic. This builds upon the existing literature regarding the correlation of funding and transfer practices and highlights the need for additional research in this area.
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Affiliation(s)
- Ruth Ellen Jones
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kristin M Gee
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Alana L Beres
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas; Children's Health, Dallas, Texas.
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Chen A, Lo Sasso AT, Richards MR. Supply-side effects from public insurance expansions: Evidence from physician labor markets. HEALTH ECONOMICS 2018; 27:690-708. [PMID: 29194846 DOI: 10.1002/hec.3625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 08/29/2017] [Accepted: 10/24/2017] [Indexed: 06/07/2023]
Abstract
Medicaid and the Child Health Insurance Programs (CHIP) are key sources of coverage for U.S. children. Established in 1997, CHIP allocated $40 billion of federal funds across the first 10 years but continued support required reauthorization. After 2 failed attempts in Congress, CHIP was finally reauthorized and significantly expanded in 2009. Although much is known about the demand-side policy effects, much less is understood about the policy's impact on providers. In this paper, we leverage a unique physician dataset to examine if and how pediatricians responded to the expansion of the public insurance program. We find that newly trained pediatricians are 8 percentage points more likely to subspecialize and as much as 17 percentage points more likely to enter private practice after the law passed. There is also suggestive evidence of greater private practice growth in more rural locations. The sharp supply-side changes that we observe indicate that expanding public insurance can have important spillover effects on provider training and practice choices.
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Affiliation(s)
- Alice Chen
- Sol Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | - Anthony T Lo Sasso
- School of Public Health, Health Policy and Administration, Institute of Government and Public Affairs, University of Illinois-Chicago, Chicago, IL, USA
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Miyawaki A, Noguchi H, Kobayashi Y. Impact of medical subsidy disqualification on children's healthcare utilization: A difference-in-differences analysis from Japan. Soc Sci Med 2017; 191:89-98. [PMID: 28917140 DOI: 10.1016/j.socscimed.2017.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 08/31/2017] [Accepted: 09/02/2017] [Indexed: 10/18/2022]
Abstract
Financial support for children's medical expenses has been introduced in many countries. Limited work has been done on price elasticity in children's healthcare demand, especially in countries other than the United States. Moreover, it remains unclear how the effects of a change in the cost sharing rate on healthcare demand would differ by medical condition. We investigated the impact of an increase in the cost sharing rate on medical service utilization among school children as a whole and for each of nine common conditions, applying a difference-in-differences approach. The study period ranged from April 1, 2012, to March 30, 2014. Participants were elementary school children in an urban area who were eligible for National Health Insurance (a community-based public insurance) during the study period and who were enrolled in the 2nd, 3rd, or 4th grade in April 2013. We collected observations from 2896 persons and 69,504 (2896 × 24 months) person-months. When elementary school children were promoted to the 4th grade, they became disqualified for a municipal medical subsidy. The control group was the children promoted to the 2nd or the 3rd grade, who remained eligible for the subsidy. All data were obtained from health insurance claims. We identified the nine most common medical conditions among the subject children, and stratified the analyses by the condition diagnosed. We found that an increase in the cost sharing rate reduced outpatient service utilization as a whole. Also, we observed an increase in inpatient service utilization, not because of worsened health conditions, but rather due to substitution of inpatient service for outpatient service. The reductions in outpatient service were heterogeneous across medical conditions; declines were sharper for mild or chronic conditions. These findings may help to characterize how a change in cost sharing rate affects health outcomes in children.
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Affiliation(s)
- Atsushi Miyawaki
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Hongo7-3-1, Bunkyo-ku, Tokyo 113-0033, Japan.
| | - Haruko Noguchi
- Faculty of Political Science and Economics, Waseda University, Nishiwaseda 1-6-1, Shinjuku-ku, Tokyo 169-8050, Japan.
| | - Yasuki Kobayashi
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, Hongo7-3-1, Bunkyo-ku, Tokyo 113-0033, Japan.
