The long-term effects of Medicaid managed care on obstetrics care in three California counties

OBJECTIVE

To evaluate the long-term effects of Medicaid managed care (MMC) on obstetric service use and program costs in California.

DATA SOURCES/STUDY SETTING

Longitudinal administrative data on Medi-Cal enrollment and claims and encounters related to pregnancy and delivery services were gathered from three counties--two long-standing MMC counties and one traditional fee-for-service Medicaid county--in California between 1987 and 1992.

STUDY DESIGN

We studied Aid to Families with Dependent Children (AFDC) beneficiaries with live singleton vaginal deliveries with associated hospital stays of 14 days or less. Effects of managed care were examined with respect to prenatal visits, length of stay for delivery, maternal postpartum readmission rates, and total program expenditures. Multivariate analyses examined how the relative effect of managed care on service use and program expenditures in each MMC county evolves over time in comparison to fee-for-service. We controlled for length of Medi-Cal enrollment prior to delivery, data censoring, and individual characteristics such as race and age.

PRINCIPAL FINDINGS

Prenatal care use is consistently lower in the MMC counties, although all three counties' prenatal care provision is well below the national standard. Drastic increases in one-day-stay deliveries were found: up to almost 50 percent of deliveries in MMC counties were one-day stays. Program cost savings associated with MMC enrollment are unambiguous.

CONCLUSIONS

MMC cost savings might have come at the expense of reduced provision of prenatal care and shorter delivery length of stay. Future studies should verify any possible causal link and the effects on maternal and infant health outcomes.

Managed care and perinatal regionalization in Washington State

OBJECTIVE

To determine if an association exists between managed care penetration and perinatal deregionalization in Washington State.

METHODS

The proportions of low birth weight (LBW) and very low birth weight (VLBW) deliveries were tabulated for each hospital in Washington State for the years 1989, 1993 and 1996. Level of perinatal care, degree of health maintenance organization (HMO) penetration, and maternal demographic characteristics including age, race, smoking, and Medicaid status were derived from state and national databases. Multiple linear regression analysis was performed for each hospital level to evaluate the association between change in proportion of LBW and VLBW deliveries and change in HMO penetration per hospital between each of the 3 years.

RESULTS

From 1989 through 1993, the proportion of LBW deliveries significantly declined at level III hospitals and rose at level I and II hospitals. This trend reversed between 1993 and 1996. Very low birth weight deliveries demonstrated more limited and somewhat contrary results, significantly decreasing, then increasing in level I hospitals, and significantly increasing in level III hospitals from 1989 to 1993. After controlling for changes in maternal characteristics over time, changes in HMO penetration at the hospital level were not significantly associated with an increasing proportion of LBW or VLBW deliveries at nonlevel III hospitals. In some analyses, increasing HMO penetration actually was significantly associated with decreasing LBW and VLBW deliveries at nonlevel III hospitals.

CONCLUSION

Despite continued growth in HMOs throughout the state, the trend toward deregionalization in Washington State noted in the early 1990s has not continued. At the hospital level, the increasing presence of HMOs is not significantly associated with perinatal deregionalization.

Recent changes in the etiology of hearing disorders: perinatal drug exposure

In recent years, we have observed causes of congenital or early onset hearing disorders that had not been recognized or known to exist before. These include drugs passed to an as-yet unborn child. Principal among them is alcohol, but others, such as cocaine, are now also occupying our attention. This article reviews the effects of such exposure on the communication skills of children who had been exposed. It is not yet clear whether there are specifically auditory effects, nor is it clear whether the communicative effects are long lasting.

Infant feeding and phonologic development

The relationship between breastfeeding and speech development was examined to determine what duration (if any) of breastfeeding is associated with better performance on a measure of phonologic development. Twenty-nine children aged 36-48 months and their parents were recruited from preschools to serve as subjects. The children's durations of exclusive breastfeeding ranged from 0 (always bottle fed) to 6 months. Phonologic development was assessed using an instrument known as the Percentage of Consonants Correct (PCC) [12]. Feeding histories were obtained by retrospective interviews with parents. Parents and teachers also made ratings of children's speech and total communication on a 5-point scale. This study fails to replicate earlier researchers' findings of an association between breastfeeding and phonologic development. No evidence was found of an association between any duration of either exclusive or partial breastfeeding and PCC scores. Pearson r correlations between parents' and teachers' ratings and PCC scores were weak. Results are discussed in comparison with previous reports of a correlation between breastfeeding and phonologic development.

