Effects of Medicaid managed care on health care use: infant emergency department and ambulatory services

Difference in Hospital Utilization Within the First 12 Months Among Low-Birth-Weight Infants in Medicaid Managed Care Versus Fee-for-Service: A Regression Discontinuity Study

OBJECTIVE

To examine the effect of Medicaid managed care (MMC) versus Medicaid fee-for-service (FFS) on emergency department (ED) use and hospitalization during the first 6 and 12 months of life among low-birth-weight (LBW) infants.

METHODS

We used the New York City Office of Vital Statistics-Statewide Planning and Research Cooperative System (OVS-SPARCS) dataset to identify 9135 LBW infants born to female Medicaid beneficiaries in New York City from January 2008-March 2012. We applied a robust regression discontinuity framework using a New York State Medicaid policy in effect at that time. This policy automatically enrolled infants born to female Medicaid beneficiaries to Medicaid managed care (MMC) or Medicaid fee-for-service (FFS) based on their birth weight (less than 1200 g vs. 1200-2500 g) during the first 6 months of their lives.

RESULTS

LBW infants in MMC had an average 0.16% points higher probability of being hospitalized within the first year of their lives than those in Medicaid FFS (p-value = 0.04).

CONCLUSIONS FOR PRACTICE

More research is necessary to understand possible differences in healthcare utilization between MMC and FFS participants with high health risks.

Effects of variations in access to care for children with atopic dermatitis

Background

An estimated 50% of children in the US are Medicaid-insured. Some of these patients have poor health literacy and limited access to medications and specialty care. These factors affect treatment utilization for pediatric patients with atopic dermatitis (AD), the most common inflammatory skin disease in children. This study assesses and compares treatment patterns and healthcare resource utilization (HCRU) between large cohorts of Medicaid and commercially insured children with AD.

Methods

Pediatric patients with AD were identified from 2 large US healthcare claims databases (2011–2016). Included patients had continuous health plan eligibility for ≥6 months before and ≥12 months after the first AD diagnosis (index date). Patients with an autoimmune disease diagnosis within 6 months of the index date were excluded. Treatment patterns and all-cause and AD-related HCRU during the observation period were compared between commercially and Medicaid-insured children.

Results

A minority of children were evaluated by a dermatology or allergy/immunology specialist. Several significant differences were observed between commercially and Medicaid-insured children with AD. Disparities detected for Medicaid-insured children included: comparatively fewer received specialist care, emergency department and urgent care center utilization was higher, a greater proportion had asthma and non-atopic morbidities, high- potency topical corticosteroids and calcineurin inhibitors were less often prescribed, and prescriptions for antihistamines were more than three times higher, despite similar rates of comorbid asthma and allergies among antihistamine users. Treatment patterns also varied substantially across physician specialties.

Conclusions

Results suggest barriers in accessing specialty care for all children with AD and significant differences in management between commercially and Medicaid-insured children. These disparities in treatment and access to specialty care may contribute to poor AD control, especially in Medicaid-insured patients.

Supplementary Information

Supplementary information accompanies this paper at 10.1186/s12895-020-00114-x.

Influenza vaccine effectiveness and disease burden in children and adolescents with sickle cell disease: 2012-2017

BACKGROUND

Data are limited on the burden of influenza and seasonal influenza vaccine effectiveness (VE) in children with sickle cell disease (SCD).

METHODS

We used a prospectively collected clinical registry of SCD patients 6 months to 21 years of age to determine the influenza cases per 100 patient-years, vaccination rates, and a test-negative case-control study design to estimate influenza VE against medically attended laboratory-confirmed influenza infection. Influenza-positive cases were randomly matched to test-negative controls on age and influenza season in 1:1 ratio. We used adjusted logistic regression models to compare odds ratio (OR) of vaccination in cases to controls. We calculated VE as [100% × (1 - adjusted OR)] and computed 95% confidence intervals (CIs) around the estimate.

RESULTS

There were 1037 children with SCD who were tested for influenza, 307 children (29.6%) had at least one influenza infection (338 infections, incidence rate 3.7 per 100 person-years; 95% CI, 3.4-4.1) and 56.2% of those tested received annual influenza vaccine. Overall VE pooled over five seasons was 22.3% (95% CI, -7.3% to 43.7%). Adjusted VE estimates ranged from 39.7% (95% CI, -70.1% to 78.6%) in 2015/2016 to -5.9% (95% CI, -88.4% to 40.4%) in the 2016/17 seasons. Influenza VE varied by age and was highest in children 1-5 years of age (66.6%; 95% CI, 30.3-84.0). Adjusted VE against acute chest syndrome during influenza infection was 39.4% (95% CI, -113.0 to 82.8%).

CONCLUSIONS

Influenza VE in patients with SCD varies by season and age. Multicenter prospective studies are needed to better establish and monitor influenza VE among children with SCD.

Pediatric outpatient utilization by differing Medicaid payment models in the United States

BACKGROUND

In the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients' healthcare utilization. Adults in capitated plans utilize primary care providers (PCP) more than emergency departments (ED), compared to fee-for-service (FFS). Pediatric data are lacking. We aim to determine the association between US capitated and FFS Medicaid payment models and children's outpatient utilization.

METHODS

This retrospective cohort compared outpatient utilization between two payment models of US Medicaid enrollees aged 1-18 years using Truven's 2014 Marketscan Medicaid database. Children enrolled > 11 months were included, and were excluded for eligibility due to disability/complex chronic condition, lack of outpatient utilization, or provider capitation penetration rate < 5% or > 95%. Negative binomial and logistic regression assessed relationships between payment model and number of visits or odds of utilization, respectively.

