Utilization of medical and health-related services among school-age children and adolescents with special health care needs (1994 National Health Interview Survey on Disability [NHIS-D] Baseline Data)

Toward an emerging model of healthcare access: A theoretical framework

AIM

To conceptualize an emerging framework of healthcare access for foreign-born persons based on well-known access models in the United States.

BACKGROUND

The COVID-19 outbreak significantly impacted all global communities, disproportionately affecting people of color and highlighting preexisting health disparities. Health and immigration policies concerning healthcare access for foreign-born people were examined. Regarding access to social benefits in the United States, the Affordable Care Act underscored initial restrictions imposed by the Deficit Reduction Act of 2005 and the Personal Responsibility and Work Opportunity Reconciliation Act in 1996 on certain underserved groups.

METHODS

Guided by the study's aim, electronic databases, including Scopus, PubMed, Web of Science, and CINAHL, were queried for relevant nursing-related literature published on Penchansky's and Andersen's models from 1968 to 2022. Compared with Penchansky's model, Andersen's model outcome measures have evolved over the years in response to dynamic health policy issues.

RESULTS

Penchansky's model has five constructs in its original form, whereas Andersen's model has three. The current study shows that each existing access model provides a unique method for evaluating various policies. In some cases, the studies are limited to a simple application of the original model with few modifications in studies specific to foreign-born groups in the United States.

DISCUSSION

There is a dearth of systematic theorization of access that incorporates social justice and health equity. Health disparities were further explained using metrics from existing access models.

CONCLUSIONS

An emerging access model conceptualizing existing access models was proposed, using constructs framed within the basic tenets of health equity and social justice.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

Applying the emerging model's constructs to future studies is anticipated to highlight opportunities for stakeholders such as policymakers, healthcare providers, nursing professionals, and community leaders to support programs that could further reduce health disparities.

Association between Adverse Childhood Experiences and Unmet Health Care Needs among Children in the United States

Although studies have investigated and found an association between adverse childhood experiences and poor health and mental health outcomes, there is a dearth of studies investigating the association between adverse childhood experiences and unmet health care needs among children. The objective of this study is to examine the association between adverse childhood experiences and unmet health care needs after adjusting for predisposing, enabling, and need factors of health care service utilization. Data for this study came from the 2016-2017 National Survey of Children's Health. An analytic sample of 46,081 children (51.3% males; average age 11.5 years) was analyzed using negative binomial regression. Based on parent reports, about 3.5% of children had unmet health care needs, and half (50%) of the sample had experienced at least one childhood adversity. Controlling for other factors, children who experienced three or more childhood adversities had 4.51 times higher odds of having unmet health care needs (AOR = 4.51, p < .001, 95% CI = 3.15-6.45) when compared to their counterparts with no childhood adversity. Children with parents who have someone to turn to for everyday emotional support were 31% less likely to have unmet health care needs (AOR = .69, p < .01, 95% CI = .54-.89). Adverse childhood experiences have a detrimental effect on unmet health care needs. The findings of this study offer an important opportunity for further research on how best to prevent adverse childhood experiences and mitigate their impact on families.

Comparing two definitions of pediatric complexity among children cared for in general and pediatric emergency departments in a statewide sample

Objective

The number of children cared for in emergency departments (EDs) with medical complexity continues to rise. We sought to identify the concordance between 2 commonly used criteria of medical complexity among children presenting to a statewide sample of EDs.

Methods

We conducted a retrospective cross-sectional study of children presenting to a statewide sample of Illinois EDs between 2016 and 2021. We classified patients as having medical complexity when using 2 definitions (≥1 pediatric Complex Chronic Condition [CCC] or complex chronic disease using the Pediatric Medical Complexity Algorithm [PMCA]) and compared their overlap and clinical outcomes.

Results

Of 6,550,296 pediatric ED encounters, CCC criteria and PMCA criteria were met in 217,609 (3.3%) and 175,708 (2.7%) encounters, respectively. Among patients with complexity, 100,015 (34.1%) met both criteria, with moderate agreement (κ = 0.49). Children with complexity by CCC had similar rates of presentation to a pediatric hospital (16.3% vs 14.8%), admission (28.5% vs 33.7%), ICU stay (10.0% vs 10.1%), and in-hospital mortality (0.5% vs 0.5%) compared to children with complexity by PMCA. The most common visit diagnoses for children with CCCs were related to sickle cell disease with crisis (3.9%), abdominal pain (3.6%), and non-specific chest pain (2.7%). The most common diagnoses by PMCA were related to depressive disorders (4.9%), sickle cell disease with crisis (4.8%), and seizures (3.2%).

Conclusions and Relevance

The CCC and PMCA criteria of multisystem complexity identified different populations, with moderate agreement. Careful selection of operational definitions is required for proper application and interpretation in clinical and health services research.

Understanding Unmet Care Needs of Rural Older Adults with Chronic Health Conditions: A Qualitative Study

BACKGROUND

Rural populations experience poorer access to the necessary health services for chronic health conditions. Although studies of rural healthcare access continue to expand, most are based on quantitative data, yet normative views and lived experiences of rural adults might offer a better understanding of healthcare access and their specific unmet needs. This qualitative study sought the views of both rural-centric older people and healthcare professionals to understand health needs, barriers, and enablers of accessing health services, with a focus on chronic health condition(s).

METHODS

Between April and July 2022, separate in-depth interviews were conducted with 20 older people (≥60 years) in a rural South Australian community. Additionally, focus group interviews were conducted with 15 healthcare professionals involved in providing health services to older adults. Transcripts were coded using the NVivo software and data were thematically analysed.

RESULTS

Participants described a range of unmet care needs including chronic disease management, specialist care, psychological distress, and the need for formal care services. Four barriers to meeting care needs were identified: Workforce shortages, a lack of continuity of care, self-transportation, and long waiting times for appointments. Self-efficacy, social support, and positive provider attitudes emerged as crucial enabling factors of service use among rural ageing populations.

DISCUSSION

Older adults confront four broad ranges of unmet needs: Chronic disease management care, specialist care, psychological care, and formal care. There are potential facilitators, such as self-efficacy, provider positive attitudes, and social support, that could be leveraged to improve healthcare services access for older adults.

The role of executive functioning, healthcare management, and self-efficacy in college students' health-related quality of life

Objective: Examine how executive functioning (EF), healthcare management, and self-efficacy relate to college students' health-related quality of life (HRQOL). Participants: Undergraduates completed questionnaires at baseline (Time 1; n = 387) and 18-24 months later (Time 2; n = 102). Methods: Participants reported on their EF and healthcare management skills at Time 1 and self-efficacy and mental and physical HRQOL at Time 2. Results: Students with fewer EF problems reported higher mental and physical HRQOL at both timepoints and those with higher healthcare management skills had higher mental and physical HRQOL at Time 1. Higher self-efficacy mediated the relation between EF and mental HRQOL, and the relation between healthcare management and mental HRQOL. Conclusions: Findings illustrate two potential pathways by which self-management, in healthcare settings or daily living, contributes to mental HRQOL during emerging adulthood. Assessing EF and healthcare management could help identify those at risk of low HRQOL and provide information that can inform interventions in college settings.

