The rest of the access-to-care puzzle. Addressing structural and personal barriers to health care for socially disadvantaged children

Factors Associated with Nonattendance to a Geriatric Clinic among Mexican Older Adults

INTRODUCTION

Outpatient appointment nonattendance (NA) represents a public health problem, increasing the risk of unfavorable health-related outcomes. Although NA is significant among older adults, little is known regarding its correlates. This study aimed to identify the correlates (including several domains from the geriatric assessment) of single and repeated NA episodes in a geriatric medicine outpatient clinic, in general and in the context of specific comorbidities.

METHODS

This is a cross-sectional study including data from 3,034 older adults aged ≥60 years with ≥1 scheduled appointments between January 1, 2016, and December 31, 2016. Appointment characteristics as well as sociodemographic, geographical, and environmental information were obtained. Univariate and multivariate multinomial regression analyses were carried out.

RESULTS

The mean age was 81.8 years (SD 7.19). Over a third (37.4%) of participants missed one scheduled appointment, and 14.4% missed ≥2. Participants with a history of stroke (OR 1.336, p = 0.041) and those with a greater number of scheduled appointments during the study time frame (OR 1.182, p < 0.001) were more likely to miss one appointment, while those with Parkinson's disease (OR 0.346, p < 0.001), other pulmonary diseases (OR 0.686, p = 0.008), and better functioning for activities of daily living (ADL) (OR 0.883, p < 0.001) were less likely to do so. High socioeconomic level (OR 2.235, p < 0.001), not having a partner (OR 1.410, p = 0.006), a history of fractures (OR 1.492, p = 0.031), and a greater number of scheduled appointments (OR 1.668, p < 0.001) increased the risk of repeated NA, while osteoarthritis (OR 0.599, p = 0.001) and hypertension (OR 0.680, p = 0.002) decreased it. In specific comorbidity populations (hypertension, type 2 diabetes mellitus, and cancer), better ADL functioning protected from a single NA, while better mobility functioning protected from repeated NA in older patients with hypertension and cancer.

DISCUSSION/CONCLUSION

Identifying geriatric factors linked to an increased probability of NA may allow one to anticipate its likelihood and lead to the design and implementation of preventive strategies and to an optimization of the use of available health resources. The impact of these factors on adherence to clinical visits requires further investigation.

How technology impacts communication between cancer patients and their health care providers: A systematic literature review

OBJECTIVE

To ensure the well-being of their patients, health care providers (HCPs) are putting more effort into the quality of the communication they provide in oncology clinics. With the emergence of Health Information Technology (HIT), the dynamics between doctors and patients in oncology settings have changed. The purpose of this literature review is to explore and demonstrate how various health information technologies impact doctor-patient communication in oncology settings.

METHOD

A systematic literature review was conducted in 4 databases (PubMed, Cochrane, Web of Science, IEEE Xplore) to select publications that are in English, published between January 2009 and September 2020. This review reports outcomes related to the impacts of using health information technologies on doctor-patient communication according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Reviews and Meta-Analysis guidelines (PRISMA).

RESULTS

We identified 31 studies which satisfied the selection and eligibility criteria. The review revealed a diverse range of HIT used to support communication between cancer patients and their HCPs in oncology settings. Outcomes related to communication were examined to demonstrate how technology can improve access to care in clinical settings and online. When technology is used effectively to support patient knowledge and shared understanding, this increases the patient's satisfaction and ability to manage emotions, make decisions, and progress in their treatment, in addition to increasing social support and building a stronger therapeutic alliance based on shared knowledge and transparency between clinicians and patients.

CONCLUSION

Technology-based solutions can help strengthen the relationship and communication between patients and their doctors. They can empower the patient's well-being, help doctors make better decisions and enhance the therapeutic alliance between them. Thus, using technology to enhance communication in healthcare settings remains beneficial if its use is structured and target oriented. Future studies should focus on comparing in-depth the difference between outpatient and inpatient settings in terms of the efforts required and the extent of the impacts from both clinicians' and cancer patients' perspectives.

Monitoring access barriers to health services in the Americas: a mapping of household surveys

OBJECTIVE

To map the range of access barriers indicators for which data can be derived from household surveys in the Americas.

METHODS

A systematic mapping review study was conducted to identify access dimensions and indicators of access barriers for general health services already described in the literature; and identify whether data for those indicators could be derived from household surveys in the Americas and what was the methodology used in these surveys.

RESULTS

The study found 49 eligible surveys (287 datasets) from 31 countries in the Americas from which 23 measures of access barriers could be generated. These indicators measure self-reported access barriers for unmet healthcare needs through forgone care, as well as delayed care, unsatisfaction with care and experiences during health service provision. Multiple barriers could be identified, although there was marked heterogeneity in variables included and how barriers were measured.