RESULTS

Of 711,008 children, 66,980(9.4%) had FFS and 644,028(90.6%) had capitated plans. Children in capitated plans had greater odds of visits to urgent care, PCP-acute, and PCP-well-child care (aOR 1.21[95%CI 1.15-1.26]; aOR 2.07[95%CI 2.03-2.13]; aOR 1.86 [95%CI 1.82-1.91], respectively), and had lower odds of visits to EDs and specialty care (aOR 0.82 [95%CI 0.8-0.83]; aOR 0.61 [95%CI 0.59-0.62], respectively), compared to FFS.

CONCLUSIONS

The majority of children in this US Medicaid population had capitated plans associated with higher utilization of acute care, but increased proportion of lower-cost sites, such as PCP-acute visits and UC. Health insurance programs that encourage capitated payment models and care through the PCP may improve access to timely acute care in lower-cost settings for children with non-complex chronic conditions.

Factors Associated With Urgent Care Reliance and Outpatient Health Care Use Among Children Enrolled in Medicaid

Importance

Urgent care (UC) centers are a growing option to address children's acute care needs, which may cause unanticipated changes in health care use.

Objectives

To identify factors associated with high UC reliance among children enrolled in Medicaid and examine the association between UC reliance and outpatient health care use.

Design, Setting, and Participants

A retrospective cohort study used deidentified data on 4 133 238 children from the Marketscan Medicaid multistate claims database to calculate UC reliance and outpatient health care use. Children were younger than 19 years, with 11 months or more of continuous Medicaid enrollment and 1 or more UC, emergency department (ED), primary care provider (PCP; physician, advanced practice nurse, or physician assistant; well-child care [WCC] or non-WCC), or specialist outpatient visit during the 2017 calendar year. Statistical analysis was conducted from November 11 to 26, 2019.

Exposures

Urgent care, ED, PCP (WCC and non-WCC), and specialist visits based on coded location of services.

Main Outcomes and Measures

Urgent care reliance, calculated by the number of UC visits divided by the sum of total outpatient (UC, ED, PCP, and specialist) visits. High UC reliance was defined as UC visits totaling more than 33% of all outpatient visits.

Results

Of 4 133 238 children in the study, 2 090 278 (50.6%) were male, with a median age of 9 years (interquartile range, 4-13 years). A total of 223 239 children (5.4%) had high UC reliance. Children 6 to 12 years of age were more likely to have high UC reliance compared with children 13 to 18 years of age (adjusted odds ratio, 1.07; 95% CI, 1.06-1.09). Compared with white children, black children (adjusted odds ratio, 0.81; 95% CI, 0.81-0.82) and Hispanic children (adjusted odds ratio, 0.61; 95% CI, 0.60-0.61) were less likely to have high UC reliance. Adjusted for age, sex, race/ethnicity, and presence of chronic or complex conditions, children with high UC reliance had significantly fewer PCP encounters (WCC: adjusted rate ratio, 0.60; 95% CI, 0.60-0.61; and non-WCC: adjusted rate ratio, 0.41; 95% CI, 0.41-0.41), specialist encounters (adjusted rate ratio, 0.31; 95% CI, 0.31-0.31), and ED encounters (adjusted rate ratio, 0.68; 95% CI, 0.67-0.68) than children with low UC reliance.

Conclusions and Relevance

High UC reliance occurred more often in healthy, nonminority, school-aged children and was associated with lower health care use across other outpatient settings. There may be an opportunity in certain populations to ensure that UC reliance does not disrupt the medical home model.

Visits to Primary Care and Emergency Department Reliance for Foster Youth: Impact of Medicaid Managed Care

OBJECTIVE

To examine the rate of access to primary and preventive care and emergency department (ED) reliance for foster youth as well as the impact of a transition from fee-for-service (FFS) Medicaid to managed care (MC) on this access.

METHODS

Secondary administrative data were obtained from Medicaid programs in one state that transitioned foster youth from an FFS to an MC (Texas) and another state, comparable in population size and racial/ethnic diversity, which continuously enrolled foster youth in an FFS system (Florida). Eligible participants were foster youth (aged 0-18 years) enrolled in these states between 2006 and 2010 (n = 126,714). A Puhani approach to difference-in-difference was used to identify the effect of transition after adjusting for race/ethnicity, gender, and health status. Data were used to calculate access to primary and preventive care as well as ED reliance. ED reliance was operationalized as the number of ED visits relative to the number of total ambulatory visits; high ED reliance was defined as ≥33%.

RESULTS

The transition to MC was associated with a 6% to 13% increase in access to primary care. Preventive care visits were 10% to 13% higher among foster youth in MC compared to those in FFS. ED reliance declined for the intervention group but to a lesser extent than did the control group, yielding a positive mean percentage change.

CONCLUSIONS

Foster youth access to care may benefit from a Medicaid MC delivery system, particularly as the plans used are designed with the unique needs of this vulnerable population.

Pediatric Emergency Department Utilization and Reliance by Insurance Coverage in the United States

OBJECTIVES

For many children, the emergency department (ED) serves as the main destination for health care, whether it be for emergent or nonurgent reasons. Through examination of repeat utilization and ED reliance (EDR), in addition to overall ED utilization, we can identify subpopulations dependent on the ED as their primary source of health care.

METHODS

Nationally representative data from the 2010 to 2014 Medical Expenditure Panel Survey were used to examine the annual ED utilization of children age 0 to 17 years by insurance coverage. Overall utilization, repeat utilization (two or more ED visits), and EDR (percentage of all health care visits that occur in the ED) were examined using multivariate models, accounting for weighting and the complex survey design. High EDR was defined as having > 33% of outpatient visits in a year being ED visits.