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Bergmark RW, Ishman SL, Phillips KM, Cunningham MJ, Sedaghat AR. Emergency department use for acute rhinosinusitis: Insurance dependent for children and adults. Laryngoscope 2017; 128:299-303. [PMID: 28730629 DOI: 10.1002/lary.26671] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/14/2017] [Accepted: 04/11/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS Patients with Medicaid or self-pay insurance status are more likely to present to the emergency department (ED) for uncomplicated acute rhinosinusitis (ARS). Our aim was to determine if this pattern holds true for both pediatric and adult visits. STUDY DESIGN Cross-sectional study using the 2005 to 2012 National Hospital Ambulatory Medical Care Surveys and National Ambulatory Medical Care Surveys. METHODS We included all visits with International Classification of Diseases, Ninth Revision codes for ARS and without codes for ARS complications. We tested for associations between insurance type and presentation to an ED versus a primary care physician (PCP), stratifying children versus adults. We used univariate and multivariable logistic regression modeling, controlling for clinical and demographic characteristics for analysis. RESULTS There were 51,579,977 uncomplicated ARS visits to PCPs (48,213,335 visits) and EDs (3,366,642 visits). Medicaid and uninsured patients were under-represented for ARS visits. Medicaid insurance was significantly associated with ED presentation for ARS for both children (adjusted odds ratio [OR] = 7.0, P < 0.001) and adults (adjusted OR = 6.8, P < 0.001). Children with ARS and self-pay insurance status were much more likely to present to the ED (adjusted OR = 48.8, P < 0.001) than adults (adjusted OR = 5.2, P < 0.001); this difference between children and adults with self-pay insurance was significant (P = 0.001). CONCLUSION With respect to absolute numbers of visits, patients with Medicaid or no insurance use less care overall for uncomplicated ARS than do privately insured patients. Medicaid is associated with ED presentation for ARS for pediatric and adult visits. Self-pay insurance status is strongly associated with ED presentation for adult and pediatric visits, and is significantly more common for children. These results suggest limitations in primary care access for uncomplicated ARS based on insurance status, particularly for uninsured pediatric patients. LEVEL OF EVIDENCE 4. Laryngoscope, 128:299-303, 2018.
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Affiliation(s)
- Regan W Bergmark
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Stacey L Ishman
- Division of Otolaryngology-Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, U.S.A
| | - Katie M Phillips
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Michael J Cunningham
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital
| | - Ahmad R Sedaghat
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts.,Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital.,Division of Otolaryngology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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16
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Peterson JK, Chen Y, Nguyen DV, Setty SP. Current trends in racial, ethnic, and healthcare disparities associated with pediatric cardiac surgery outcomes. CONGENIT HEART DIS 2017; 12:520-532. [PMID: 28544396 DOI: 10.1111/chd.12475] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/10/2017] [Accepted: 04/22/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Despite overall improvements in congenital heart disease outcomes, racial and ethnic disparities have continued. The purpose of this study is to examine the effect of race and ethnicity, as well as other risk factors on congenital heart surgery length of stay and in-hospital mortality. DESIGN From the 2012 Healthcare Cost and Utilization Project Kids Inpatient Database (KID), we identified 13 130 records with Risk Adjustment in Congenital Heart Surgery complexity score-eligible procedures. Multivariate logistic and linear regression modeling with survey weights, stratification and clustering was used to examine the relationships between predictor variables and length of stay as well as in-hospital mortality. RESULTS No significant mortality differences were found among all race and ethnicity groups across each age group. Black neonates and black infants had a longer length of stay (neonatal estimate = 8.73 days, P = .0034; infant estimate 1.10 days, P = .0253), relative to whites. Government-sponsored insurance was associated with increased odds of neonatal mortality (odds ratio = 1.51, P = .0055), increased length of stay in neonates (estimate = 4.26 days, P = .0009) and infants (estimate = 1.52 days, P = .0181), relative to private insurance. Government-sponsored insurance was associated with increased number of chronic conditions, which were also associated with increased LOS (estimate 8.39 days, P < .001 in neonates; estimate 3.60 days, P < .001 in infants; estimate 1.87 days, P < .001 children). CONCLUSIONS Racial/ethnic disparities in congenital heart surgical outcomes may be changing compared with previous studies using the KID database. Increased length of stay in children with government-sponsored insurance may reflect expansion of individual states government-sponsored insurance eligibility criteria for children with complex chronic medical conditions. These findings warrant cautious optimism regarding racial and ethnic disparities in congenital heart surgery outcomes.