CONCLUSIONS

This study identified tracer indicators that countries in the Americas could use to monitor the population that experience healthcare needs but fail to seek and obtain appropriate healthcare, and what the main barriers are. The surveys identified are well validated and allow the disaggregation of these indicators by equity stratifiers. Given the variability of the methodologies used in these surveys, comparability across countries could be limited. As such, their virtue lies in helping stakeholders compare levels of access barriers over time for a given country or a group of countries. Country buy-in will directly affect the extent to which access barriers data are collected, reported, and used.

Facilitating factors and barriers to accessibility and utilization of kangaroo mother care service among parents of low birth weight infants in Mangochi District, Malawi: a qualitative study

Background

Kangaroo Mother Care (KMC) is one of the interventions widely used in low-income countries to manage Low Birth Weight Infants (LBWIs), a global leading cause of neonatal and child mortality. LBWI largely contributes to neonatal mortality in Malawi despite the country strengthening and implementing KMC, nationwide, to enhance the survival of LBWIs. This qualitative study aimed to assess the facilitating factors and barriers to accessibility and utilization of KMC service by the parent of low birth weight infants (PLBWIs) in Mangochi District, Malawi.

Methods

Two focused group discussions assessed factors facilitating and hindering the accessibility and utilization of KMC service were conducted in April 2018 that reached out to (N = 12) participants; (n:6) PLBWI practicing KMC at Mangochi district hospital (MDH) referred from four health facilities and (n:6) high-risk pregnant mothers (HRPMs) visiting antenatal care (ANC) clinic at MDH. The availability of KMC at MDH was assessed using KMC availability checklist. The study used purposive, convenient and simple random sampling to identify eligible participants. Thematic analysis was used to analyze the findings.

Results

Sixteen themes emerged on facilitating factors and barriers to accessibility and utilization of KMC service by the PLBWIs. The identified themes included; availability of KMC providers, social factor (social support and maternal love), timing of KMC information, knowledge on KMC, health linkage systems, recognition of LBWIs, safety on the use of KMC, preference of LBWI’s care practice, lived experience on KMC practice, KMC expert clients, perceived causes of LBWI births, cultural/traditional factors, religious beliefs, health-seeking behavior, women empowerment and quality of care.

Conclusions

Although KMC was available in some of the health facilities, integration of KMC messages in ANC guidelines, community awareness and in sensitization of any health intervention may enhance KMC accessibility and utilization by the targeted population.

Access to Care and Cardiovascular Disease Prevention: A Cross-Sectional Study in 2 Latino Communities

Cardiovascular disease (CVD) is the leading killer of Americans. CVD is understudied among Latinos, who have high levels of CVD risk factors. This study aimed to determine whether access to health care (ie, insurance status and having a usual source of care) is associated with 4 CVD prevention factors (ie, health care utilization, CVD screening, information received from health care providers, and lifestyle factors) among Latino adults and to evaluate whether the associations depended on CVD clinical risk/disease.Data were collected as part of a community-engaged food environment intervention study in East Los Angeles and Boyle Heights, CA. Logistic regressions were fitted with insurance status and usual source of care as predictors of the 4 CVD prevention factors while controlling for demographics. Analyses were repeated with interactions between self-reported CVD clinical risk/disease and access to care measures.Access to health care significantly increased the odds of CVD prevention. Having a usual source of care was associated with all factors of prevention, whereas being insured was only associated with some factors of prevention. CVD clinical risk/disease did not moderate any associations.Although efforts to reduce CVD risk among Latinos through the Affordable Care Act could be impactful, they might have limited impact in curbing CVD among Latinos, via the law's expansion of insurance coverage. CVD prevention efforts must expand beyond the provision of insurance to effectively lower CVD rates.

Oral Health Disparities and Unmet Dental Needs among Preschool Children in Chelsea, MA: Exploring Mechanisms, Defining Solutions

BACKGROUND

Significant disparities exist in children's receipt of preventive dental care (PDC) in the United States. Many of the children at greatest risk of dental disease do not receive timely PDC; when they do receive dental care, it is often more for relief of dental pain. Chelsea is a low-income, diverse Massachusetts community with high rates of untreated childhood caries. There are various dental resources available in Chelsea, yet many children do not access dental care at levels equivalent to their needs.

OBJECTIVE

Using Chelsea as a case-study, to explore factors contributing to forgone PDC (including the age 1 dental visit) in an in-depth way.