RESULTS

A total of 47,926 children were included in the study. Approximately 12% of children visited an ED within a 1-year period. A greater number of children with public insurance (15.2%) visited an ED at least once, compared to privately insured (10.1%) and uninsured (6.4%) children. Controlling for covariates, children with public insurance were more likely to visit the ED (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.40-1.73) than children with private insurance, whereas uninsured children were less likely (aOR = 0.64, 95% CI = 0.51-0.81). Children age 3 and under were significantly more likely to visit the ED than children age 15 to 17, whereas female children and Hispanic and non-Hispanic other race children were significantly less likely to visit the ED than male children and non-Hispanic white children. Among children with ED visits, 21% had two or more visits to the ED in a 1-year period. Children with public insurance were more likely to have two or more visits to the ED (aOR = 1.53, 95% CI = 1.19-1.98) than children with private insurance whereas there was no significant difference in repeat ED utilization for uninsured children. Publicly insured (aOR = 1.70, 95% CI = 1.47-1.97) and uninsured children (aOR = 1.90, 95% CI = 1.49-2.42) were more likely to be reliant on the ED than children with private insurance.

CONCLUSIONS

Health insurance coverage was associated with overall ED utilization, repeat ED utilization, and EDR. Demographic characteristics, including sex, age, income, and race/ethnicity were important predictors of ED utilization and reliance.

Emergency department presentations in infants: Predictors from an Australian birth cohort

AIM

Infants under 12 months of age are disproportionately represented amongst emergency department (ED) presentations, and infants are more likely to be frequent ED users. This study aimed to describe and identify psychosocial predictors of ED presentation in infants.

METHODS

A prospective birth cohort from Queensland and New South Wales (Environments for Healthy Living) was used to understand infant health service use. Baseline and 12-month questionnaire data pertaining to children born between 2006 and 2011 were used to identify predictors of ED presentation, using multiple regression analysis.

RESULTS

Of the 2184 children in the cohort with available baseline and 12-month data, 579 (27%) presented at least once to an ED during their first 12 months of life. Statistically significant predictors of ED presentation in the multivariate analysis included the mother having asthma (odds ratio (OR) 1.67, 95% confidence interval (CI) 1.15-2.39) and a higher Kessler-6 score (a measure of psychological distress) of the primary carer at baseline (OR 1.04, 95% CI 1.01-1.08). Maternal education level was not associated with ED presentations of infants.

CONCLUSIONS

This study describes maternal and child factors of children who present to the ED in the first year of life. Factors related to an infant's support system were found to be predictors for an ED presentation in the first year of life. This study emphasises the need to review the maternal medical history and psychosocial situation. There may be benefits for health-care practitioners to take the opportunity (such as during routine childhood immunisation) to perform a brief screening tool (such as the Kessler-6) to understand psychological distress experienced by mothers. This may influence the likelihood of a child presenting to an ED within the first 12 months of life.

Factors Contributing to Inappropriate Visits of Frequent Attenders and Their Economic Effects at an Emergency Department in Singapore

OBJECTIVES

This study aimed to determine which factors contribute to frequent visits at the emergency department (ED) and what proportion were inappropriate in comparison with nonfrequent visits.

METHODS

This study was a retrospective, case-control study comparing a random sample of frequent attenders and nonfrequent attenders, with details of their ED visits recorded over a 12-month duration. Frequent attenders were defined as patients with four or more visits during the study period.

RESULTS

In comparison with nonfrequent attenders (median age = 45.0 years, interquartile range [IQR] = 28.0 to 61.0 years), frequent attenders were older (median = 57.5 years, IQR = 34.0 to 74.8 years; p = 0.0003). They were also found to have more comorbidities, where 53.3% of frequent attenders had three or more chronic illnesses compared to 14% of nonfrequent attenders (p < 0.0001), and were often triaged to higher priority (more severe) classes (frequent 52.2% vs. nonfrequent 37.6%, p = 0.0004). Social issues such as bad debts (12.7%), heavy drinking (3.3%), and substance abuse (2.7%) were very low in frequent attenders compared to Western studies. Frequent attenders had a similar rate of appropriate visits to the ED as nonfrequent attenders (55.2% vs. 48.1%, p = 0.0892), but were more often triaged to P1 priority triage class (6.7% vs. 3.2%, p = 0.0014) and were more often admitted for further management compared to nonfrequent attenders (47.5% vs. 29.6%, p < 0.001). The majority of frequent attender visits were appropriate (55.2%), and of these, 81.1% resulted in admission. For the same number of patients, total visits made by frequent attenders ($174,247.60) cost four times as much as for nonfrequent attenders ($40,912.40). This represents a significant economic burden on the health care system.

CONCLUSIONS

ED frequent attenders in Singapore were associated with higher age and presence of multiple comorbidities rather than with social causes of ED use. Even in integrated health systems, repeat ED visits are frequent and expensive, despite minimal social causes of acute care. EDs in aging populations must anticipate the influx of vulnerable, elderly patients and have in place interventional programs to care for them.

Emergency department visits in the neonatal period in the United States

OBJECTIVES

This study aimed to estimate the incidence of emergency department (ED) visits in the neonatal period in a nationally representative sample and to examine variation by race.

METHODS

The National Hospital Ambulatory Medical Care Survey is a nationally representative survey of utilization of ambulatory care services including EDs. We studied all ED visits for patients who were younger than 28 days old from 2003 to 2008. Using the national birth certificate data, we calculated the visit rates by race. Emergency department visits were also characterized by age, insurance status, diagnosis category, region, and hospital type (safety-net vs non-safety-net hospitals).