The role of executive functioning in health self-management and the transition to adult health care among college students

ObjectiveTo examine the role of executive functioning (EF) in health self-management and the transition to adult health care among college students. Participants: A total of 378 undergraduate students from a public university participated in the study. Methods: Participants reported on EF, health self-management skills, and their readiness to transition to adult care. Mediation analyses were conducted to evaluate indirect effects of EF on readiness to transition via health self-management skills. Results: Students with greater EF difficulties were less ready to transition to adult care. Specific aspects of health self-management (Medication management/Appointment keeping) mediated the relationship between EF and readiness to transition. Conclusion: EF is a key developmental aspect of health self-management and transition readiness. Assessing EF strengths/weaknesses in students with suboptimal health self-management skills may provide valuable information for informing the development of individually-tailored transition plans in university health centers, thereby enhancing developmentally appropriate care during the college years.

Children With Special Health Care Needs: How Special Are Their Health Care Needs?

OBJECTIVE

To assess use and needs for general practitioner, specialist, emergency department, hospital inpatient, and hospital outpatient services for children with special health care needs (CSHCN). To assess the level of CSHCN's needs compared with other children.

METHODS

Health service use and needs for children aged 4 to 15 years were assessed using the nationally representative Longitudinal Study of Australian Children survey with 25,011 observations. Odds ratios of service use and unmet needs for CSHCN compared to other children were estimated. CSHCN were further grouped as those 1) needing only additional medication, 2) needing only additional medical care, or 3) needing both as defined by the CSHCN screener questions.

RESULTS

The prevalence of those meeting criteria for CSHCN was 16.1%. In the past 12 months, 77.7% of CSHCN used any general practitioner care and 46.4%, 21.7%, 12.4%, and 15.0%, respectively, used specialty care, emergency department, hospital inpatient, and outpatient services. Approximately half of CSHCN were identified as having special needs due to needing additional medication. Their service use and unmet needs are only slightly elevated. Another group of CSHCN who need both more medication and medical care comprises less than one third of all CSHCN. These children have the highest odds of using specialty care (odds ratio 12.3, P < .001), and of having unmet specialty care need (odds ratio 7.4, P < .001) compared to children without special needs.

CONCLUSIONS

Our findings highlight the importance of ensuring specialty care for CSHCN, especially the one third with most elevated needs. This estimate might guide future care planning.

Health Behaviors, Physical Health, and Health Care Utilization in Children With ADHD

Objective: To compare health behaviors, physical health outcomes, and health care utilization between children with and without ADHD. Method: In this cross-sectional study, we obtained data for children with and without ADHD from the Korean National Health and Nutrition Examination Survey. To investigate the association between ADHD and health outcomes, we estimated the adjusted prevalence ratios (APRs) in these groups. Results: Among 10,838 children aged 7 to 18 years with and without ADHD, those with ADHD had significantly higher APRs for overall health problems, physical illness, and injuries than those without ADHD. Despite having health care needs, children with ADHD were less likely than those without ADHD to use health care services. However, there were no significant associations between most health behaviors and ADHD. Conclusion: Increased efforts are needed to provide quality health care services to address the medical conditions of children with ADHD and to enhance their health care utilization when needed.

Outpatient healthcare access and utilization for neonatal abstinence syndrome children: A systematic review

OBJECTIVE

The objective of this study was to systematically assess the literature regarding postnatal healthcare utilization and barriers/facilitators of healthcare in neonatal abstinence syndrome (NAS) children.

METHODS

A systematic search was performed in PubMed, Cochrane Database of Systematic Reviews, PsychINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Web of Science to identify peer-reviewed research. Eligible studies were peer-reviewed articles reporting on broad aspects of primary and specialty healthcare utilization and access in NAS children. Three investigators independently reviewed all articles and extracted data. Study bias was assessed using the Newcastle-Ottawa Assessment Scale and the National Institute of Health Study Quality Assessment Tool.

RESULTS

This review identified 14 articles that met criteria. NAS children have poorer outpatient appointment adherence and have a higher rate of being lost to follow-up. These children have overall poorer health indicated by a significantly higher risk of ER visits, hospital readmission, and early childhood mortality compared with non-NAS infants. Intensive multidisciplinary support provided through outpatient weaning programs facilitates healthcare utilization and could serve as a model that could be applied to other healthcare fields to improve the health among this population.

CONCLUSIONS

This review investigated the difficulties in accessing outpatient care as well as the utilization of such care for NAS infants. NAS infants tend to have decreased access to and utilization of outpatient healthcare following hospital birth discharge. Outpatient weaning programs have proven to be effective; however, these programs require intensive resources and care coordination that has yet to be implemented into other healthcare areas for NAS children.

Prevalence of Brain Injuries among Children with Special Healthcare Needs

OBJECTIVES

To investigate differences in brain injury prevalence among US children by special healthcare needs status, accounting for sociodemographic and family characteristics, and to examine correlated health conditions among children with special healthcare needs (CSHCN).

STUDY DESIGN

We conducted cross-sectional analyses using parent/caregiver responses to the 2016 National Survey of Children's Health (n = 50 212 children). CSHCN status was based on responses to a 5-item tool designed to identify children through assessment of functional limitations, prescription medication use, elevated service use or need, use of specialized therapies, and ongoing emotional, developmental, or behavioral conditions. Brain injury history was reported by parents/caregivers based on healthcare provider diagnosis. Bivariate and multivariable analyses were conducted.

RESULTS

Lifetime history of brain injury was significantly higher among CSHCN than non-CSHCN (6.7% vs 2.3%, P < .001). CSHCN make up 19% of the total US child population but comprise 42% of children with lifetime brain injuries. In addition, the prevalence of a number of comorbid conditions and functional limitations was significantly higher among CSHCN with lifetime brain injury vs those without brain injury.

CONCLUSIONS

The prevalence of lifetime history of brain injury is nearly 3 times greater among CSHCN than among non-CSHCN. Several comorbid conditions among CSHCN are significantly associated with lifetime history of brain injury. Further studies are needed to examine the extent to which brain injury in CSHCN may exacerbate or be misdiagnosed as other comorbid conditions.

Different Demands, Same Goal: Promoting Transition Readiness in Adolescents and Young Adults With and Without Medical Conditions

PURPOSE

This study aimed to examine differences in transition readiness, self-involvement and parental involvement in completing medical tasks, and general self-efficacy between a sample of older adolescents and young adults (AYAs) with medical conditions and a sample of healthy peers. Relations among these variables were also examined.

METHODS

The sample included 494 AYAs (mean age = 19.30 years, standard deviation = 1.33) who reported on their levels of transition readiness, self-involvement and parental involvement in completing medical tasks, and general self-efficacy.

RESULTS

AYAs with medical conditions reported significantly higher levels of transition readiness and self-involvement in completing medical tasks and lower levels of parent involvement in completing medical tasks than healthy peers. Parent involvement in completing medical tasks indirectly related to transition readiness through AYA self-involvement in completing medical tasks for both AYAs with medical conditions and healthy peers.