Evoked otoacoustic emissions in preterm infants

Since Kemp's discovery of the otoacoustic emissions phenomenon [7], much study has been given to understanding the nature of it and its ontogeny. Development of the evoked otoacoustic emissions (EOAE) has spurred much interest because they may used as a valid and relatively quick test to assess cochlear integrity in the very youngest patients. One thing that has been learned is that EOAE amplitudes are much larger in normal ears of infants than in normal ears of adults. We asked about the form of this development in a longitudinal, rather than cross-sectional, study in an investigation on children born before 40 weeks postconceptional age. We were able to examine reliably five ears of four preterm babies while they remained in the neonatal intensive care unit. The EOAEs of these ears were then studied to determine whether and how they changed over time. To do this, we examined both their amplitudes and their spectral properties. It turned out that there are properties of the EOAE spectrum that may be related to post-conceptional age. These are described herein. These findings are expected to have considerable clinical utility as more and more researchers are able to confirm their validity.

Diplophonia in a neonate

Diplophonia has never been described in a neonate. An unusual case, then, of diplophonia in a neonate is described here. There is a description of the acoustic characteristics of this infant's cry and a discussion of their significance. This contributes to a review of the differential diagnosis of diplophonia. Moreover, this case further shows the essential relation between laryngoscopic findings and acoustical data.

Why and how should we study infant cry?

The study of the acoustics of infants' vocalizations has important implications for the study of infant development and for clinical prediction. We suggest procedures that enhance the probability of discriminating among sub-glottal, periglottal, and supraglottal sites of pathology, With these procedures, then, it should become possible to contribute to diagnosis and therefore to treatment.

Review of a high risk register for congenital or early-onset deafness

This paper is an attempt to assess the success of a high risk register for congenital or early onset of severe to profound hearing impairment. With some years experience, and a large number of publications, it is possible to evaluate (at least in part) the extent to which such a register actually does permit us to identify these infants. To that end, an extensive review is reported here and some recommendations are made.

Degeneration of speech, language, and hearing in a patient with mucopolysaccharidosis VII

Mucopolysaccharidosis VII (MPS-VII) is probably the rarest of the mucopolysaccharidoses; literature reveals only 20 cases. We have had the opportunity to study and treat such a child in our clinic, and this paper documents his speech, language, and hearing. Results demonstrated a delay with respect to his chronological age in all cognitive, linguistic, and social domains. He had a mixed hearing loss which could have contributed to his diminishing speech and language abilities; he had chronic otitis media. After 59 h of speech and language intervention (over a period of 19 months), primarily for language treatment, standardized tests revealed that his scores had decreased over time. During this period, both his speech production and his hearing got poorer. At about the time of his 8th birthday, he underwent a permanent tracheostomy, altering further therapy. Although MPS-VII is a very rare disorder, what has been learned here may apply to other MPSs and even to other multiply handicapped patients. We hope that the presentation of our findings may assist others when confronted with complex, degenerative disorders.

Inter-stimulus interval in audiometry for neonates

The usual paradigm employed for both clinical and experimental evaluation of auditory responsiveness of newborns dictates that signal presentations be separated by a minimum of 15 s. Furthermore, this paradigm requires that there be 8 presentations of the signal and that two responses among the 8 trials should be taken as normal responsiveness. Many have been concerned about accepting 25% as normal, and would prefer a paradigm that could lead to increased responsiveness. A procedure with inter-stimulus intervals longer than 15 s might be that paradigm. Therefore, the following experiment employed inter-stimulus intervals of 15, 30 and 60 s to examine responsiveness of infants young enough to be in a newborn nursery. Each infant received 24 signal presentations (8 with each of the 3 inter-stimulus intervals), and these were counter-balanced across babies. Although there is evidence of response habituation across time, there is also evidence that longer inter-stimulus intervals do lead to increased responsiveness.

The acoustic characteristics of the cry of an infant with unilateral vocal fold paralysis

We have previously shown the acoustic similarity among well, full-term infants of the same post-conceptional and post-partum ages (Int. J. Pediat. Otorhinolaryngol., 10 (1985) 1-8). The objective of that research was to provide a template against which the cries of any given infant may be compared. This paper shows a more detailed analysis of both the normal infants' cries and the cry of an infant with a unilateral vocal fold paralysis. It is evident from this analysis that this infant's cry is not normal as it displays a spectrum not found in the cries of normal infants. What this research shows is that a technique is available with which it is possible to make a screening identification of those infants who merit further investigation. It is an objective of such research to determine if the cry of a given infant is abnormal in specifiable, and therefore diagnostic, ways. In this instance, we can conclude that the cry of this infant differs from that of one with a normal airway.