RESULTS

There was an average of 320,540 neonatal ED visits in the United States per year, with an estimated 7.6% of births visiting the ED within 28 days. Estimated rates of ED visits were highest among non-Hispanic blacks, with 14.4% (95% confidence interval [CI], 10.0-19.2) of newborns having an ED visit in the neonatal period, compared with 6.7% (95% CI, 4.9-7.2) for whites and 7.7% (95% CI, 5.7-9.8) for Hispanics. Hispanic and black neonates were more likely to be seen in safety-net hospitals (75.8%-78.2%) than white (57.1%) patients (P = 0.004).

CONCLUSIONS

In this first nationally representative study of neonatal visits to the ED, visits were common, with the highest rates in non-Hispanic blacks. Hispanic and black neonates were more commonly seen in safety-net hospitals. Reasons for high visit rates deserve further study to determine whether hospital discharge practices and/or access to primary care are contributing factors.

Effects of an education and training intervention on caregiver knowledge of nonurgent pediatric complaints and on child health services utilization

OBJECTIVES

The objective of this study was to test the impact of an education and training intervention about management of common childhood illnesses on caregiver knowledge and health service use by an index child.

METHODS

This was a quasi-experimental, preintervention-postintervention pilot study of a primary care-based intervention among 32 caregivers of urban children aged 7 months to 5 years. Intervention consisted of a 90-minute educational activity developed after input from focus groups and taught by pediatric nurses; it addressed management of fever, colds, and minor trauma in children at home. Caregiver knowledge before, immediately after, and 6 months after intervention was tested using a written instrument. Health services utilization for an index child in the family was collected 6 months before and after intervention.

RESULTS

Caregiver knowledge, as assessed by mean score on the test instrument, increased immediately after the intervention. It was lower at 6-month follow-up but remained higher than pretest. Total health services utilization, adjusted for patient and caregiver factors, did not change significantly 6 months after the intervention. After-hours calls to the primary care physician increased from a mean of 0.33 to 1.46 per patient (P = 0.047), making it the only behavior with significant change. Preintervention health services utilization was the strongest positive predictor of postintervention health services use.

CONCLUSIONS

The primary care-based intervention led to increased caregiver knowledge regarding management of common minor childhood illnesses and to increased after-hours telephone use. There was no significant decrease in ED use. To reduce reliance on the ED for nonurgent conditions, additional strategies may be needed.

Feasibility of computerized screening for intimate partner violence in a pediatric emergency department

OBJECTIVES

This study aimed to evaluate the feasibility of caregiver-initiated computerized screening in a pediatric emergency department (ED) to identify home safety risks, with a specific emphasis on intimate partner violence (IPV).

METHODS

Home safety screening kiosks were developed using information technology as the first step in a plan to decrease family violence. Caregivers self-initiated a standard-of-care screening process that included both non-IPV and IPV items. An ED social worker received an automated text page and printed summary of the findings when a caregiver endorsed IPV. System activity was tracked by comparing frequency of completed screens to the daily ED census and by determining the percentage of completed screens that were positive for IPV. The reliability of the technology was evaluated as percentage of days of system downtime. Meetings with ED personnel and direct observations of families were conducted to identify potential barriers and successes to the technology utilization.

RESULTS

During a 15-month period, 13,057 computerized screens occurred, with a 4-fold increase in the computerized screening rate after ED triage nurses became champions of these efforts. Fourteen percent of the computerized screens were positive for IPV. The reliability of the technology was considered quite high, with rare system downtime (4.2% of days) reported during the 15 months. There were several themes identified by caregivers and providers regarding barriers to successful use of the safety screening.

CONCLUSIONS

A reliable, caregiver-initiated system is possible to offer consistent opportunity to conduct unobtrusive, private screening for IPV and other home safety concerns.

Emergency department reliance: a discriminatory measure of frequent emergency department users

OBJECTIVE

High emergency department (ED) use has previously been defined as a person's having a large number of ED visits, implying that all frequent users are the same. ED reliance (EDR), the percentage of all health care visits that occur in the ED, considers ED use in relation to primary care use and, thus, may discriminate among high-ED-user populations. Our objective was to determine whether EDR, as a complementary use measure, could differentiate frequent users secondary to increased need for care from those with access issues.

METHODS

We conducted an analysis of prospectively collected data from the Medical Expenditure Panel Survey from 2000-2001 and 2001-2002. Frequent ED users were defined as having >or=2 ED visits, and EDR was dichotomized as high (>0.33) or low (<or=0.33). Odds of being a frequent user or having high EDR were analyzed by using logistic regression.

RESULTS

A total of 8823 children were included. Within frequent-ED-use populations, young children and children with special health care needs were less likely (odds ratio: 0.55 and 0.72, respectively) to have high EDR, whereas those with lower education, low income, and public insurance and those of black race were more likely to have high EDR.

CONCLUSIONS

EDR is a readily available measure in large administrative databases that discriminates among frequent-user populations, differentiating increased need for ED services from lack of access to quality primary care.

Revisiting predictors of parental health care-seeking behaviors for nonurgent conditions at one inner-city hospital

INTRODUCTION

To determine important predictors of why parents seek care for their children at a pediatric emergency department (ED) compared to their child's primary care provider's (PCP's) walk-in clinic.

DESIGN

Cross-sectional study.

SETTING

An inner-city hospital located in New York City, from April 2003 to January 2004.

PARTICIPANTS

A convenience sample of 170 parents with children younger than 18 years, Medicaid beneficiaries, had a PCP, and presented with a nonurgent medical problem either at the pediatric ED or walk-in clinic.

MAIN OUTCOME MEASURE

The main outcome measure was the setting in which parents sought care for their child; odds ratios (ORs) were calculated for parents seeking care in the pediatric ED compared to those seeking care at the walk-in clinic, adjusting for predisposing, enabling, and need-related factors.