CONCLUSIONS

AYAs with medical conditions appear to have greater transition readiness skills and demonstrate more independence in completing medical tasks than healthy peers. For AYAs with medical conditions and healthy peers, transition readiness appears to be enhanced as parents decrease their involvement in completing AYAs' medical tasks and AYAs increase self-involvement in completing these tasks. AYAs with medical conditions, as well as healthy peers, may benefit from programming delivered in primary care, specialty clinic, or educational settings that focuses on increasing AYAs' involvement in and responsibility for managing their health care.

Healthcare service use and costs for autism spectrum disorder: a comparison between medicaid and private insurance

Healthcare costs and service use for autism spectrum disorder (ASD) were compared between Medicaid and private insurance, using 2003 insurance claims data in 24 states. In terms of costs and service use per child with ASD, Medicaid had higher total healthcare costs ($22,653 vs. $5,254), higher ASD-specific costs ($7,438 vs. $928), higher psychotropic medication costs($1,468 vs. $875), more speech therapy visits (13.0 vs. 3.6 visits), more occupational/physical therapy visits (6.4 vs. 0.9 visits), and more behavior modification/social skills visits (3.8 vs. 1.1 visits) than private insurance (all p < 0.0001). In multivariate analysis, being enrolled in Medicaid had the largest effect on costs, after controlling for other variables. The findings emphasize the need for continued efforts to improve private insurance coverage of autism.

The potential for technology to enhance independence for those aging with a disability

Technologies of all kinds can sustain and accelerate improvements in health and quality of life for an aging population, and enhance the independence of persons with disabilities. Assistive technologies are widely used to promote independent functioning, but the aging of users and their devices produces unique challenges to individuals, their families, and the health care system. The emergence of new "smart" technologies that integrate information technology with assistive technologies has opened a portal to the development of increasingly powerful, individualized tools to assist individuals with disabilities to meet their needs. Yet, issues of access and usability remain to be solved for their usefulness to be fully realized. New cohorts aging with disabilities will have more resources and more experience with integrated technologies than current elders. Attention to technological solutions that help them adapt to the challenges of later life is needed to improve quality of life for those living long lives with disabilities.

Do unmet needs differ geographically for children with special health care needs?

The purpose of this study was to identify geographic differences in health indicators for children with special health care needs (CSHCN). It was hypothesized that geographic differences in unmet health care needs exist among CSHCN by region in the United States. Data were obtained from the National Survey of Children with Special Health Care Needs, 2005-2006. Nine variables representing unmet needs were analyzed by geographic region. The region with the highest percent of unmet needs was identified for each service. Logistic regression was utilized to determine differences by region after controlling for age, gender, ethnicity, race, federal poverty level, relationship of responder to child, insurance status, severity of condition, and size of household. A total of 40,723 CSHCN were represented. Crude analysis demonstrated that the greatest unmet need for routine preventive care, specialist care, prescription medications, physical/occupational/speech therapy, mental health care, and genetic counseling occurred in the West. The greatest unmet need for preventive dental care, respite care, and vision care occurred in the South. Significant differences between regions remained for six of the nine services after controlling for potential confounders. Geographic differences in unmet health care needs exist for CSHCN. Further delving into these differences provides valuable information for program and policy planning and development. Meeting the needs of CSHCN is important to reduce cost burden and improve quality of life for the affected child and care providers.

Healthcare utilization and expenditure analysis between individuals with intellectual disabilities and the general population in Taiwan: a population-based nationwide child and adolescent study

This study examines differences in outpatient-visit frequency and medical expenditures between (1) children and adolescents in Taiwan with intellectual disabilities and (2) children and adolescents in Taiwan's general population. A cross-sectional study was conducted to analyze data from 2007 provided by Taiwan's National Health Insurance program. A total of 236,045 beneficiaries younger than 19 years made use of outpatient services; among them, 35,802 had a principal diagnosis of mental retardation (intellectual disability). The average number of ambulatory visits was 14.9 ± 12.4, which is much higher than in the United States and other developed countries. The mean number of annual visits of the individuals with intellectual disabilities was significantly higher than that of the general population in Taiwan (20.1 ± 20.0 vs. 14.0 ± 12.2); age, gender, urbanization level of residential area, and copayment status affected outpatient visit frequency. The mean annual outpatient costs were NTD6371.3 ± NTD11989.1 for the general population and NTD19724.9 ± NTD40469.9 for those with intellectual disabilities (US $1 equals approximately NTD30). Age, gender, urbanization level of residential area, and copayment status were the determinants that accounted for this difference in cost. Children and adolescents with intellectual disabilities had higher use rates of rehabilitative and psychiatric services than the general population. We conclude that individuals with intellectual disabilities had higher demands than the general population for healthcare services, especially for rehabilitative and psychiatric services.

Medical home and pediatric primary care utilization among children with special health care needs

INTRODUCTION

The medical home model seeks to improve health care delivery by enhancing primary care. This study examined the relationship between the presence of a medical home and pediatric primary care office visits by children with special health care needs (CSHCN) using the data from 2005-2006 National Survey of Children with Special Healthcare Needs.

METHOD

Survey logistic regression was used to analyze the relationship.

RESULTS

When CSHCN age, gender, ethnicity/race, functional status, insurance status, household education, residence, and income were included in the model, CSHCN with a medical home were 1.6 times more likely to have six or more annual pediatric primary care office visits than were children without a medical home [odds ratio = 1.60, 95% confidence interval = (1.47, 1.75)]. Female CSHCN, younger CSHCN, children with public health insurance, children with severe functional limitations, and CSHCN living in rural areas also were more likely to have a larger number of visits.

DISCUSSION

By controlling for child sociodemographic characteristics, this study provides empirical evidence about how medical home availability affects primary care utilization by CSHCN.

Medical complexity and pediatric emergency department and inpatient utilization

OBJECTIVES

To characterize the use of and disposition from a tertiary pediatric emergency department (PED) by children with chronic conditions with varying degrees of medical complexity.

METHODS

We conducted a retrospective cohort study using a dataset of all registered PED patient visits at Seattle Children's Hospital from January 1, 2008, through December 31, 2009. Children's medical complexity was classified by using a validated algorithm (Clinical Risk Group software) into nonchronic and chronic conditions: episodic chronic, lifelong chronic, progressive chronic, and malignancy. Outcomes included PED length of stay (LOS) and disposition. Logistic regression generated age-adjusted odds ratios (AOR) of admission with 95% confidence intervals (CIs).

RESULTS

PED visits totaled 77 748; 20% (15 433) of which were for children with chronic conditions. Compared with visits for children without chronic conditions, those for children with chronic conditions had increased PED LOS (on average, 79 minutes longer; 95% CI 77-81; P < .0001) and hospital (51% vs 10%) and PICU (3.2% vs 0.1%) admission rates (AOR 10.3, 95% CI 9.9-10.7 to hospital and AOR 25.0, 95% CI 17.0-36.0 to PICU). Admission rates and PED LOS increased with increasing medical complexity.