Early development of the acoustic reflex

Acoustic reflex testing was conducted on 2-day-old and on 6-week-old infants to determine how frequently, if at all, the acoustic reflex occurs, if it can be reliably observed, and also to determine what is the mean normal acoustic reflex threshold for pure tones and broad-band noise in these populations. Twenty normal infants were tested in each group. Each infant was considered to be normal by the following criteria: full term, normal pregnancy normal pregnancy and delivery, birth weight greater than 2500 g, 5-min Apgar of 7 or greater, and considered to be not at risk for hearing loss by the absence of any high risk factors. Subjects were tested following feedings. Acoustic reflexes were obtained from subjects with normal tympanograms (+/- 50 mm H2O) for 500, 1,000, 2,000, and 4,000 Hz and broad-band noise stimuli. Behavioral responses were common, requiring quieting pauses in testing and repeated stimulation for habituation of the behavioral component. Acoustic reflexes were observed, and normative reflex threshold data were obtained. The number of reflexes obtained and the mean acoustic reflex thresholds for these age-groups are reported.

Acoustical analyses of neonates' vocalizations

Crying and other vocalizations of normal children under the age of 3 days were recorded and analyzed. The purpose was to establish a norm, in acoustical terms, to which one could compare the cry of any given newborn of the same age. One hopes that such a template may assist in the identification of such neonates who have airway obstructions and/or inadequate neuromotor control of respiration. The data reveal two things. One is that the type of vocalization (cry or non-cry) is not relevant to the analysis. The other finding is that spontaneous vocalization (as distinguished from elicited vocalization) is satisfactory for the purpose.

Stimulus, response, and state variables in the testing of neonates

This paper endeavors to answer three closely related questions: What motor behavior displayed by an infant may be considered to be a response to acoustic stimulation? What acoustic phenomena elicit such behavior? Does responsiveness vary with postconceptual age? Review of our work over the past decade reveals that we know the answers to the first two questions, but not the third. Briefly, arousal responses (eye and limb movements) are reliably elicited by wideband signals but not by narrowband signals. However, there is still confusion about whether preterm infants are more or less responsive than full term infants.

SSW test performance-intensity functions for hearing-impaired adults

The present study investigated the effects of intensity on hearing-impaired adults' performance on the Staggered Spondaic Word (SSW) test. Fifteen adults having mild-to-moderate cochlear hearing losses were administered the 40-item SSW test which was subdivided into four groups of ten items each, and presented at different intensity levels (20, 30, 40, and 50 dB SL re the three-frequency, pure-tone average). Subjects' responses were used to generate performance-intensity functions. Scores were analyzed for overall, competing, and noncompeting conditions. No significant differences were found for these hearing-impaired listeners' performance for items presented at the standard 50 dB and those at the low sensation levels.

Purification and characterization of human T-lymphocyte-derived erythroid-potentiating activity

The human T-lymphoblast cell line, Mo, secretes a number of lymphokines, including erythroid-potentiating activity (EPA), an important early regulator of erythropoiesis. We report purification of EPA to homogeneity, from serum-free Mo-conditioned medium. Purification was accomplished by sequential concentration, ammonium sulfate precipitation, lentil lectin affinity chromatography, gel filtration, and reverse-phase high-performance liquid chromatography. EPA was assayed by its ability to stimulate the growth of large erythroid colonies (bursts) from normal human peripheral blood. The purified EPA has a molecular weight of 28,000 and appears as a single band when analyzed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis under reducing or nonreducing conditions. Purified EPA stimulates the growth of both early and late erythroid precursors from human bone marrow, as well as colony formation by the K562 human erythroleukemia cell line. Purified EPA has no colony-stimulating factor activity nor does it appear to be a structural protein of the human T-cell leukemia virus subtype II which infects the Mo cells.

The effect of noise bandwidth on the auditory arousal response of neonates

Eighteen full-size, full-term, healthy, newborn infants were used in an experiment to determine the relative efficiency of three different noise spectra as audible stimuli. These three signals were high-pass filtered noises with cutoff frequencies of 500, 1000, and 2000 Hz. The metric of efficiency was a very simple count: how many times did an infant display an arousal response to each signal? Each of the three signals was presented eight times to each infant, but the 24 signals were presented in a different random order to each infant. Results showed that neonates are more responsive to wider band signals but are also responsive to lower frequencies. These data are consistent with our earlier findings (also described) and continue to support the use of calibrated wideband signals for auditory screening of newborns.

Visual scoring of the middle latency response

Interjudge validity and intrajudge reliability were studied in a task in which three sets of judges (scores) identified middle latency responses under varying conditions of intensity and number of stimuli per response. The results demonstrated that intensity level was the only factor that had a statistically significant effect on the scorers' judgments. As intensity decreased it became increasingly difficult to detect middle latency responses; however, silent controls were clearly identified as response absent. Definite trends were seen for the scorer groups as a function of experience; the experienced groups generally had slightly higher mean confidence levels and percent correct judgments than the naive scorers. Surprisingly, increasing the number of stimuli had no significant effect on the scorers' judgments. Last, intrajudge reliability was high across all scorers for all conditions except at 10 dB SL. Most of the unreliable judgments and difficulty in detection (interjudge validity) occurred at the 10 dB SL.