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Affiliation(s)
- Jennifer K Peterson
- Long Beach Memorial Hospital/Miller Children's and Women's Hospital, Long Beach, California, USA
| | - Yanjun Chen
- Biostatistics, Epidemiology, and Research Design Unit, University of California, Irvine, California, USA
| | - Danh V Nguyen
- Department of Medicine, University of California, Irvine School of Medicine, Orange, California, USA
| | - Shaun P Setty
- Long Beach Memorial Hospital/Miller Children's and Women's Hospital, Long Beach, California, USA
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17
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Bailey SR, Marino M, Hoopes M, Heintzman J, Gold R, Angier H, O'Malley JP, DeVoe JE. Healthcare Utilization After a Children's Health Insurance Program Expansion in Oregon. Matern Child Health J 2017; 20:946-54. [PMID: 26987861 DOI: 10.1007/s10995-016-1971-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The future of the Children's Health Insurance Program (CHIP) is uncertain after 2017. Survey-based research shows positive associations between CHIP expansions and children's healthcare utilization. To build on this prior work, we used electronic health record (EHR) data to assess temporal patterns of healthcare utilization after Oregon's 2009-2010 CHIP expansion. We hypothesized increased post-expansion utilization among children who gained public insurance. METHODS Using EHR data from 154 Oregon community health centers, we conducted a retrospective cohort study of pediatric patients (2-18 years old) who gained public insurance coverage during the Oregon expansion (n = 3054), compared to those who were continuously publicly insured (n = 10,946) or continuously uninsured (n = 10,307) during the 2-year study period. We compared pre-post rates of primary care visits, well-child visits, and dental visits within- and between-groups. We also conducted longitudinal analysis of monthly visit rates, comparing the three insurance groups. RESULTS After Oregon's 2009-2010 CHIP expansions, newly insured patients' utilization rates were more than double their pre-expansion rates [adjusted rate ratios (95 % confidence intervals); increases ranged from 2.10 (1.94-2.26) for primary care visits to 2.77 (2.56-2.99) for dental visits]. Utilization among the newly insured spiked shortly after coverage began, then leveled off, but remained higher than the uninsured group. CONCLUSIONS This study used EHR data to confirm that CHIP expansions are associated with increased utilization of essential pediatric primary and preventive care. These findings are timely to pending policy decisions that could impact children's access to public health insurance in the United States.
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Affiliation(s)
- Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA.
| | - Miguel Marino
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
- School of Public Health, Division of Biostatistics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Megan Hoopes
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA
| | - John Heintzman
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Rachel Gold
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA
- Kaiser Permanente Center for Health Research Northwest, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Jean P O'Malley
- School of Public Health, Division of Biostatistics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
- OCHIN, Inc., 1881 SW Naito Parkway, Portland, OR, 97201, USA
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18
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Housing Instability and Children's Health Insurance Gaps. Acad Pediatr 2017; 17:732-738. [PMID: 28232258 PMCID: PMC6058677 DOI: 10.1016/j.acap.2017.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 02/07/2017] [Accepted: 02/14/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the extent to which housing instability is associated with gaps in health insurance coverage of preschool-age children. METHODS Secondary analysis of data from the Early Childhood Longitudinal Study-Birth Cohort, a nationally representative study of children born in the United States in 2001, was conducted to investigate associations between unstable housing-homelessness, multiple moves, or living with others and not paying rent-and children's subsequent health insurance gaps. Logistic regression was used to adjust for potentially confounding factors. RESULTS Ten percent of children were unstably housed at age 2, and 11% had a gap in health insurance between ages 2 and 4. Unstably housed children were more likely to have gaps in insurance compared to stably housed children (16% vs 10%). Controlling for potentially confounding factors, the odds of a child insurance gap were significantly higher in unstably housed families than in stably housed families (adjusted odds ratio 1.27; 95% confidence interval 1.01-1.61). The association was similar in alternative model specifications. CONCLUSIONS In a US nationally representative birth cohort, children who were unstably housed at age 2 were at higher risk, compared to their stably housed counterparts, of experiencing health insurance gaps between ages 2 and 4 years. The findings from this study suggest that policy efforts to delink health insurance renewal processes from mailing addresses, and potentially routine screenings for housing instability as well as referrals to appropriate resources by pediatricians, would help unstably housed children maintain health insurance.