CONCLUSIONS

Children with chronic conditions comprise a significant portion of annual PED visits in a tertiary pediatric center; medical complexity is associated with increased PED LOS and hospital or PICU admission. Clinical Risk Group may have utility in identifying high utilizers of PED resources and help support the development of interventions to facilitate optimal PED management, such as pre-arrival identification and individual emergency care plans.

A qualitative exploration of Malaysian cancer patients' perceptions of cancer screening

BACKGROUND

Despite the existence of different screening methods, the response to cancer screening is poor among Malaysians. The current study aims to examine cancer patients' perceptions of cancer screening and early diagnosis.

METHODS

A qualitative methodology was used to collect in-depth information from cancer patients. After obtaining institutional ethical approval, patients with different types and stages of cancer from the three major ethnic groups (Malay, Chinese and Indian) were approached. Twenty semi-structured interviews were conducted. All interviews were audiotaped, transcribed verbatim, and translated into English for thematic content analysis.

RESULTS

Thematic content analysis yielded four major themes: awareness of cancer screening, perceived benefits of cancer screening, perceived barriers to cancer screening, and cues to action. The majority of respondents had never heard of cancer screening before their diagnosis. Some participants reported hearing about mammogram and Pap smear tests but did not undergo screening due to a lack of belief in personal susceptibility. Those who had negative results from screening prior to diagnosis perceived such tests as untrustworthy. Lack of knowledge and financial constraints were reported as barriers to cancer screening. Finally, numerous suggestions were given to improve screening behaviour among healthy individuals, including the role of mass media in disseminating the message 'prevention is better than cure'.

CONCLUSIONS

Patients' narratives revealed some significant issues that were in line with the Health Belief Model which could explain negative health behaviour. The description of the personal experiences of people with cancer could provide many cues to action for those who have never encountered this potentially deadly disease, if incorporated into health promotion activities.

Toronto's 2-1-1 healthcare services for immigrant populations

BACKGROUND

Although access to information on health services is particularly important for recent immigrants, numerous studies have shown that their use of information and referral services is limited. This study explores the role played by 2-1-1 Toronto in supporting recent immigrants.

PURPOSE

The study objectives were to (1) understand whether 2-1-1 Toronto is reaching and supporting recent immigrants and (2) gain a better appreciation of the information needs of this population group.

METHODS

A phone survey was conducted in 2005-2006 to collect information on 2-1-1 users' characteristics and levels of satisfaction. Survey data were compared (in 2006) with census data to assess their representativeness. To achieve Objective 2, semistructured qualitative interviews were conducted and analyzed in 2006-2007, with a subset of Spanish-speaking callers.

RESULTS

Recent immigrants were overrepresented among 2-1-1 callers. However, the survey population was substantially younger and had higher levels of formal education than the general population. Health-related queries represented almost one third of the total. The survey showed very high levels of satisfaction with the service. Many interviewees described their first experiences with the Canadian healthcare system negatively. Most of them had relied on disjointed, low-quality information sources. They trusted 2-1-1 but had discovered it late.

CONCLUSIONS

Results are mixed in terms of 2-1-1's support to immigrants. A significant percentage of users do not take full advantage of the service. The service could become the information "entry point" for recent immigrants if it was able to reach them early in the resettlement process. Proactive, community-oriented work and a more creative use of technology could help.

Migration background and patient satisfaction in a pediatric nephrology outpatient clinic

BACKGROUND

We examined the association of a migration background and patient satisfaction in a pediatric nephrology outpatient clinic in Germany.

METHODS

This was a cross-sectional study of 348 families presenting at the Pediatric Nephrology Outpatient Department of Charité University Children's Hospital in Berlin during 2008. Parents were asked to complete a questionnaire containing basic sociodemographic information, a subjective categorical rating of disease severity and communication with the medical team, and a validated patient satisfaction score (ZUF-8) derived from a customer satisfaction score used by industry and modified for healthcare providers.

RESULTS

Of the 348 families included in the study, 131 patients (38 %) had a migration background (20 different nationalities, 22 different native languages). Patient satisfaction (rated on a scale from 8 to 40) was significantly higher in families without (32.9  ±  4.6) than in those with a migration background (30.8  ±  4.7; p < 0.0001). A multivariate linear regression analysis revealed that trust in doctors, friendliness of the doctor, severity of the child's disease, number of medications prescribed, and a migration background were significantly and independently correlated with patient satisfaction.

CONCLUSIONS

Migrant families were less satisfied with the provision of the outpatient care provided by our department than non-migrants.

Receipt of transition services within a medical home: do racial and geographic disparities exist?

OBJECTIVES

(1) Rank states and southern region by racial disparity between black and white Youth with Special Health Care Needs (YSHCN) for Healthcare Transition receipt; (2) Determine if a racial and geographic disparity exists after control of characteristics.

METHODS

The 05/06 National Survey of Children with Special Health Care Needs data were used. A composite of Medical Home and Transition Outcome Measures captured Healthcare Transition. If both were met, Healthcare Transition was received; otherwise, if neither were met, it was not received. Race was grouped as Non-Hispanic black or white. Census Bureau regions defined geography. South was categorized as Deep South or remaining southern states. Characteristics included sex, age, health condition effect, education, poverty, adequate insurance, and metropolitan status. Observations were limited to YSHCN. Chi-square and logistic regression were conducted. Alpha was set to .05.

RESULTS

A national 42% healthcare transition rate, and 25% racial gap was calculated (higher rate among white YSHCN). White YSHCN had more than twice, and Midwestern had 44% higher Healthcare Transition odds in regression analysis; sex, health condition effect, insurance, and education remained significant. For the Southern region, the Healthcare Transition rate was 38% with a 26% racial gap. White YSHCN had about 2.6 higher odds, and southern geography was not associated in regression analysis. Education, poverty, adequate insurance, and health condition effect remained significant.

CONCLUSIONS

A low Healthcare Transition rate was found, and disparities are poignant. Culturally salient intervention programs to address racial and geographic disparities are needed for Healthcare Transition eligible YSHCN.

Medical home disparities between children with public and private insurance

OBJECTIVE

To compare the prevalence of a medical home for children with public versus private insurance and identify components of the medical home that contribute to any differences.

METHODS

We performed a secondary data analysis of the 2007 National Survey of Children's Health. A medical home was defined as meeting each of 5 components: 1) usual source of care; 2) personal doctor/nurse; 3) family-centered care; 4) care coordination, if needed; and 5) no problems getting a referral, if needed. We estimated the national prevalence of the medical home and its components for children with public versus private insurance. Comparisons were made using logistic regression, unadjusted and adjusted for sociodemographic factors.

RESULTS

A total of 67% of privately insured children met all 5 components of the medical home, compared with only 45% of publicly insured children (P < .001). The gap in medical home prevalence between public and private groups remained significant after controlling for sociodemographic characteristics (public vs private adjusted odds ratio [AOR] 0.82; 95% confidence interval [95% CI] 0.73-0.92). Over 90% of children in both groups reported having a usual source of care and a personal doctor/nurse. Only 58% of publicly insured children reported family-centered care, compared with 76% of privately insured children (P < .001). This difference was significant after adjustment for sociodemographic characteristics (public vs private AOR 0.87; 95% CI 0.77-0.99).