Developmental norms for the acoustic reflex

Acoustic reflexes were observed in 45 infants between the ages of 12 and 36 weeks. As age increased, smaller ranges of signal levels were needed to elicit the reflex and less intensity was required, but a noise stimulus did not show age-related changes. Stimulus frequency was not a source of variation of response. The reflex arc has undergone maturation by 12 weeks of age and continues to mature to 36 weeks.

The use of noise-making toys as audiometric devices

For a considerable period of time in the literature concerned with pediatric audiology--or, more specifically, audiometry for infants--it has been suggested that one should or should not use measurable noise-making toys as stimulus devices. Proponents of their use suggest that they are intrinsically more attractive to infants and therefore enhance responsiveness. Opponents of the use of such devices have based their claims on the idea that the signal produced by such devices are neither calibrated nor replicable. It is probably the case that both positions are correct, and this leaves the practitioner without expert advice. The study reported here is a simple electroacoustic evaluation of a set of such toys which are now commercially available. The experiment consisted of having two persons use each device 3 times according to the instructions provided with the materials. The toys consist of a bell, a horn, two rattles, and a squeaking toy. The signals produced by these several repetitions of the toys were subjected to one-third octave band analysis by a Bruel and Kjaer Model 2112 spectrometer. A result showed that the signals produced by these toys are indeed replicable, but generally have such flat spectra that they may not be selectively useful except as gross screening devices.

Cardiovascular response to acoustic stimuli in one-, two-, and three-month-old infants

Fifteen normal infants were seen at the ages of 1, 2, and 3 months. Cardiac responses to auditory stimuli of various frequencies and intensities were evaluated to determine the effects of age of the infant, frequency of the stimulus, and intensity of the stimulus. Heart rate was measured by a fingertip pulse counter and recorded on a polygraph. While the heart rate was being monitored, the infant was presented with a series of tone bursts of 1.5-sec duration with an interstimulus interval of 13.5 sec. Frequencies and intensities of stimuli were found to have no effects on the response. The cardiac rate response was influenced more by the ages of the infants than by stimulus parameters. Variability of the data for two-month-old children seemed to indicate a transition occurring at this age. However, the major influence upon the response was found to be the prestimulus heart rate.

Prediction of hearing aid users' satisfaction

This study raised the question of whether certain methods of hearing aid evaluation could predict subjects' satisfaction and willingness to use their aids. For this purpose, we compared two hearing aid evaluation methods on 30 subjects between the ages of 55 and 65 years, all of whom were hearing aid users for some months. Five signal-to-noise ratios were used. The results of this experiment indicated a significant and positive correlation between subject satisfaction and subject willingness to use the hearing aid. Results of multiple regression analyses indicated that both evaluation methods were better predictors of usage than of satisfaction.

The cardiovascular response to acoustic stimuli

The purposes of this investigation were to determine whether adults display alterations of cardiac rate under acoustical stimulus conditions and whether such alterations are influenced by signal level. The stimulus consisted of a narrow band of noise centered at 1 000 Hz and presented at 20, 40, 60 and 80 dB SPL. The stimulus was found to produce alterations of heart rate significantly different from variation under non-stimulus conditions, indicating that cardiovascular responses occurred. However, the responses themselves were unaffected by differences of sound pressure level.

Idiosyncratic cardiovascular response of human neonates to acoustic stimuli

The heart rate response of acoustic stimuli was assssed for 15 newborns between the ages of 24 and 48 hr. Results of the analyses of covariance demonstrated that although the subjects responded to the stimuli, their responses were idiosyncratic in magnitude, direction, and pattern of rate change. Although spectrum and duration of the stimuli were varied, they were found not to be significant sources of response variation.

Language deficiency of disadvantaged children

This investigation examined the extent to which culturally disadvantaged children are retarded in language development compared to other children. Subjects were 53 children between the ages of 48 months and 67 months, 40 of whom were considered culturally disadvantaged. All children were given the Illinois Test of Psycholinguistic Abilities, and 50 utterances were elicited from each child. As had been hypothesized, on virtually every test the culturally disadvantaged children scored significantly lower than did the other children.

Flutter pereption in normal listeners

A total of 150 normal, adult males classified into five age groups was tested for the auditory flutter frequency threshold by a method of limits. The five variables employed in the study were: age, ear, psychophysical method, sound pressure level, and sound-time ratio. The following conclusions were derived: (a) the auditory flutter frequency threshold varies with psychophysical method and sound-time ratio; and (b) the auditory flutter frequency threshold does not vary with age, ear, and sound intensity.