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19
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Hawkins SS, Hristakeva S, Gottlieb M, Baum CF. Reduction in emergency department visits for children's asthma, ear infections, and respiratory infections after the introduction of state smoke-free legislation. Prev Med 2016; 89:278-285. [PMID: 27283094 PMCID: PMC8323994 DOI: 10.1016/j.ypmed.2016.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 04/28/2016] [Accepted: 06/05/2016] [Indexed: 11/18/2022]
Abstract
Despite the benefits of smoke-free legislation on adult health, little is known about its impact on children's health. We examined the effects of tobacco control policies on the rate of emergency department (ED) visits for childhood asthma (N=128,807), ear infections (N=288,697), and respiratory infections (N=410,686) using outpatient ED visit data in Massachusetts (2001-2010), New Hampshire (2001-2009), and Vermont (2002-2010). We used negative binomial regression models to analyze the effect of state and local smoke-free legislation on ED visits for each health condition, controlling for cigarette taxes and health care reform legislation. We found no changes in the overall rate of ED visits for asthma, ear infections, and upper respiratory infections after the implementation of state or local smoke-free legislation or cigarette tax increases. However, an interaction with children's age revealed that among 10-17-year-olds state smoke-free legislation was associated with a 12% reduction in ED visits for asthma (adjusted incidence rate ratios (aIRR) 0.88; 95% CI 0.83, 0.95), an 8% reduction for ear infections (0.92; 0.88, 0.97), and a 9% reduction for upper respiratory infections (0.91; 0.87, 0.95). We found an overall 8% reduction in ED visits for lower respiratory infections after the implementation of state smoke-free legislation (0.92; 0.87, 0.96). The implementation of health care reform in Massachusetts was also associated with a 6-9% reduction in all children's ED visits for ear and upper respiratory infections. Our results suggest that state smoke-free legislation and health care reform may be effective interventions to improve children's health by reducing ED visits for asthma, ear infections, and respiratory infections.
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Affiliation(s)
| | - Sylvia Hristakeva
- Boston College, Department of Economics, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA.
| | - Mark Gottlieb
- Northeastern University School of Law, Public Health Advocacy Institute, 360 Huntington Avenue, Suite 117CU, Boston, MA 02115-5004, USA.
| | - Christopher F Baum
- Boston College, School of Social Work, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA; Boston College, Department of Economics, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA; Deutsches Institut für Wirtschaftforschung (DIW Berlin), Department of Macroeconomics, Mohrenstraße 58, 10117 Berlin, Germany.
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20
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Hannan J, Brooten D, Page T, Galindo A, Torres M. Low-Income First-Time Mothers: Effects of APN Follow-up Using Mobile Technology on Maternal and Infant Outcomes. Glob Pediatr Health 2016; 3:2333794X16660234. [PMID: 27508211 PMCID: PMC4964150 DOI: 10.1177/2333794x16660234] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 06/14/2016] [Indexed: 11/30/2022] Open
Abstract
Background. Low-income mothers have greater challenges in accessing health care services due changes in the health care system and budget cuts. The purpose of this randomized clinical trial was to test a nurse practitioner (NP) intervention using cell phone and texting on maternal/infant outcomes. Methods. The sample included 129 mother-infant pairs. Intervention group mothers received NP 2-way cell phone follow-up intervention post–hospital discharge for 6 months. Results. Intervention mothers’ perceived social support was significantly higher. Intervention infants received their first newborn follow-up visit significantly earlier (6 vs 9 days); significantly more infants were immunized at recommended times (2, 4, and 6 months of age); and there were fewer infant morbidities compared to controls. The intervention saved between $51 030 and $104 277 in health care costs averted. Conclusion. This easy-to-use, safe intervention is an effective way to reach a wide range of populations and demonstrated improved maternal/infant outcomes and decreased cost.