CONCLUSIONS

Significant medical home disparities exist between publicly and privately insured children, driven primarily by disparities in family-centered care. Efforts to promote the medical home must recognize and address determinants of family-centered care.

Evaluation of the processes of family-centred care for young children with intellectual disability in Western Australia

INTRODUCTION

Government early intervention services for children with intellectual disability (ID) in Western Australia have adopted the model of family-centred care. The aim of this study was to evaluate how well it was being practised, to describe the pattern of service utilization and to identify factors influencing parental perceptions of family-centred care.

METHODS

The study included children aged 0-6 years with ID, who were registered clients of Disability Services Commission, Western Australia. Parents completed a postal survey questionnaire about the frequency and type of services received and their perceptions of services using the Measure of Processes of Care (MPOC-56) questionnaire. Mean scores for the five MPOC domains were compared using anova against the independent variables of child age group, child diagnostic group, service type and frequency, place of residence, family and demographic variables. Significant variables in each domain were then entered into multivariate analyses.

RESULTS

Of 292 eligible families, 165 (59%) returned a completed questionnaire. While over 50% of children had contact with occupational, speech and physical therapists at least once per month, less than 20% of children had at least annual contact with either psychology or dental services. Families rated their satisfaction highest for 'respectful and supportive care' and lowest for 'providing general information'. Individual item analyses indicated less satisfaction with 'co-ordinated and comprehensive care'. Higher means were associated with more frequent contact with occupational therapy.

CONCLUSION

Overall respondents reported early intervention services for young children with ID in Western Australia provided satisfactory family-centred care by means of the 56-item MPOC. The frequency of contact with allied health professionals was positively associated with parental ratings of family-centred care. The study indicates under-servicing in dental care and psychology services.

Policy statement--emergency information forms and emergency preparedness for children with special health care needs

Children with chronic medical conditions rely on complex management plans for problems that cause them to be at increased risk for suboptimal outcomes in emergency situations. The emergency information form (EIF) is a medical summary that describes medical condition(s), medications, and special health care needs to inform health care providers of a child's special health conditions and needs so that optimal emergency medical care can be provided. This statement describes updates to EIFs, including computerization of the EIF, expanding the potential benefits of the EIF, quality-improvement programs using the EIF, the EIF as a central repository, and facilitating emergency preparedness in disaster management and drills by using the EIF.

Unmet health care needs among CSHCN with neurologic conditions

OBJECTIVE

Children with neurologic conditions require a variety of services. With this study we examined health care needs and unmet needs among children with neurologic conditions.

METHODS

Cross-sectional data reported by parents of 3- to 17-year-olds in the 2005-2006 National Survey of Children With Special Health Care Needs were analyzed. Demographic characteristics, health care needs, and unmet needs of children with special health care needs (CSHCN) and neurologic conditions were descriptively compared with an independent referent group of children without special health care needs; statistical contrasts were performed as a function of the type (conditions included in the Diagnostic and Statistical Manual of Mental Disorders [DSM] or not) and number of reported neurologic conditions.

RESULTS

Compared with the parents of children without special health care needs, parents of CSHCN with neurologic conditions were more likely to report unmet health care needs for their child. After adjustment for demographic factors and severity of functional limitation, CSHCN with at least 2 conditions had more visits to a health care provider, needed more services, and reported more unmet needs than CSHCN with a single DSM condition. The magnitude of need among CSHCN was greatest among those with at least 1 of each type of neurologic condition.

CONCLUSIONS

Unmet health care needs exist among CSHCN with neurologic conditions and are particularly pronounced among children with a combination of both DSM and non-DSM disorders. The health care needs among CSHCN with multiple neurologic conditions may be better served by targeted efforts to improve care coordination.

Critical issues in craniofacial care: quality of life, costs of care, and implications of prenatal diagnosis

Since the 2000 Surgeon General's Report on Oral Health (SGROH), substantial areas of inquiry relative to individuals, especially children and youth, with orofacial clefts and other craniofacial conditions have emerged. These areas include access to and cost of care, stigmatization and quality of life, and social and ethical issues around prenatal diagnosis. This update on the 2000 SGROH examines what we have learned about the cost and ability to access cleft and craniofacial care, prenatal diagnosis, and how quality of life is impacted by these conditions and the burden of care. The development of new research tools to assess quality of life since 2000 will permit further study of the impact of oral and craniofacial conditions on children and families and the effect of treatment on quality of life. Despite a better understanding of the higher use of services and increased costs of care for families of children with craniofacial conditions, major gaps in research must be addressed to assist with program planning and policy development for these groups of children and their families. Further work is also needed to assess the cost-effectiveness of craniofacial team care and to better understand family experience with accessing needed care. Finally, prenatal detection and diagnosis of clefts and craniofacial conditions have advanced dramatically, and the roles of craniofacial professionals and teams have been affected. New understandings of prenatal diagnosis and genomic sciences are redefining genetic counseling, therapy, and future preventive initiatives.

Adolescent health care use: investigating related determinants in Greece

The frequency of health care use is crucial for adolescent well-being and health systems. The present study was the first to test a set of variables in a representative sample of Greek adolescents in order to identify factors that predict health care use and contribute to improving health service planning. Questionnaires were administered to a random sample of adolescents (N=1 194) aged 11-18 years and their parents (N=973) in 2003. Data from 894 participants with full data were analyzed. Parents' education, adolescents' chronic health needs, physical well-being and emotional/behavioural problems as well as parent-child relationship were independent predictors of health care use, although some factors, such as gender, age, type of residence, family affluence, social support and parental health status that previous research identified as predictors were not confirmed. Beyond the need of health care, other factors also play an important role in the utilization of health services by adolescents and their families.

Children with chronic conditions in pediatric intensive care units located in predominantly French-speaking regions: Prevalence and implications on rehabilitation care need and utilization

OBJECTIVE

To estimate the prevalence of chronic conditions and/or disability in intensive care units admitting children (Pediatric Intensive Care Unit [PICU]) or both neonates and children (Neonatal and Pediatric Intensive Care Unit [NPICU]) and to describe available rehabilitation resources.

DESIGN

A cross-sectional study on two separate days, using a web questionnaire.

SETTING

NPICU/PICUs affiliated to the Groupe Francophone de Réanimation et Urgences Pédiatriques and the Réseau Mère-Enfant de la Francophonie.

PATIENTS

Children >1 month of gestationally corrected age.

MEASUREMENTS AND MAIN RESULTS

Disability was defined as a Pediatric Overall Performance Category >or=3 before admission and chronic conditions as hospitalization since birth or the presence before admission of any condition requiring ongoing pediatric subspecialty care that was expected to last >or=12 months. Intensivists indicated what rehabilitation services they would have ideally prescribed ("perceived needs") and those provided. Of 45 affiliated units, 8 PICUs and 15 NPICUs participated. Staff included or had access to a psychologist (11 and 5, respectively), a social worker (10 and 3), a physiotherapist (11 and 12), a "psychomotrician" (2 and 8), a child educator (1 and 6), and a speech-language pathologist (0 and 6). Among 289 recorded intensive care unit-days, 236 were analyzed (excluding those for children admitted after surgery): 57 concerned children hospitalized since birth and 179 children admitted from home. Among these 179 recorded intensive care unit-days, 107 concerned children with chronic conditions (including 50 concerning disabled children) and 72 previously healthy children. Thus, prevalence of chronic conditions, including children hospitalized since birth, was 67%. Rehabilitation services included respiratory physical therapy (552 visits), musculoskeletal physical therapy (71), neurologic physical therapy (37), rehabilitation for swallowing (11), and for speech-language disorders (1), representing 79% of perceived needs.