METHODS

We used a qualitative study design that included semi-structured interviews with parents of preschool children residing in Chelsea, and Chelsea-based providers including pediatricians, dentists, a dental hygienist and early childhood care providers. We examined: a) parents' dental attitudes and oral health cultural beliefs; b) parents' and providers' perspectives on facilitators and barriers to PDC, reasons for unmet needs, and proposed solutions to address the problem. We recorded, transcribed and independently coded all interviews. Using rigorous, iterative qualitative data analyses procedures, we identified emergent themes.

RESULTS

Factors perceived to facilitate receipt of PDC included Head-Start oral health policies, strong pediatric primary care/dental linkages, community outreach and advertising, and parents' own oral health experiences. Most parents and providers perceived there to be an adequate number of accessible dental services and resources in Chelsea, including for Medicaid enrollees. However, several barriers impeded children from receiving timely PDC, the most frequently cited being insurance related problems for children and adults. Other barriers included limited dental services for children <2 years, perceived poor quality of some dental practices, lack of emphasis on prevention-based dental care, poor care-coordination, and insufficient culturally-appropriate care. Important family-level barriers included parental oral health literacy, cultural factors, limited English proficiency and competing priorities. Several solutions were proposed to address identified barriers.

CONCLUSION

Even in a community with a considerable number of dental resources, various factors may preclude access to these services by preschool-aged children. Opportunities exist to address modifiable factors through strategic oral health policies, community outreach and improved care coordination between physicians, dentists and early childhood care providers.

Merging systems: integrating home visitation and the family-centered medical home

To improve the health of children and bend the health care cost curve we must integrate the individual and population approaches to health and health care delivery. The 2012 Institute of Medicine (IOM) report Primary Care and Public Health: Exploring Integration to Improve Population Health laid out the continuum for integration of primary care and public health stretching from isolation to merging systems. Integration of the family-centered medical home (FCMH) and home visitation (HV) would promote overall efficiency and effectiveness and help achieve gains in population health through improving the quality of health care delivered, decreasing duplication, reinforcing similar health priorities, decreasing costs, and decreasing health disparities. This paper aims to (1) provide a brief description of the goals and scope of care of the FCMH and HV, (2) outline the need for integration of the FCMH and HV and synergies of integration, (3) apply the IOM's continuum of integration framework to the FCMH and HV and describe barriers to integration, and (4) use child developmental surveillance and screening as an example of the potential impact of HV-FCMH integration.

Patient-centred access to health care: conceptualising access at the interface of health systems and populations

Background

Access is central to the performance of health care systems around the world. However, access to health care remains a complex notion as exemplified in the variety of interpretations of the concept across authors. The aim of this paper is to suggest a conceptualisation of access to health care describing broad dimensions and determinants that integrate demand and supply-side-factors and enabling the operationalisation of access to health care all along the process of obtaining care and benefiting from the services.

Methods

A synthesis of the published literature on the conceptualisation of access has been performed. The most cited frameworks served as a basis to develop a revised conceptual framework.

Results

Here, we view access as the opportunity to identify healthcare needs, to seek healthcare services, to reach, to obtain or use health care services, and to actually have a need for services fulfilled. We conceptualise five dimensions of accessibility: 1) Approachability; 2) Acceptability; 3) Availability and accommodation; 4) Affordability; 5) Appropriateness. In this framework, five corresponding abilities of populations interact with the dimensions of accessibility to generate access. Five corollary dimensions of abilities include: 1) Ability to perceive; 2) Ability to seek; 3) Ability to reach; 4) Ability to pay; and 5) Ability to engage.

Conclusions

This paper explains the comprehensiveness and dynamic nature of this conceptualisation of access to care and identifies relevant determinants that can have an impact on access from a multilevel perspective where factors related to health systems, institutions, organisations and providers are considered with factors at the individual, household, community, and population levels.

Increasing dental care utilization by Medicaid-eligible children: a dental care coordinator intervention

OBJECTIVES

The aim of this study was to determine the effect of a dental care coordinator intervention on increasing dental utilization by Medicaid-eligible children compared with a control group.

METHODS

One hundred and thirty-six children enrolled in Medicaid aged 4 to 15 years at baseline in 2004 who had not had Medicaid claims for 2 years, were randomly assigned to intervention or control groups for 12 months. Children and caregivers in the intervention group received education, assistance in finding a dentist if the child did not have one, and assistance and support in scheduling and keeping dental appointments. All children continued to receive routine member services from the dental plan administrator, including newsletters and benefit updates during the study.

RESULTS

Dental utilization during the study period was significantly higher in the intervention group (43 percent) than in the control group (26 percent). The effect was even more significant among children living in households well below the Federal Poverty Level. The intervention was effective regardless of whether the coordinator was able to provide services in person or via telephone and mail.

CONCLUSION

The dental care coordinator intervention significantly increased dental utilization compared with similar children who received routine Medicaid member services. Public health programs and communities endeavoring to reduce oral health disparities may want to consider incorporating a dental care coordinator along with other initiatives to increase dental utilization by disadvantaged children.