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Affiliation(s)
- Jean Hannan
- Florida International University, Nicole Wertheim College of Nursing and Health Sciences Miami, FL, USA
| | - Dorothy Brooten
- Florida International University, Nicole Wertheim College of Nursing and Health Sciences Miami, FL, USA
| | - Timothy Page
- Florida International University, Nicole Wertheim College of Nursing and Health Sciences Miami, FL, USA
| | - Ali Galindo
- Florida International University, Nicole Wertheim College of Nursing and Health Sciences Miami, FL, USA
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21
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Abstract
The persistence of child poverty in the United States and the pervasive health consequences it engenders present unique challenges to the health care system. Human capital theory and empirical observation suggest that the increased disease burden experienced by poor children originates from social conditions that provide suboptimal educational, nutritional, environmental, and parental inputs to good health. Faced with the resultant excess rates of pediatric morbidity, the US health care system has developed a variety of compensatory strategies. In the first instance, Medicaid, the federal-state governmental finance system designed to assure health insurance coverage for poor children, has increased its eligibility thresholds and expanded its benefits to allow greater access to health services for this vulnerable population. A second arm of response involves a gradual reengineering of health care delivery at the practice level, including the dissemination of patient-centered medical homes, the use of team-based approaches to care, and the expansion of care management beyond the practice to reach deep into the community. Third is a series of recent experiments involving the federal government and state Medicaid programs that includes payment reforms of various kinds, enhanced reporting, concentration on high-risk populations, and intensive case management. Fourth, pediatric practices have begun to make use of specific tools that permit the identification and referral of children facing social stresses arising from poverty. Finally, constituencies within the health care system participate in enhanced advocacy efforts to raise awareness of poverty as a distinct threat to child health and to press for public policy responses such as minimum wage increases, expansion of tax credits, paid family leave, universal preschool education, and other priorities focused on child poverty.
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Affiliation(s)
- Andrew D Racine
- Albert Einstein College of Medicine and the Montefiore Health System, Bronx, NY.
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22
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Kogan MD, Dykton C, Hirai AH, Strickland BB, Bethell CD, Naqvi I, Cano CE, Downing-Futrell SL, Lu MC. A new performance measurement system for maternal and child health in the United States. Matern Child Health J 2016; 19:945-57. [PMID: 25823557 PMCID: PMC4428536 DOI: 10.1007/s10995-015-1739-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Objective
The Title V Maternal and Child Health (MCH) Block Grant is the linchpin for US MCH services. The first national performance measures (NPMs) for MCH were instituted in 1997. Changing trends in MCH risk factors, outcomes, health services, data sources, and advances in scientific knowledge, in conjunction with budgetary constraints led the Maternal and Child Health Bureau (MCHB) to design a new performance measurement system. Methods A workgroup was formed to develop a new system. The following guiding principles were used: (1) Afford States more flexibility and reduce the overall reporting burden; (2) Improve accountability to better document Title V’s impact; (3) Develop NPMs that encompass measures in: maternal and women’s health, perinatal health, child health, children with special health care needs, adolescent health, and cross-cutting areas. Results A three-tiered performance measurement system was proposed with national outcome measures (NOMs), NPMs and evidence-based/informed strategy measures (ESMs). NOMs are the ultimate goals that MCHB and States are attempting to achieve. NPMs are measures, generally associated with processes or programs, shown to affect NOMs. ESMs are evidence-based or informed measures that each State Title V program develops to affect the NPMs. There are 15 NPMs from which States select eight, with at least one from each population area. MCHB will provide the data for the NOMs and NPMs, when possible. Conclusions The new performance measurement system increases the flexibility and reduces the reporting burden for States by allowing them to choose 8 NPMs to target, and increases accountability by having States develop actionable ESMs. Significance The new national performance measure framework for maternal and child health will allow States more flexibility to address their areas of greatest need, reduce their data reporting burden by having the Maternal and Child Health Bureau provide data for the National Outcome and Performance Measures, yet afford States the opportunity to develop measurable strategies to address their selected performance measures.