CONCLUSIONS

Prevalence of chronic conditions in NPICU/PICU was 67%. More attention must be paid to the rehabilitation care needs of patients during their NPICU/PICU stay and after discharge.

The future of health insurance for children with special health care needs

CONTEXT

Because of their elevated need for services, health insurance is particularly important for children with special health care needs. In this article we assess how well the current system is meeting the insurance needs of children with special health care needs and how emerging trends in health insurance may affect their well-being.

METHODS

We begin with a review of the evidence on the impact of health insurance on the health care experiences of children with special health care needs based on the peer-reviewed literature. We then assess how well the current system meets the needs of these children by using data from 2 editions of the National Survey of Children With Special Health Care Needs. Finally, we present an analysis of recent developments and emerging trends in the health insurance marketplace that may affect this population.

RESULTS

Although a high proportion of children with special health care needs have insurance at any point in time, nearly 40% are either uninsured at least part of the year or have coverage that is inadequate. Recent expansions in public coverage, although offset in part by a contraction in employer-based coverage, have led to modest but significant reductions in the number of uninsured children with special health care needs. Emerging insurance products, including consumer-directed health plans, may expose children with special health care needs and their families to greater financial risks.

CONCLUSIONS

Health insurance coverage has the potential to secure access to needed care and improve the quality of life for these children while protecting their families from financially burdensome health care expenses. Continued vigilance and advocacy for children and youth with special health care needs are needed to ensure that these children have access to adequate coverage and that they fare well under health care reform.

Influenza vaccination in adolescents with high-risk conditions

OBJECTIVES

We assessed influenza vaccination rates from 1992 to 2002, individual continuity of vaccination, and missed opportunities for vaccination in adolescents with high-risk conditions.

METHODS

We performed a retrospective observational study of 18 703 adolescents with high-risk conditions who were enrolled in a large health maintenance organization and received care at a multisite practice for >or=1 influenza season and the preceding year, between 1992 and 2002, was performed. Subjects were identified as having a high-risk condition if they had >or=1 visit with an associated International Classification of Diseases, Ninth Revision, Clinical Modification code during the season or previous year. Influenza vaccination rates were compared by season in logistic regression analyses, using generalized estimating equations for repeated measurements of subjects enrolled for multiple seasons. Vaccination continuity was measured for adolescents who were enrolled for 4 consecutive seasons (1999-2002) as the number of seasons during which vaccine was received. Missed opportunities were defined as visits during the first 4 months of influenza season at which an unvaccinated adolescent did not receive vaccine.

RESULTS

For adolescents with high-risk conditions, influenza vaccination rates varied from 8.3% to 15.4%. Rates improved significantly from 1992 to 1993, from 8.3% to 12.8%, and again in 2001, reaching 15.4%. Only 11.1% of those enrolled continuously from 1999 to 2002 received vaccine during all 4 seasons. According to season from 1992 to 2002, 45.7% to 53.6% of unvaccinated subjects had >or=1 missed opportunity.

CONCLUSIONS

Influenza vaccination rates in adolescents with high-risk conditions improved from 1992 to 2002 but were still low in recent years. Individual vaccination continuity was poor. Numerous opportunities already exist for improving coverage.

Association of functional limitation with health care needs and experiences of children with special health care needs

OBJECTIVE

The goal was to evaluate whether having a functional limitation was associated with health care needs and experiences of children with special health care needs.

METHODS

We used caregivers' responses in the National Survey of Children with Special Health Care Needs (2001). Functional limitation was categorized as severe, some, or no limitation. We performed analyses of the relationships of functional limitation to measures of health care needs and experiences.

RESULTS

Children with special health care needs with severe functional limitation were more likely to have received specialized educational services, to have had physician visits, and to have needed health services, compared with those with no limitation. They had significantly greater odds of delayed care, unmet health care and care-coordination needs, referral problems, dissatisfaction, and difficulty using health services, compared with those without limitation. Caregivers of children with special health care needs with severe limitation were twice as likely as those with no limitation to report that providers did not spend enough time, listen carefully, provide needed information, and make family members partners in the child's care. Compared with children with special health care needs without limitation, those with severe limitation had worse health insurance experiences, in terms of insurance coverage, copayments, being able to see needed providers, and problems with health insurance. The impact on families (financial problems, need to provide home care, or need to stop or to cut work) of children with special health care needs with severe functional limitation was much greater than the impact on families of children with special health care needs without limitation. For most measures examined, results for some limitation were between those for severe limitation and no limitation.

CONCLUSIONS

Functional limitation is significantly associated with the health care needs and experiences of children with special health care needs.

Correlates of therapy use and expenditures in children in the United States

INTRODUCTION

This paper describes correlates of use and expenditures for therapies (physical, occupational, speech or home health services) among children in the US.

METHODS

It is data from the Medical Expenditure Panel Survey, a nationally-representative US sample. The Characteristics of users and describe patterns of expenditures were examined.

RESULTS

Use is quite low, only 3.8% of children use services or 4.3% once the use that occurs in the special education system is included. Children more likely to use therapy include those with presumably greater need: children with chronic conditions, functional limitations and/or a history of hospitalizations or injuries. There is significant interaction of minority status and having a functional limitation. Expenditures are low when examined across the child population. Among a small proportion of higher users, therapy expenditures account for a larger proportion of overall health expenditures.

CONCLUSIONS

The educational system adds only slightly to the overall rate of use. In general use appears to be related to the need for such services. Some children, likely including racial/ethnic minority children, may under-use services. Lack of insurance is not related to less use, perhaps because there are other ways to get some services (family care or services provided through the public health system) or because not all insurers cover therapy services. Therapy expenditures account for high proportion of overall expenditures among the high user of therapy whereas, for the entire child populations, therapy expenditures account for a very small part of overall health expenditures.

Predictors of adolescent health care utilization

This study, using Andersen's health care utilization model, examined how predisposing characteristics, enabling resources, need, personal health practices, and psychological factors influence health care utilization using a nationally representative, longitudinal sample of Canadian adolescents. Second, this study examined whether this process varies across physicians, non-physicians, and dentists. The results indicate that need and psychological factors were strong determinants of utilization. Predisposing factors were associated with utilization, although there were few enabling resources. Differences were found for utilization of different services. Females, adolescents who were older, from single parent families, with lower self-rated health, lower health status, higher disability, higher distress and involved in health compromizing practices were more likely to visit physicians and non-physicians. Higher dentist utilization was related to higher income, single parent status, being younger, having lower health status, and higher disability. Predisposing and enabling factors were not mediators of utilization. The findings suggest that health care providers could be an important source of counselling on psychological, lifestyle issues, and physical concerns.