Interpersonal Psychotherapy for Depressed Adolescents (IPT- A): Extending the Reach from Academic to Community Settings1

Depression is a persistent and impairing illness for adolescents. Many adolescents have limited access to care and/or do not receive adequate treatment for their depression. Researchers have developed a number of empirically supported interventions for adolescent depression; the challenge is to bring these treatments into community settings and assess their effectiveness under real world conditions. This paper provides a critical examination of research conducted on the use of Interpersonal Psychotherapy for depressed adolescents (IPT-A). The paper presents evidence for the efficacy and effectiveness of IPT-A. Implementation and dissemination efforts are discussed in regard to lessons learned and directions for future research.

Cumulative social disadvantage and child health

CONTEXT

Disparities in child health are a major public health concern. However, it is unclear whether these are predominantly the result of low income, race, or other social risk factors that may contribute to their health disadvantage. Although others have examined the effects of the accumulation of risk factors, this methodology has not been applied to child health.

OBJECTIVE

We tested 4 social risk factors (poverty, minority race/ethnicity, low parental education, and not living with both biological parents) to assess whether they have cumulative effects on child health and examined whether access to health care reduced health disparities.

DESIGN

We analyzed data on 57,553 children <18 years from the 1994 and 1995 National Health Interview Survey Disability Supplement. Of the 4 risk factors, 3 (poverty, low parental education, and single-parent household) were consistently associated with child health. These were summed, generating the Social Disadvantage Index (range: 0-3).

RESULTS

A total of 43.6% of children had no social disadvantages, 30.8% had 1, 15.6% had 2, and 10.0% had all 3. Compared with those with no social disadvantages, the odds ratios (ORs) of being in "good, fair, or poor health" (versus "excellent or very good") were 1.95 for 1 risk, 3.22 for 2 risks, and 4.06 for 3 risks. ORs of having a chronic condition increased from 1.25 (1 risk) to 1.60 (2 risks) to 2.11 (3 risks). ORs for activity limitation were 1.51 (1 risk) to 2.14 (2 risks) and 2.88 (3 risks). Controlling for health insurance did not affect these findings.

CONCLUSIONS

The accumulation of social disadvantage among children was strongly associated with poorer child health and having insurance did not reduce the observed health disparities.

Unmet need and problems accessing specialty medical and related services among children with special health care needs

OBJECTIVES

To extend what is known about parent reports of their child's need for specialty medical and related services, unmet need, and specific types of access problems among children with special health care needs (CSHCN).

METHODS

Using data from a 1998-1999 20-state survey of families of CSHCN, we examined differences in parent report of need for services by child characteristics, investigated parent report of unmet need and access problems by service area and number of services needed, and estimated the likelihood of four access problems and unmet need by child, family, and health insurance characteristics.

RESULTS

Overall, the sample children had numerous service needs, although the prevalence of need varied by service type and child characteristics. Reports of unmet need were greater for older children and for children with multiple service needs, unstable health care needs or a behavioral health condition, parents who were in poor health or had more than a high school education, and families whose insurance coverage was inconsistent or lacked a secondary plan. Reports of access problems were greatest for mental health and home health services. The two most prevalent access problems were finding a skilled provider and getting enough visits.

CONCLUSIONS

The results underscore the importance of finding new ways to link children with behavioral health problems to mental health services, implementing coordinated care and the other core dimensions of the medical home concept, increasing the number of specialty pediatricians and home health providers, and expanding coverage for a wider range of mental health services.

Barriers to care-seeking for children's oral health among low-income caregivers

OBJECTIVES

We identified psychosocial, structural, and cultural barriers to seeking dental care among nonutilizing caregivers of Medicaid-enrolled children.

METHODS

We used Medicaid utilization records to identify utilizing and nonutilizing African American and White caregivers of Medicaid-enrolled children in Jefferson County, Kentucky. We conducted 8 focus groups (N=76) with a stratified random sample of responding caregivers; transcripts were qualitatively analyzed.

RESULTS

Psychosocial factors associated with utilization included oral health beliefs, norms of caregiver responsibility, and positive caregiver dental experiences. Utilizing groups reported higher education; health beliefs included identifying oral health with overall health and professional preventive dental care with caregiver responsibility for children's overall health. These beliefs may mediate shared structural barriers, including transportation, school absence policies, discriminatory treatment, and difficulty locating providers who accept Medicaid. Expectation of poor oral health among some low-income caregivers was among factors identified with nonutilization.

CONCLUSIONS

Disadvantaged caregivers reported multiple barriers to accessing dental care for their children. Providers, Medicaid administrators, and schools must coordinate steps to encourage caregiver-controlled dental care, build trust, and link professional preventive dental care with caregiver responsibility for children's overall health.