RESULTS

Of the 170 parent-child visits, 87 (51%) were seeking care at the ED and 83 (49%) at their child's walk-in clinic. In logistic regression, single parenting was the strongest predictor for seeking care in the ED (OR, 5.54; 95% confidence interval [CI], 1.4-26.9), followed by Hispanic ethnicity (OR, 4.96; 95% CI, 1.43-17.2), low parental perceptions of their child's physical health (OR, 0.90; 95% CI, 0.82-0.99), controlling for number of chronic conditions, parental working status, and satisfaction with their PCP.

CONCLUSIONS

Single parenting, Hispanic ethnicity, and perceptions of health are associated with health care-seeking behaviors in high cost settings among Medicaid beneficiaries. Targeted education programs could be used to influence future site of care.

Multimethod evaluation of health policy change: an application to Medicaid managed care in a rural state

OBJECTIVE

To answer questions about the impacts of Medicaid managed care (MMC) at the individual, organizational/community, and population levels of analysis.

DATA SOURCES/STUDY SETTING

Multimethod approach to study MMC in New Mexico, a rural state with challenging access barriers.

STUDY DESIGN

Individual level: surveys to assess barriers to care, access, utilization, and satisfaction. Organizational/community level: ethnography to determine changes experienced by safety net institutions and local communities. Population level: analysis of secondary databases to examine trends in preventable adverse sentinel events.

DATA COLLECTION/EXTRACTION METHODS

SURVEY

multivariate statistical methods, including factor analysis and logistic regression. Ethnography: iterative coding and triangulation to assess documents, field observations, and in-depth interviews. Secondary databases: plots of sentinel events over time.

PRINCIPAL FINDINGS

The survey component revealed no consistent changes after MMC, relatively favorable experiences for Medicaid patients, and persisting access barriers for the uninsured. In the ethnographic component, safety net institutions experienced increased workload and financial stress; mental health services declined sharply. Immunization rate, as an important sentinel event, deteriorated.

CONCLUSIONS

MMC exerted greater effects on safety net providers than on individuals and did not address problems of the uninsured. A multimethod approach can facilitate evaluation of change in health policy.

Effects of insurance status on children's access to specialty care: a systematic review of the literature

Background

The current climate of rising health care costs has led many health insurance programs to limit benefits, which may be problematic for children needing specialty care. Findings from pediatric primary care may not transfer to pediatric specialty care because pediatric specialists are often located in academic medical centers where institutional rules determine accepted insurance. Furthermore, coverage for pediatric specialty care may vary more widely due to systematic differences in inclusion on preferred provider lists, lack of availability in staff model HMOs, and requirements for referral. Our objective was to review the literature on the effects of insurance status on children's access to specialty care.

Methods

We conducted a systematic review of original research published between January 1, 1992 and July 31, 2006. Searches were performed using Pubmed.

Results

Of 30 articles identified, the majority use number of specialty visits or referrals to measure access. Uninsured children have poorer access to specialty care than insured children. Children with public coverage have better access to specialty care than uninsured children, but poorer access compared to privately insured children. Findings on the effects of managed care are mixed.

Conclusion

Insurance coverage is clearly an important factor in children's access to specialty care. However, we cannot determine the structure of insurance that leads to the best use of appropriate, quality care by children. Research about specific characteristics of health plans and effects on health outcomes is needed to determine a structure of insurance coverage that provides optimal access to specialty care for children.

Racial and ethnic differences in receipt of primary care services between medicaid fee-for-service and managed care plans

We used a cross-sectional, population-based sample of Medicaid beneficiaries aged 18-64 to determine whether managed care enrollment was associated with reduced racial/ethnic disparities in self-reported access to primary care services compared with fee-for-service. Managed care beneficiaries reported greater access in each racial/ethnic category and for each outcome than did fee-for-service beneficiaries, although associations were not always statistically significant. Racial/ethnic minorities enrolled in managed care plans reported as much benefit from managed care enrollment as did whites. Within Medicaid, interventions aimed at the health insurance delivery model can facilitate increased access to primary care services without enhancing racial/ethnic disparities.

Methods of categorizing emergency department visit urgency: a survey of pediatric emergency medicine physicians

OBJECTIVE

Between 20% and 80% of emergency department (ED) visits are nonurgent. This variability in estimates is partially due to the multiple classification methods used, none of which has undergone validity or reliability testing. Our objectives were to determine the methods thought to be most valid and to understand expert perceptions of nonurgent ED utilization.

METHODS

A survey of the Pediatric Emergency Medicine (PEM) Special Interest Group at the 2005 Pediatric Academic Societies meeting was conducted. An education session with case-based discussion for categorizing ED visit urgency was presented. Six methods were reviewed: implicit criteria, explicit criteria, resource utilization, diagnoses, Current Procedural Terminology Codes, and nurse triage category. The primary outcome was the percentage of respondents ranking each method first or second best for categorizing urgency. Respondents also identified ED resources and presenting symptoms constituting an urgent visit.

RESULTS

Seventy-four percent of attendees completed the survey, most were Pediatric Emergency Medicine physicians. Implicit criteria were rated highest, with 65.1% ranking it first or second, followed by explicit criteria (53.8%). With limited data available, resource utilization ranked highest (68.6%), followed by nurse triage (61.2%). There was an agreement that certain presenting symptoms and resources were adequate for determining ED visit urgency; however, there was no agreement on whether x-rays, urinalyses, or fever in a child older than 3 months was sufficient to identify urgency.

CONCLUSIONS

Methods using complete medical record information are favored to determine ED visit urgency. Resource utilization and nurse triage are preferred when limited data are available. This survey will serve as the basis for endorsement of methodologically sound criteria for ED visit urgency.