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Affiliation(s)
- Michael D Kogan
- Maternal and Child Health Bureau, Health Resources and Services Administration, 5600 Fishers Lane, Rockville, MD, 20857, USA,
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Kreider AR, French B, Aysola J, Saloner B, Noonan KG, Rubin DM. Quality of Health Insurance Coverage and Access to Care for Children in Low-Income Families. JAMA Pediatr 2016; 170:43-51. [PMID: 26569497 PMCID: PMC8011294 DOI: 10.1001/jamapediatrics.2015.3028] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE An increasing diversity of children's health coverage options under the US Patient Protection and Affordable Care Act, together with uncertainty regarding reauthorization of the Children's Health Insurance Program (CHIP) beyond 2017, merits renewed attention on the quality of these options for children. OBJECTIVE To compare health care access, quality, and cost outcomes by insurance type (Medicaid, CHIP, private, and uninsured) for children in households with low to moderate incomes. DESIGN, SETTING, AND PARTICIPANTS A repeated cross-sectional analysis was conducted using data from the 2003, 2007, and 2011-2012 US National Surveys of Children's Health, comprising 80,655 children 17 years or younger, weighted to 67 million children nationally, with household incomes between 100% and 300% of the federal poverty level. Multivariable logistic regression models compared caregiver-reported outcomes across insurance types. Analysis was conducted between July 14, 2014, and May 6, 2015. EXPOSURES Insurance type was ascertained using a caregiver-reported measure of insurance status and each household's poverty status (percentage of the federal poverty level). MAIN OUTCOMES AND MEASURES Caregiver-reported outcomes related to access to primary and specialty care, unmet needs, out-of-pocket costs, care coordination, and satisfaction with care. RESULTS Among the 80,655 children, 51,123 (57.3%) had private insurance, 11,853 (13.6%) had Medicaid, 9554 (18.4%) had CHIP, and 8125 (10.8%) were uninsured. In a multivariable logistic regression model (with results reported as adjusted probabilities [95% CIs]), children insured by Medicaid and CHIP were significantly more likely to receive a preventive medical (Medicaid, 88% [86%-89%]; P < .01; CHIP, 88% [87%-89%]; P < .01) and dental (Medicaid, 80% [78%-81%]; P < .01; CHIP, 77% [76%-79%]; P < .01) visits than were privately insured children (medical, 83% [82%-84%]; dental, 73% [72%-74%]). Children with all insurance types experienced challenges in access to specialty care, with caregivers of children insured by CHIP reporting the highest rates of difficulty accessing specialty care (28% [24%-32%]), problems obtaining a referral (23% [18%-29%]), and frustration obtaining health care services (26% [23%-28%]). These challenges were also magnified for privately insured children with special health care needs, whose caregivers reported significantly greater problems accessing specialty care (29% [26%-33%]) and frustration obtaining health care services (36% [32%-41%]) than did caregivers of children insured by Medicaid, and a lower likelihood of insurance always meeting the child's needs (63% [60%-67%]) than children insured by Medicaid or CHIP. Caregivers of privately insured children were also significantly more likely to experience out-of-pocket costs (77% [75%-78%]) than were caregivers of children insured by Medicaid (26% [23%-28%]; P < .01) or CHIP (38% [35%-40%]; P < .01). CONCLUSIONS AND RELEVANCE This examination of caregiver experiences across insurance types revealed important differences that can help guide future policymaking regarding coverage for families with low to moderate incomes.
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Affiliation(s)
- Amanda R. Kreider
- PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Benjamin French
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Jaya Aysola
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia4Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia5Division of General Pediatrics
| | - Brendan Saloner
- Department of Health Policy and Management, Bloomberg School of Public Health at Johns Hopkins University, Baltimore, Maryland7Department of Mental Health, Bloomberg School of Public Health at Johns Hopkins University, Baltimore, Maryland8Institute for He
| | - Kathleen G. Noonan
- PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania5Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania9Master of Public Health Program, University of Pennsylvania, Philadelphia
| | - David M. Rubin
- PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania5Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania10Department of Pediatrics, Perelman School of Medicine at the University of
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DeVoe JE, Tillotson CJ, Angier H, Wallace LS. Predictors of children's health insurance coverage discontinuity in 1998 versus 2009: parental coverage continuity plays a major role. Matern Child Health J 2015; 19:889-96. [PMID: 25070735 DOI: 10.1007/s10995-014-1590-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To identify predictors of coverage continuity for United States children and assess how they have changed in the first 12 years since implementation of the Children's Health Insurance Program in 1997. Using data from the nationally-representative Medical Expenditure Panel Survey, we used logistic regression to identify predictors of discontinuity in 1998 and 2009 and compared differences between the 2 years. Having parents without continuous coverage was the greatest predictor of a child's coverage gap in both 1998 and 2009. Compared to children with at least one parent continuously covered, children whose parents did not have continuous coverage had a significantly higher relative risk (RR) of a coverage gap [RR 17.96, 95 % confidence interval (CI) 14.48-22.29 in 1998; RR 12.88, 95 % CI 10.41-15.93 in 2009]. In adjusted models, parental continuous coverage was the only significant predictor of discontinuous coverage for children (with one exception in 2009). The magnitude of the pattern was higher for privately-insured children [adjusted relative risk (aRR) 29.17, 95 % CI 20.99-40.53 in 1998; aRR 25.54, 95 % CI 19.41-33.61 in 2009] than publicly-insured children (aRR 5.72, 95 % CI 4.06-8.06 in 1998; aRR 4.53, 95 % CI 3.40-6.04 in 2009). Parental coverage continuity has a major influence on children's coverage continuity; this association remained even after public health insurance expansions for children. The Affordable Care Act will increase coverage for many adults; however, 'churning' on and off programs due to income fluctuations could result in coverage discontinuities for parents. If parental coverage instability persists, these discontinuities may continue to have a negative impact on children's coverage stability as well.