Attenuation of Racial Differences in Health Service Utilization Patterns for Previously Uninsured Children in the Delta

CONTEXT

A school-based health insurance program for children of the working poor was conducted in 2 isolated, rural communities in the Lower Mississippi Delta region. The larger of the 2 communities had an array of locally available health care providers, whereas the smaller community did not. In response to this lack of available care, the project designed and delivered outreach programs, including transportation to providers.

PURPOSE

The purpose of this paper is to examine the role of race, age, and gender in the relationships between the utilization of care and the impact of outreach programs.

METHOD

General estimating equation models are used to examine the response of utilization variables to race, age, gender, and community. Four years of insurance claims data are analyzed.

FINDINGS

Race is seen to be an important component of utilization. The majority of participants were African American; however, children receiving prescription services, emergency room care, routine physician visits, and hospital outpatient services were more likely to be white. Outreach programs in vision and dental services were found to eliminate racial differences and increase utilization. A relatively strong gender effect was found in prescription, wellness, vision, and dental services.

CONCLUSIONS

Previous research has shown differences by race in utilization of care. Our findings show that targeted outreach programs can significantly diminish these differences. Findings also suggest that barriers to health care for poor rural children are closely linked to transportation and availability of providers, not merely to cost of care or insurance.

Utilization of well-baby care visits provided by Taiwan's National Health Insurance Program

In April of 1995, Taiwan's National Health Insurance Program started providing each eligible child a total of six well-baby care visits. The first four are for infancy, the fifth is for the second and the third years of life, and the sixth is for the fourth year. These services are in addition to neonatal screening and a series of primary immunizations that have been publicly financed and utilized conventionally for years. The purposes of this study were to investigate the utilization level of these well-baby care visits, and explore relevant factors. The results reveal that 36% of eligible children did not use any of the first four visits, 58% did not utilize the fifth, and 82% did not use the sixth in the late 1990s. It appears that the take-up of these services is much less than satisfactory. Maternal awareness of and attitudes toward the services appeared to be the most important factors influencing utilization. These two factors not only were most influential, but also significantly contributed to disparities in utilization among different regions and types of residential districts. As a result, they should be the focus of interventions for advancing well-baby care. While these two factors are at the individual level, they are not independent from the health care system because the health care system has impacts on individual factors. Since physicians can serve as a good vehicle for teaching parents about relevant information and correct attitudes, and most physicians in Taiwan complained about the payment scheme, offering stronger incentives for physicians to promote such services might be helpful for achieving a high utilization level of well-baby care.

Behind schedule: improving access to care for children one practice at a time

Access to health care, the timely use of personal health services to achieve the best possible health outcomes, remains a fundamental problem for children in the United States. To date, research and interventions addressing children's access to care have largely focused on policy-level features of the health care system (such as health insurance and geographic availability of providers) with some, although limited, success. Ultimately, access to health care implies entry into the health care system. Practice scheduling systems are the point of entry to primary care health services for children and thus directly determine access to care in pediatric and family medicine practices. Here we explore the rationale for improving access to care for children from an additional angle: through improving practice scheduling systems. It is our hypothesis that some of the most promising contemporary interventions to improve children's access involve improving primary care scheduling systems. These approaches should complement successful policy-level interventions to improve access to care for children.

Oral health and use of dental services among Hispanics

OBJECTIVES

This study examined factors related to oral health and dental service use among Mexican-Americans, Cuban-Americans, and Puerto Ricans from the Hispanic Health and Nutrition Examination Survey, 1982-84 (HHANES).

METHODS

Categorical measures of oral health were created: (1) perceived oral health status, (2) evaluated oral health status, (3) decayed permanent teeth, (4) teeth missing due to caries, (5) total permanent teeth present, and (6) periodontal classification. The effects of acculturation, education, dental insurance, and perceived condition of teeth and gums on dental service use in the past two and five years were examined using logistic regression. All analyses were performed separately for each of the three samples using SAS-callable SUDDAN.

RESULTS

Dental insurance and education were the most important factors in determining use of dental cleanings and use of dental care. For Mexican-Americans, Cuban-Americans, and Puerto Ricans, acculturation was a factor in determining use of dental care in the past five years.

CONCLUSIONS

While dental insurance and education appear to be the most important factors for determining both use of dental cleaning services and use of dental care in all three samples, acculturation also had some impact for determining use of dental care.