Unscheduled revisits to a pediatric emergency department: risk factors for children with fever or infection-related complaints

OBJECTIVE

Unscheduled revisits (URVs) may serve as markers of quality of care and may be costly both in financial terms as well as in limitations they place on primary care. We performed this study to examine the association between characteristics easily obtainable during an emergency department (ED) visit and URV to identify a subpopulation of children who may warrant interventions to decrease URV.

METHODS

This is a case-control study of patients visiting an urban tertiary care pediatric ED for a fever or infectious disease-related complaint. Cases were defined as patients who had URVs that occurred within 72 hours of an initial ED visit. Control patients were selected by simple random sampling of an enumerated computerized list of all ED visits. Data on independent variables of interest were collected from a chart review and telephone interview with the patient's caregiver. Bivariate and multivariate analyses were performed to determine factors associated with URV.

RESULTS

Seventy-five percent of cases and controls participated in the study. Logistic regression analysis revealed 3 factors independently associated with URV for fever or infectious disease-related complaints in children. These included presence of chronic disease (adjusted odds ratio 1.75, 95% confidence interval 1.01-3.03), Medicaid insurance (adjusted odds ratio 1.86, 95% confidence interval 1.04-3.32) and acute triage category (adjusted odds ratio 1.83, 95% confidence interval 1.08-3.10).

CONCLUSIONS

These factors may be used to identify children in the ED at greater risk for URV and may point to a need for improved discharge instructions and enhanced communication with primary care and systems to arrange follow-up. Results of this work may also identify at-risk populations for future qualitative research or intervention studies on URV to EDs.

Patterns of health care use that may identify young children who are at risk for maltreatment

OBJECTIVES

Early identification of children who are at risk for maltreatment continues to pose a challenge to the medical community. The objective of this study was to determine whether children who are at risk for maltreatment have characteristic patterns of health care use before their diagnosis of abuse or neglect that distinguish them from other children.

METHODS

We performed a case-control study among Medicaid-enrolled children to compare patterns of health service among maltreated children in the year before a first report for abuse or neglect that led to an immediate placement into foster care, with patterns of health service use among matched control subjects. Exposure variables, obtained from Medicaid claims, included the total number of non-emergency department (ED) outpatient visits, the total number of ED visits, the frequency of injury-related diagnoses, the frequency of nonspecific diagnoses that have been previously linked to abuse, and the number of changes in a child's primary care provider. Multivariate models were performed adjusting for cash assistance eligibility, race, and child comorbidities.

RESULTS

We characterized the health service use patterns, during the year before their first maltreatment report, of 157 children with serious and substantiated abuse or neglect. Health service use during the same period was also characterized among 628 control subjects who were matched by age, gender, and number of months of Medicaid eligibility. Sixteen percent of cases changed their primary care providers, compared with 10% of the control subjects. Multivariable modeling demonstrated that maltreated children were 2.62 (95% confidence interval: 1.40-4.91) times more likely than control subjects to have had 1 previous change in primary care provider and 6.87 (95% confidence interval: 1.96-24.16) times more likely to have changed providers 2 or more times during the year before their first maltreatment report. There were no differences between case patients and control subjects in the frequency of ED visits and rates of diagnoses of injury or nonspecific somatic complaints.

CONCLUSIONS

Victims of serious and substantiated physical abuse and neglect change ambulatory care providers with greater frequency than nonabused children. Recognition of this patient characteristic may allow for earlier identification of children who are at risk for additional or future maltreatment.

Decreased attendance at cystic fibrosis centers by children covered by managed care insurance

OBJECTIVE

The evolution of managed care has raised concerns about differential access to care for children with cystic fibrosis (CF). We tested the hypothesis that children with CF with managed care attended CF centers less frequently compared with children with non-managed care.

METHODS

We conducted a prospective cohort study by telephone every 4 months to measure access to care at CF centers among 630 randomly selected patients aged 6-18 years from 15 US CF centers. We analyzed data with unconditional logistic regression and generalized estimating equations.

RESULTS

Attendance at CF centers was significantly reduced among children with managed care (odds ratio [OR] = 0.74; 95% confidence interval [CI] = 0.57, 0.98; P=0.03) and among girls (OR=0.68; 95% CI=0.48, 0.97; P=0.04).

CONCLUSIONS

Children with CF with managed care attended CF centers significantly less frequently than those with non-managed care. These findings suggest that children with CF with managed care may not have equal access to experts in CF as children with non-managed care. Families should consider this when selecting their medical insurance plan. These findings may apply to other children with special health care needs.

Nonemergent emergency room utilization for an inner-city pediatric population

OBJECTIVE

To identify patient reasons for accessing an urban Pediatric Emergency Room (PER) for primary care and to explore attitudes and practice regarding alternative sources for their medical home.

METHODS

A total of 210 questionnaires, consisting of 24 questions each, were completed in a face-to-face interview performed by trained interviewers. Questions asked included sources of medical care, frequency of use, and factors that went into caregiver decisions for using different sources of care.

RESULTS

Caregivers choose the PER because of the short amount of time it takes for their child to be seen and discharged by a physician. Nearly 60% ranked wait time to see a doctor more important than seeing the same doctor every time (37.6%). About one-third of caregivers routinely brought their children to the PER for illness that is not serious. Only 77% of caregivers claimed that their children have a regular doctor. Many caregivers cited that they are seen more by their regular doctor for shots (well visits) than for ill visits and are seen in the PER for illness. In this study, 56% of children did not see the same regular doctor as their siblings.

CONCLUSIONS

Efficiency and speed of health care delivery is of prime importance to this primarily Medicaid urban population. If strategies are to be implemented to attract these patients to a medical home that will strengthen their ties to their regular doctor, then the needs prioritized by the caregiver must be taken into consideration.