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Affiliation(s)
- Jennifer E DeVoe
- Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mailcode FM, Portland, OR, 97239, USA,
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Grace AM, Horn I, Hall R, Cheng TL. Children, Families, and Disparities: Pediatric Provisions in the Affordable Care Act. Pediatr Clin North Am 2015; 62:1297-311. [PMID: 26318953 PMCID: PMC4826597 DOI: 10.1016/j.pcl.2015.06.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The Affordable Care Act has caused and continues to cause sweeping changes throughout the health system in the United States. Poorly explained, complex, controversial, confusing, and subject to continuous legal and regulatory definition, the law stands as a hallmark piece of legislation that will change the health sector in America forever. This article summarizes the Affordable Care Act with a focus on children, families, and disparities. Also provided is the context of the current system of health care coverage in the United States.
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Affiliation(s)
- Aimee M. Grace
- Office of U.S. Senator Brian Schatz, Washington, D.C.,Children’s National Health System, Washington, D.C
| | - Ivor Horn
- Center for Diversity and Health Equity, Seattle Children’s Hospital, Seattle, WA
| | - Robert Hall
- American Academy of Pediatrics, Washington, D.C
| | - Tina L. Cheng
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, Department of Population, Family and Reproductive Health, Bloomberg School of Public Health
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Laskin BL, Mitsnefes MM, Dahhou M, Zhang X, Foster BJ. The mortality risk with graft function has decreased among children receiving a first kidney transplant in the United States. Kidney Int 2014; 87:575-83. [PMID: 25317931 PMCID: PMC4344899 DOI: 10.1038/ki.2014.342] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 08/08/2014] [Accepted: 08/14/2014] [Indexed: 01/30/2023]
Abstract
Mortality has decreased in children with end stage kidney disease. Decreases in mortality during dialysis and improved graft survival contributed to this improvement. However, it is unknown if rates of death with graft function have also improved. We measured this in first transplant recipients under 21 years old registered in the USRDS. Cox models were used with a time-dependent renal replacement therapy modality variable to estimate the hazard ratios for death with graft function associated with a 1-year increment in the calendar year of transplant. There were 157,201 person-years of observation among 17,468 recipients with 82.2% of study time during graft function and 17.8% during dialysis after graft failure. There were 2003 deaths (12.7 deaths/1000 person-years) overall of which 985 occurred with graft function (7.6 deaths/1000 person-years) and 1018 occurred during dialysis after graft failure (36.1 deaths/1000 person-years). Each 1-year increment in calendar year of first transplant was associated with a significantly lower risk of death, both over all observation (HR 0.97 [0.96, 0.98]) and focusing on time with graft function (HR 0.98 [0.97, 0.99]). Living donation was significantly associated with better survival while dialysis after graft failure was associated with a much higher mortality risk (HR 4.85 [4.40, 5.35]) compared with graft function. Thus, the risk of death with graft function has decreased in children receiving a first kidney transplant. Increasing living donation and minimizing dialysis may further improve outcomes.
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Affiliation(s)
- Benjamin L Laskin
- Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Mourad Dahhou
- Montreal Children's Hospital Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
| | - Xun Zhang
- Montreal Children's Hospital Research Institute, McGill University Health Centre, Montreal, Quebec, Canada
| | - Bethany J Foster
- 1] Montreal Children's Hospital Research Institute, McGill University Health Centre, Montreal, Quebec, Canada [2] Division of Nephrology, Department of Pediatrics, McGill University Faculty of Medicine, Montreal, Quebec, Canada [3] Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
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