Comparing frequent and average users of elementary school-based health centers in the Bronx, New York City

This study analyzed health care utilization at three school-based health centers (SBHCs) in the Bronx, New York City, and compared characteristics of "frequent" and "average" service users. Encounter form data for visits by 2,795 students who received services at least once between September 7, 1998, and June 30, 1999, were reviewed. Demographic comparisons between clinic users and the total school population, and between "frequent" (five or more visits/year) and "average" (one to four visits/year) users were made. The two groups also were compared after primary diagnoses were classified into five general categories. Some 96% (3,469/3,614) of students were registered in the SBHCs, of whom 81% (2,795/3,469) used clinic services at least once during the school year. Clinic users did not differ from the general school population by gender, but were younger (p < 0.01). "Frequent" users were more likely than "average" users to be older (p < 0.01), but they did not differ by gender, race/ethnicity, or insurance status. "Frequent" users comprised 28% of the clinic-using population, but accounted for 72.5% of all visits. Similarly, "average" users comprised 72.4% of the clinic-using population, but accounted for 27.5% of all visits. "Frequent" users generated most visits for mental health and chronic medical conditions, while "average" users generated most visits for preventive care, acute medical care, and injuries/emergencies (p < 0.01 for all). Important challenges for elementary SBHCs include developing new approaches that meet children's needs while protecting clinic resources, like scheduling group interventions for those with on-going health care needs who require frequent use of school health services.

Access to care, unmet health needs, and poverty status among children with and without chronic conditions

OBJECTIVES

To compare insurance coverage, access to care, and unmet health needs of children with and without chronic conditions in a national probability sample of the US population and to examine the role of poverty status in any demonstrated differences between the 2 groups.

DESIGN

We analyzed parent-report data on children 0-17 years old from the 1994 National Health Interview Survey Disability Supplement (NHIS-D) and from the health insurance and access to care files of the 1994 Family Resources Supplement to the NHIS. In the NHIS-D, 4452 (14.8%) of the 30032 children were identified as having a chronic condition by a noncategorical method. We compared insurance coverage, access to care, and unmet needs of children with and without conditions overall and also compared them within 3 different income levels relative to the national poverty index: 1) below, 2) within 100%-200%, and 3) >200% above poverty level.

RESULTS

In bivariate analyses, children with chronic conditions were more likely to be covered by some type of health insurance (odds ratio [OR], 1.3) and to have a usual provider both for medical ("sick") care (OR, 1.4) and for routine or preventive care (OR, 1.4). They also were more likely to have the same provider for medical care and routine or preventive care (OR, 1.2) and to have seen their health care provider in the last year (OR, 1.8) than children without chronic conditions (all P <.0001). Nonetheless, children with chronic conditions were twice as likely to have had at least 1 unmet need from a list of 4 services that included dental care, prescription medications, eyeglasses, and mental health services (OR, 2.0). They also were more likely to have more than 1 unmet need from the list (OR, 3.1), to have been unable to get needed medical care (OR, 3.1), and to have delayed obtaining medical care because of worry about its cost (OR, 1.8). Children with chronic conditions were at greater risk for unmet needs than were children without conditions across all income levels. The magnitude of the disparity between the groups increased with family income level. Differences persisted even after controlling for sociodemographic variables and insurance status.

CONCLUSION

Despite higher levels of insurance coverage and greater access to regular providers of medical and routine care compared with healthy peers, children with chronic conditions are reported by their parents to be less likely than other children to receive the full range of needed health services. The magnitudes of the differences are small, yet the pattern of disadvantage in meeting health care needs among children with conditions compared with healthy peers is consistent across many different variables and it exists across income levels.

Use of health services by insurance status among children with asthma

OBJECTIVES

It is well known that asthmatic children receiving Medicaid use the emergency department (ED) more frequently than otherwise-insured asthmatic children. However, the extent to which this difference is attributable to provider characteristics, medication use, access to primary care, and symptomatology is poorly understood. These factors were explored as independent predictors of health care utilization.

METHODS

Baseline data from a prospective cohort study of childhood asthma severity were used. Subjects were recruited from seven New England hospitals. Home interviews collected data on monthly symptoms, health care visits, insurance status, as well as sociodemographics and asthma-related risk factors (n = 804). Characteristics of providers' practices, board certifications, and asthma specialty were obtained from Folio's Medical Dictionaries for Connecticut and Massachusetts.

RESULTS

After adjusting for frequency of asthma-related primary care visits, primary provider practice type, use of asthma specialist, age, gender, medication use, and symptomatology, Medicaid children still used the ED more frequently for asthma services than privately insured children (RR, 1.7; 95% CI, 1.1, 2.5). In general, race/ethnicity did not modify the relationship between insurance status and health care use, except that black children receiving Medicaid were 90% (95% CI, 0.0, 0.7) less likely to have had > or = 3 routine primary care visits for asthma in the previous year than black privately insured children. White children receiving Medicaid were 2.5 (95% CI, 1.0, 6.9) times more likely to use the ED for asthma than privately insured white children.