Epidemiology of pediatric emergency department use at an urban medical center

OBJECTIVES

Dramatic increases in emergency department (ED) use contribute to rising healthcare costs and decrease continuity of care in the United States. Yet little is known about the acuity, frequency of visits, and demographic characteristics of children using the ED. This study examines general demographic trends over a 3-year period and examines whether there are factors associated with varying acuity at an urban academic pediatric ED.

METHODS

Analysis of administrative ED records from fiscal years (FY) 1999 to 2001 for children 0 to 18 years was performed to assess demographic characteristics, periodicity of ED use, and acuity level.

RESULTS

Patient demographic characteristics, periodicity, and acuity were comparable for ED visits across each study year with approximately 25,000 annual visits. Among ED users in FY 2001, 42% sought urgent care exclusively, 12% received both urgent and nonurgent care, and 46% used the ED solely for nonurgent care. Of those with only nonurgent visits, 80% had 1 visit. In FY 2001, ED use was predominantly among patients who were black (77.3%) and were 1 to 4 years of age (35.4%). Relative to all patients, a greater percentage of those who used the ED exclusively for nonurgent care were black (87.2% vs. 76.0%, P < 0.05) and lived within 2 miles of the hospital (45.2% vs. 37.4%, P < 0.05).

CONCLUSIONS

Nearly half of pediatric emergency visits are for nonurgent care. Racial disparities in use of the ED for nonurgent care may be related to patient's proximity to the hospital. Patterns of use are stable across the 3 years. Further study is needed to identify mutable factors in emergency care use.

Emergency department use and perceived delay in accessing illness care among children with Medicaid

BACKGROUND

Children covered by Medicaid are at increased risk of emergency department (ED) utilization.Objective.-To examine whether an association exists between ED use and perceived delay in accessing acute care.

DESIGN AND SETTING

Cross-sectional study. We used data from the Consumer Assessment of Health Plans Survey collected by Washington State Medicaid in 2000. We used multivariate logistic regression to determine the odds of any ED use, using a model that included whether the parent reported not always receiving illness care for the child as soon as wanted (perceived delay), age, gender, race/ethnicity, health status, presence of a special health care need, primary language, needing an interpreter, parental education, and having a regular provider.

SUBJECTS

Parents of a random sample of children from 9 Medicaid managed care plans were surveyed if their children were <15 years old and enrolled at least 6 months.

MAIN OUTCOME MEASURES

Any ED use in the past 6 months.

RESULTS

The response rate was 56.3%, yielding 5142 subjects. Of children with illnesses in the previous 6 months, 69.1% of parents reported that their child always received care as soon as they wanted; 19.9%, 8.2%, and 2.8% reported usually, sometimes, and never, respectively. Not always (vs always) receiving illness care as soon as wanted was significantly associated with increased odds of any ED use (adjusted odds ratio: 1.79; 95% confidence interval: 1.35- 2.36).

CONCLUSION

Children with managed care Medicaid are more likely to use the ED if parents perceive any delay in receiving illness care.

Placement changes and emergency department visits in the first year of foster care

OBJECTIVES

Despite great needs, many children in foster care do not receive adequate medical care. Suboptimal care may be attributable in part to placement changes, which disrupt continuity of care by both a consistent surrogate parent and potentially a primary care physician. These disruptions in turn may lead to increased use of the emergency department (ED) for outpatient care. The primary aim of this study was to test whether a greater rate of placement changes was associated with increasing use of the ED among children in their first year of foster care. The secondary aim was to compare ED visit rates with rates of visits to other ambulatory care settings among children in foster care and other Medicaid-eligible children not in foster care.

METHODS

Using Medicaid claims linked to foster care administrative data, we assembled a retrospective cohort of foster children in a large urban municipality from 1993 to 1996. Eligible children spent at least 9 months in a new episode of foster care and were continuously eligible for Medicaid during a 1-year follow-up period. A comparison cohort was drawn from Medicaid-eligible children not in foster care during fiscal year 1995. The dependent variable was the rate of visits to the ED or other ambulatory care settings during a 1-year follow-up period. A negative binomial model estimated visit rates to the ED and other ambulatory care settings as the number of foster care placements increased. Potential interactions were considered between age and location of service use (ED or ambulatory care setting), between age and foster care placements, and between location of service use and number of foster care placements.

RESULTS

The 2358 children in the sample accounted for 1206 ED visits during the follow-up period; 38% experienced >or=2 placement changes. Children of all ages exhibited increasing reliance on the ED for ambulatory care services as the number of placements increased, with the rates of ED use more than doubling for all age groups beyond infancy. However, other ambulatory care service use increased by only 41% to 53%; there was much less utilization in these nonemergency settings for all children but particularly toddlers and infants, compared with their Medicaid-eligible peers. Although the absolute rates of all visits for younger foster children (<6 years of age) were low, older foster children had increasingly greater ED use than did their Medicaid-eligible peers, with nearly double the rate of ED visits in the adolescent age group. A temporal relationship between placements and ED visits was also identified; 75% of ED visits occurring within 3 weeks of a placement change occurred in the period after a placement change.

CONCLUSIONS

Foster children received fewer overall outpatient services than did their Medicaid-eligible peers, but with age and increasing numbers of placements, had higher visit rates and received a greater proportion of their overall outpatient care in the ED. These results suggest that poor access to nonemergent ambulatory care settings might have contributed to an increasing reliance on ED settings as foster care placements increased. The temporal relationship between ED visits and placement changes underscores the need for better health care management for foster children, particularly in the period after placement changes.

Placement stability and mental health costs for children in foster care

OBJECTIVE

Although prior population-based studies have found that children in foster care use more mental health services than their Medicaid peers, less is known about how different experiences in foster care impact the likelihood of mental health service use. The primary aim of this study is to test the hypothesis that instability of foster care placements is associated with higher costs for mental health care services. The secondary aim is to test the hypothesis that foster care children are also more likely to generate high costs for mental health services if they generate higher costs for non-mental health claims.