Quality medical homes: meeting children's needs for therapeutic and supportive services

OBJECTIVE

The objective of this study was to determine whether the quality of a medical home is associated with access to needed therapeutic and supportive services among children with special health care needs.

METHODS

Data from the 2000-2001 National Survey of Children With Special Health Care Needs were used in the analysis. The primary group of interest was children who were 0 to 17 years of age and needed therapeutic (n = 15,793) or supportive (n = 23,376) services. For each characteristic of a quality medical home, the percentage of children who needed and received therapeutic and supportive services was generated. Logistic regression was used to control for covariates while modeling the association between overall quality of a child's medical home and having unmet needs for therapeutic or supportive services.

RESULTS

Of all children identified as needing services, 16.2% had unmet therapeutic and 9.8% unmet supportive service needs. Only 23.9% of the children who needed therapeutic and 32.5% of children who needed supportive services met the criteria of having a quality medical home. High-quality care within medical homes was associated with a decreased likelihood of having unmet needs for therapeutic and supportive services. Each characteristic of a quality medical home was associated with unmet need, as were severity of the child's condition, family income of <200% of the federal poverty level, underinsurance, and maternal education beyond high school.

CONCLUSIONS

Among other factors, having a poor-quality medical home seems to be a barrier to receiving needed therapeutic or supportive services for children with special health care needs. Efforts on the part of pediatricians to establish quality medical homes for all children could have the added benefit of facilitating access to needed therapeutic and supportive services and promoting the health and well-being of children with special health care needs and their families.

Improving underserved children's access to health care: practitioners' views

This article describes the results of three focus groups conducted with a variety of children's health care providers in a county in the southeastern United States. The purpose of the research was to investigate practitioners' views on the barriers impeding access to health care for medically underserved children. The focus groups were the third phase of a larger study designed to collect data on communication patterns among children's health care providers as well as information on children's access to care. The results include suggestions for actions practitioners can take to improve medically underserved children's access to health care.

Emergency department overcrowding and children

Emergency department (ED) overcrowding has been a serious issue on the national agenda for the past 2 decades and is rapidly becoming an increasingly significant problem for children. The goal of this report is to focus on the issues of overcrowding that directly impact children. Our findings reveal that although overcrowding seems to affect children in ways similar to those of adults, there are several important ways in which they differ. Recent reports document that more than 90% of academic emergency medicine EDs are overcrowded. Although inner-city, urban, and university hospitals have historically been the first to feel the brunt of overcrowding, community and suburban EDs are now also being affected. The overwhelming majority of children (92%) are seen in general community EDs, with only a minority (less than 10%) treated in dedicated pediatric EDs. With the exception of patients older than 65 years, children have higher visit rates than any other age group. Children may be at particularly increased risk for medical errors because of their inherent variability in size and the need for age-specific and weight-based dosing. We strongly recommend that pediatric issues be actively included in all future aspects of research and policy planning issues related to ED overcrowding. These include the development of triage protocols, clinical guidelines, research proposals, and computerized data monitoring systems.

Genetic Counseling, Insurance Status, and Elements of Medical Home: Analysis of the National Survey of Children with Special Health Care Needs

OBJECTIVE

To examine associations between receiving genetic counseling and the enabling factors of insurance and medical home.

METHODS

This study uses data from the National Survey of Children with Special Health Care Needs (CSHCN). We use descriptive statistics to characterize families of CSHCN who needed and received genetic counseling as well as families who needed but did not receive genetic counseling. We conduct logistic regression to calculate the association between receiving genetic counseling, insurance status, and medical home while adjusting for child's age, mother's education, race, ethnicity, and severity of condition.

RESULTS

Seven percent of families with CSHCN, representing 643,432 CSHCN nationwide, reported needing genetic counseling in 2001. Of those in need of genetic counseling, an estimated 123,117 CSHCN reported not receiving genetic counseling. Compared to CSHCN with continuous insurance coverage, CSHCN with interrupted insurance coverage and CSHCN without insurance are significantly less likely to receive genetic counseling. The odds of receiving genetic counseling by CSHCN with medical homes are 2.70 times higher compared to peers without medical homes (95% CI: 1.58, 4.61; p </= .001). Among the four elements comprising medical home in this study, family-centered care is the only element significantly associated with receiving genetic counseling.

CONCLUSIONS

Our analysis presents evidence that receiving genetic counseling is positively associated with having continuous insurance coverage and receiving family-centered care. We discuss how researchers and policy makers may use these finding to explore strategies for improving care systems for CSHCN.

The effect of poverty and caregiver education on perceived need and access to health services among children with special health care needs

OBJECTIVES

We examined the association between several variables and the use of specialist physician services, developmental therapies, and prescription medications among children with special health care needs (N=38866).

METHODS

We used a bivariate probit model to estimate whether a given child needed specialized services and whether that child accessed those services; we controlled for activity limitations and severity of special needs. Variables included family income, mother's (or other caregiver's) educational level, health insurance coverage, and perceived need for specialized services. We used data from the 2001 National Survey of Children with Special Health Care Needs.

RESULTS

Lower-income and less-educated parents were less likely than higher-income and more-educated parents to say their special needs children needed specialized health services. The probability of accessing specialized health services-when needed-increased with both higher family income and insurance coverage.

CONCLUSIONS

Children with special health care needs have less access to health services because their parents do not recognize the need for those services. An intervention in the form of information at the family level may be an appropriate policy response.

Role of insurance for children with special health care needs: a synthesis of the evidence

OBJECTIVE

Children with special health care needs constitute a particularly vulnerable subpopulation of children. Health insurance coverage has the potential to enhance access to care and improve the quality of life for these children while protecting their families from financially burdensome health care expenses. The purpose of this review is to assess and synthesize recent research in the peer-reviewed literature pertaining to the role of insurance for children with special health care needs. A marked increase in the volume of research on this topic makes this an opportune time to summarize these contributions and begin the process of formalizing an evidence base that can inform health policy decisions. Our intention is to further the evidence base by providing a literature-driven assessment of the role of health insurance in influencing access, utilization, satisfaction, quality, expenditures, and health outcomes for children with special health care needs.

METHODS

A systematic literature review was conducted on the effects of insurance status, insurance type, and insurance features on access, utilization, satisfaction, quality, expenditures, and health status.

RESULTS

The strongest evidence emerged for the positive effects of insurance on access and utilization. Limited evidence on the effect of insurance on satisfaction with care showed improved satisfaction ratings for the insured. The studies with findings relevant to out-of-pocket expenditures for insured versus uninsured children with special health care needs all found significantly higher out-of-pocket burden and financial problems among the uninsured. Evidence was mixed for the effects of insurance type (public or private) and insurance characteristics (eg, managed care or fee-for-service payment mechanisms) on outcomes. None of the studies that we reviewed attempted to assess the impact of health insurance on health outcomes.