CONCLUSIONS

The results suggest that enabling, structural, and need factors do not necessarily explain observed differences in pediatric asthma health care use by insurance status. Future investigation must explore other explanatory factors such as maternal attitudes and beliefs and patient-provider communication.

From concept to application: the impact of a community-wide intervention to improve the delivery of preventive services to children

OBJECTIVE

To improve health outcomes of children, the US Maternal and Child Health Bureau has recommended more effective organization of preventive services within primary care practices and more coordination between practices and community-based agencies. However, applying these recommendations in communities is challenging because they require both more complex systems of care delivery within organizations and more complex interactions between them. To improve the way that preventive health care services are organized and delivered in 1 community, we designed, implemented, and assessed the impact of a health care system-level approach, which involved addressing multiple care delivery processes, at multiple levels in the community, the practice, and the family. Our objective was to improve the processes of preventive services delivery to all children in a defined geographic community, with particular attention to health outcomes for low-income mothers and infants.

DESIGN

Observational intervention study in 1 North Carolina county (population 182 000) involving low- income pregnant mothers and their infants, primary care practices, and departments of health and mental health. An interrupted time-series design was used to assess rates of preventive services in office practices before and after the intervention, and a historical cohort design was used to compare maternal and child health outcomes for women enrolled in an intensive home visiting program with women who sought prenatal care during the 9 months before the program's initiation. Outcomes were assessed when the infants reached 12 months of age.

INTERVENTIONS

Our primary objective was to achieve changes in the process of care delivery at the level of the clinical interaction between care providers and patients that would lead to improved health and developmental outcomes for families. We selected interventions that were directed toward major risk factors (eg, poverty, ineffective care systems for preventive care in office practices) and for which there was existing evidence of efficacy. The interventions involved community-, practice-, and family-level strategies to improve processes of care delivery to families and children. The objectives of the community-level intervention were: 1) to achieve policy level changes that would result in changes in resources available at the level of clinical care, 2) to engage multiple practice organizations in the intervention to achieve an effect on most, if not all, families in the community, and 3) to enhance communication between, among, and within public and private practice organizations to improve coordination and avoid duplication of services. The objective of the practice-level interventions was to overcome specific barriers in the process of care delivery so that preventive services could be effectively delivered. To assist the health department in implementing the family-level intervention, we provided assistance in hiring and training staff and ongoing consultation on staff supervision, including the use of structured protocols for care delivery, and regular feedback data about implementation of the program. Interventions with primary care practices focused on the design of the delivery system within the office and the use of teamwork and data in an "office systems" approach to improving clinical preventive care. All practices (N = 8) that enrolled at least 5 infants/month received help in assessing performance and developing systems (eg, preventive services flow sheets) for preventive services delivery. Family-level interventions addressed the process of care delivery to high-risk pregnant women (<100% poverty) and their infants. Mothers were recruited for the home visiting intervention when they first sought prenatal care at the community health center, the county's largest provider of prenatal care to underserved women. The home visiting intervention involved teams of nurses and educators and involved 2 to 4 visits per month through the infant's first year of life to provide parental education on fetal and infant health and development, enhance parents' informal support systems, and link parents with needed health and human services. We included training in injury prevention and discipline, and home visitors assisted mothers in obtaining care from one of the primary care offices.

RESULTS

There were high levels of participation, changes in the organization of the delivery system, and improvements in preventive health outcomes. Agencies cooperated in joint contracting, staff training, and defining program eligibility. All 8 eligible practices agreed to participate and 7/8 implemented at least 1 new office system element. Of eligible women, 89% agreed to participate, and outcome data were available on 80% (180/225). After adjusting for differences in baseline characteristics, intervention group women were significantly more likely than comparison group women to use contraceptives (69% vs 47%), not smoke tobacco (27% vs 54%) and have a safe and stimulating home environment for their children. Intervention group children were more likely to have had an appropriate number of well-child care visits (57% vs 37%) and less likely to be injured (2% vs 7%). Intervention mothers also received Aid to Families with Dependent Children for fewer months after the birth of their child (7.7 months vs 11.3 months).

CONCLUSIONS

We observed a number of positive effects at all 3 levels of intervention. Policy-level changes at the state and community led to lasting changes in the organization and financing of care, which enabled changes in clinical services to take place. These changes have now been expanded beyond this community to other communities in the state. We were also able to engage multiple practice organizations, reduce duplication, and improve the coordination of care. Changes in the process of preventive services delivery were noted in participating practices. Finally, the outcomes of the family-level intervention were comparable in direction and magnitude to the outcomes of previous randomized trials of the intervention. All the changes were achieved over a relatively brief 3-year study period, and many have been sustained since the project was completed. Tiered, interrelated interventions directed at an entire population of mothers and children hold promise to improve the effectiveness and outcomes of health care for families and children.