METHODS

Using administrative child welfare data linked to Medicaid claims, we assembled a unique retrospective cohort of adjudicated dependent children >2 years old who entered foster care between July 1993 and June 1995, spent at least 9 months in care, and were Medicaid eligible during a 1-year follow-up period. The primary outcome was high mental health service use, defined as having costs in the top decile of the sample. The primary independent variables were the number of foster care placements during the year and whether placements were interrupted by a return home for at least 1 month during that year (episodic foster care). We used logistic regression to estimate the association between placements and service utilization, with adjustment for age and physical health care costs.

RESULTS

Of the 1635 children in the study, 41% had > or = 3 foster care placements, and 5% had episodic foster care during the year of observation. The top 10% of mental health service users accounted for 83% of the 2.4 million dollars in mental health costs. Both multiple placements and episodic foster care increased the predicted probability of high mental health service use. Higher physical health care costs also increased the probability of high mental health use for all children, but this increased probability was most dramatic among children with episodic foster care (probability of high mental health use: 0.78; 95% confidence interval: 0.42-0.94).

CONCLUSIONS

Foster care placement instability was associated with increased mental health costs during the first year in foster care, particularly among children with increasing general health care costs. These findings highlight the importance of interventions that address the global health of children in foster care and may permit better targeting of health care resources to subgroups of children most likely to use services.

Association between infant continuity of care and pediatric emergency department utilization

OBJECTIVE

The objective of this study was to examine the association between continuity of care (COC) and emergency department (ED) utilization during infancy, when the bonds between a provider and a family are first forming and health care utilization is at it highest levels.

METHODS

A retrospective birth cohort was conducted of children who were born between December 1, 1999, and April 30, 2000; health care use during the first 25 months of life was analyzed. A COC score was calculated from well-child visits in the first 7 months of life. Subsequent ED utilization, for both a 12-month and an 18-month period, was evaluated through 2 measures: 1) ED reliance (the fraction of all visits that occurred in the ED) and 2) number of ED visits. Spearman rank correlation coefficients (r(s)) between COC and ED utilization were calculated. Partial rank correlations were calculated controlling for Medicaid status, income, gender, and the total number of health care visits.

RESULTS

A total of 181 children were included in the study; 96 (53%) were male, and 48 (27%) were covered by Medicaid. COC scores ranged from 0 to 1, with a median of 1. COC scores were negatively correlated with both ED reliance (r(s) = -.214) and number of ED visits (r(s) = -.215) with 12 months of follow-up. The negative correlation was even stronger at 18 months of follow-up (ED reliance: r(s) = -.247; number of ED visits: r(s) = -.242), and this relationship remained significant with partial rank correlations.

CONCLUSIONS

Improved COC in infancy is associated with a decrease in subsequent ED utilization. Interventions aimed at increasing the continuity of early well-child visits may decrease ED utilization.

Return visits to a pediatric emergency department

OBJECTIVES

To determine the incidence of return visits (RVs), types of RVs, and factors associated with RVs to a pediatric emergency department (ED).

METHODS

: Retrospective cohort study of patients seen in an urban, tertiary care pediatric ED.

MAIN OUTCOME

RV within 48 hours, identified from a computerized log.

RESULTS

The total RV rate was 3.5% (95% confidence interval, 3.3-3.6), similar to rates (2.4% to 3.4%) reported in general EDs. Most (78.5%) RVs were unscheduled, 17% were scheduled, and 4% were called back to the ED. Infectious disease (45%), respiratory (16%), and trauma (16%) accounted for most RV diagnoses. When compared with the overall ED population, RV patients were more likely to be younger than 2 years [relative risk, 1.3 (1.2-1.4)], to be admitted to the hospital [relative risk, 1.3 (1.2-1.5)], and to be triaged as acute [relative risk, 1.1 (1.0-1.2)]. Patients called back to the ED were younger, more likely to be triaged as acute, and more likely to be admitted than other RV patients. Significant diagnoses were made at RV in 7 (0.4%; 95% confidence interval, 0.1-0.7) patients, half of whom were called back to the ED or had a scheduled RV.

CONCLUSION

Similarities between our pediatric ED RV rate and other published research implies that benchmarking and quality improvement tools for RV can be used and compared in both pediatric and general EDs. Focusing on systems to call patients back to the ED when necessary may be an efficient way to reduce medical error and adverse patient outcomes.

The effects of access to pediatric care and insurance coverage on emergency department utilization

OBJECTIVE

To compare children who used the emergency department (ED) in a rural, border community with those who did not over a 1-year period to estimate the effects of access to pediatric care, insurance coverage, ethnicity, gender, age, and area of residence on ED utilization.

DESIGN

Multivariate logit models are used to estimate the independent influence of demographic characteristics, insurance coverage, and access to pediatric care on ED utilization during 1999 by children 0 to 19 years of age.

RESULTS

Controlling for age, gender, ethnicity, and area of residence, children who received care from a private practice pediatric group were 73% less likely to utilize the ED if insured and 93% less likely if uninsured to use the ED than children who had not visited a pediatrician. Uninsured children were nearly 4 times more likely to use the ED than insured children. Among insured children, those covered by Medicaid were 54% less likely to use the ED than children with private insurance. Compared with white, non-Hispanic children, Asian or Hispanic children were no more likely to use the ED. Insured Native American children were more than twice as likely as white, non-Hispanic children to utilize the ED.

CONCLUSIONS

Access to pediatric care is associated with a marked decrease in ED utilization regardless of insurance status. This decrease in ED utilization is especially large for uninsured children.