CONCLUSIONS

Our review of the literature found plentiful evidence demonstrating the positive and substantial impact of insurance on access and utilization. There also is clear evidence that insurance protects families against financially burdensome expenses. The evidence is less conclusive for satisfaction and quality and is nonexistent for health status. These latter outcomes should be the focus of future studies.

Mental health care services for children with special health care needs and their family members: prevalence and correlates of unmet needs

OBJECTIVES

To estimate the prevalence and correlates of unmet needs for mental health care services for children with special health care needs and their families.

METHODS

We use the National Survey of Children With Special Health Care Needs to estimate the prevalence of unmet mental health care needs among children with special health care needs (1-17 years old) and their families. Using logistic-regression models, we also assess the independent impact of child and family factors on unmet needs.

RESULTS

Substantial numbers of children with special health care needs and members of their families have unmet needs for mental health care services. Children with special health care needs who were poor, uninsured, and were without a usual source of care were statistically significantly more likely to report that their mental health care needs were unmet. More severely affected children and those with emotional, developmental, or behavioral conditions were also statistically significantly more likely to report that their mental health care needs went unmet. Families of severely affected children or of children with emotional, developmental, or behavioral conditions were also statistically significantly more likely to report that their mental health care needs went unmet.

CONCLUSIONS

Our results indicate that children with special health care needs and their families are at risk for not receiving needed mental health care services. Furthermore, we find that children in families of lower socioeconomic status are disproportionately reporting higher rates of unmet needs. These data suggest that broader policies to identify and connect families with needed services are warranted but that child- and family-centered approaches alone will not meet the needs of these children and their families. Other interventions such as anti-poverty and insurance expansion efforts may be needed as well.

Health care utilization and needs after pediatric traumatic brain injury

OBJECTIVE

Children with moderate to severe traumatic brain injury (TBI) show early neurobehavioral deficits that can persist several years after injury. Despite the negative impact that TBI can have on a child's physical, cognitive, and psychosocial well-being, only 1 study to date has documented the receipt of health care services after acute care and the needs of children after TBI. The purpose of this study was to document the health care use and needs of children after a TBI and to identify factors that are associated with unmet or unrecognized health care needs during the first year after injury.

METHODS

The health care use and needs of children who sustained a TBI were obtained via telephone interview with a primary caregiver at 2 and 12 months after injury. Of the 330 who enrolled in the study, 302 (92%) completed the 3-month and 288 (87%) completed the 12-month follow-up interviews. The health care needs of each child were categorized as no need, met need, unmet need, or unrecognized need on the basis of the child's use of post-acute services, the caregiver's report of unmet need, and the caregiver's report of the child's functioning as measured by the Pediatric Quality of Life Inventory (PedsQL). Regardless of the use of services or level of function, children of caregivers who reported an unmet need for a health care service were defined as having unmet need. Children who were categorized as having no needs were defined as those who did not receive services; whose caregiver did not report unmet need for a service; and the whose physical, socioemotional, and cognitive functioning was reported to be normal by the caregiver. Children with met needs were those who used services in a particular domain and whose caregivers did not report need for additional services. Finally, children with unrecognized needs were those whose caregiver reported cognitive, physical, or socioemotional dysfunction; who were not receiving services to address the dysfunction; and whose caregiver did not report unmet need for services. Polytomous logistic regression was used to model unmet and unrecognized need at 3 and 12 months after injury as a function of child, family, and injury characteristics.

RESULTS

At 3 months after injury, 62% of the study sample reported receiving at least 1 outpatient health care service. Most frequently, children visited a doctor (56%) or a physical therapist (27%); however, 37% of caregivers reported that their child did not see a physician at all during the first year after injury. At 3 and 12 months after injury, 26% and 31% of children, respectively, had unmet/unrecognized health care needs. The most frequent type of unmet or unrecognized need was for cognitive services. The top 3 reasons for unmet need at 3 and 12 months were (1) not recommended by doctor (34% and 31%); (2) not recommended/provided by school (16% and 17%); and (3) cost too much (16% and 16%). Factors that were associated with unmet or unrecognized need changed over time. At 3 months after injury, the caregivers of children with a preexisting psychosocial condition were 3 times more likely to report unmet need compared with children who did not have one. Also, female caregivers were significantly more likely to report unmet need compared with male caregivers. Finally, the caregivers of children with Medicaid were almost 2 times more likely to report unmet need compared with children who were covered by commercial insurance. The only factor that was associated with unrecognized need at 3 months after injury was abnormal family functioning. At 12 months after injury, although TBI severity was not significant, children who sustained a major associated injury were 2 times more likely to report unmet need compared with children who did not. Consistent with the 3-month results, the caregivers of children with Medicaid were significantly more likely to report unmet needs at 1 year after injury. In addition to poor family functioning's being associated with unrecognized need, nonwhite children were significantly more likely to have unrecognized needs at 1 year compared with white children.

CONCLUSIONS

A substantial proportion of children with TBI had unmet or unrecognized health care needs during the first year after injury. It is recommended that pediatricians be involved in the post-acute care follow-up of children with TBI to ensure that the injured child's needs are being addressed in a timely and appropriate manner. One of the recommendations that trauma center providers should make on hospital discharge is that the parent/primary caregiver schedule a visit with the child's pediatrician regardless of the post-acute services that the child may be receiving. Because unmet and unrecognized need was highest for cognitive services, it is important to screen for cognitive dysfunction in the primary care setting. Finally, because the health care needs of children with TBI change over time, it is important for pediatricians to monitor their recovery to ensure that children with TBI receive the services that they need to restore their health after injury.

Disparities in use of and unmet need for therapeutic and supportive services among school-age children with functional limitations: a comparison across settings

OBJECTIVES

To determine whether family resources predict use of therapeutic and supportive services and unmet needs in medical versus educational settings.

DATA SOURCE

Children 5-17 years of age with at least one functional limitation (n=3,434) from the 1994 to 1995 Disability Supplement to the U.S. National Health Interview Survey.

STUDY DESIGN

Family resources included the child's type of health insurance, household education level, and poverty status. Therapeutic services included audiology; social work; occupational, physical, or speech therapy. Supportive services included special equipment, personal care assistance, respite care, transportation, or environmental modifications. Need was controlled by child health status and the severity and type of functional limitation(s). Age, gender, race/ethnicity, family size, and structure were covariates. DATA ANALYSIS METHODS: Logistic regression provided estimates of associations between-family resources and use of or unmet need for therapeutic and supportive services. Multinomial methods were used to determine therapeutic service outcomes in medical versus educational settings.

PRINCIPAL FINDINGS

Children with public insurance were two to three times more likely to use services than children with private or no insurance regardless of type of service. Household education and public insurance were associated with supportive and therapeutic service use, but for therapeutic services only among children receiving services beyond the school setting. Household education predicted unmet need for both types of services and therapeutic services across settings. Findings should be interpreted cautiously, given the survey's dependence on respondent report to define the need for services and the potential for overrepresentation of children with more severe needs in the public insurance category.

CONCLUSIONS

Disparities in the use of services by household education level and by type of health insurance across service settings suggests inequitable access among the U.S. policies and programs serving children with functional limitations. Family income and education appear to give families an advantage in obtaining services and in identifying a child's unmet need.