Pediatric asthma among minority populations

Minority children in the United States are at higher risk for asthma and related hospitalizations than white children, and their asthma tends to be more severe. Empirical studies have yet to demonstrate a definitive cause for their high risk and severity. The strongest candidate-predictors include cockroach allergens, household smoking, air pollution, poor access to quality health care, and underutilization of inhaled anti-inflammatory medications. In particular, recent studies have shown that black and Latino children continue to misuse health care and medications because of lack of access to culturally sensitive pediatricians who understand their needs and barriers, which contributes to more severe, poorly controlled asthma. It has been suggested that interventions for minority asthmatic children focus on improving access to asthma medical homes that deliver culturally appropriate and relevant care tailored to the needs of the family, improving family-provider communication, and improving knowledge and acceptance of asthma clinical practice guidelines, particularly for providers who work in community-based clinics.

Perceived access to pediatric primary care by insurance status and race

The Nemours system of children's clinics in Delaware was designed to offer comprehensive primary care (medical homes), to children regardless of families' abilities to pay for services. Racial and insurance status differences in perceptions of access to the provisions of medical home and differences by the Short Medical Home Index are assessed. A probabilities proportionate to size sampling method was used to randomly select families in nine clinics. A total of 323 caregivers of children ages 6 to 48 months were surveyed. Results suggest that there are minimal differences in perceptions of access to provisions of the medical home concept by insurance status and race in the clinics studied. However, when using a composite measure of medical home, differences in perceptions were found. The results suggest that insurance status and racial differences in perceptions of access remain even when the system is specifically designed to provide medical homes without regard to demographic factors. Future studies should focus on improving patient interactions with clinic personnel to ensure that access to provisions of care are understood by all consumers.

The impact of a pediatric medical home on immunization coverage

This study assessed whether having access to provisions in the American Academy of Pediatrics "medical home" concept was associated with being age-appropriately immunized at 3, 12, and 24 months. Cross-sectional data on 495 Delaware children were collected from June 1994 to June 1995. Immunization status was determined with the Delaware immunization registry. The medical home was not significantly associated with immunization coverage. This study confirms that race, insurance status, maternal education, and family incomes are predictive of having poor immunization outcomes. Simply providing medical homes may not be an effective strategy to improve use of preventive services.

Perceived barriers to prenatal care services

PURPOSE

The purpose of this study was to determine barriers to prenatal care services and to determine if barriers differed by demographic characteristics in a low-income population.

DESIGN

Descriptive correlational study with 110 women who sought prenatal care after the 20th week of gestation.

RESULTS

Two items were major barriers to seeking prenatal care: long waiting times at the time of appointments and the cost of getting care. Significant relationships were found based on the age and race of the women.

CLINICAL IMPLICATIONS

Some identifiable variables prevented these women from seeking early prenatal care; however, the barriers identified are amenable to change. Strategies to reduce barriers could include providing more culturally competent care, more timely appointments, better use of the woman's time when appointments are kept, educating women in the community about the availability of low-cost care, and assistance at prenatal care sites for facilitating completion of insurance and financial applications. Barriers to prenatal care varied by demographic group; therefore, identifying the characteristics of the group being served seems important in efforts to decrease barriers to care.

The extent of barriers and linkages to health care for head start children

Data were gathered as part of a larger survey of 218 Head Start Programs in Region II (New York City, New York State (excluding New York City), New Jersey, Puerto Rico and U.S. Virgin Islands) in 1993-94. The general purpose of the survey was to obtain information on child health, screening practices, training needs, family health and community problems, barriers to diagnosis and treatment and the extent of linkages between Head Start programs and health and nutrition providers at the local level. In this study barriers to the care of Head Start children and their families were examined as perceived by the Health Coordinators or other health related staff of the Health Services Component of these programs. The extent of linkages with health and nutrition service providers were also examined. The most frequently reported barriers were lack of parent participation (72%), private transportation not available (67%), parents' perception of quality of care (64%), distance to provider (63%), cost of transportation (63%), lack of funding (56%), limited/inconvenient hours (56%), and health services not available in the community (55%). On average, programs reported linkages to 14.5 providers (including an average of 4 nutrition programs). More than 90% of them reported linkages with public health services, child protective services, WIC and private physicians/dentists. Finally, the extent of barriers and linkages were compared across different geographic areas. Significant barriers were identified in this study, yet the survey confirmed and validated the extensive nature of formal linkages with health and nutrition service providers at the local levels. These findings may indicate that the current levels of service availability may not be sufficient to meet the severity and diversity of health needs of this population.