Preventive health care for children with and without special health care needs

Oral Health Among Children and Youth With Special Health Care Needs

OBJECTIVES

We sought to estimate the prevalence of oral health problems and receipt of preventive oral health (POH) services among children and youth with special health care needs (CYSHCN) and investigate associations with child- and family-level characteristics.

METHODS

We used pooled data from the 2016-2018 National Survey of Children's Health. The analytic sample was limited to children 1 to 17 years old, including 23 099 CYSHCN and 75 612 children without special health care needs (non-CYSHCN). Parent- and caregiver-reported measures of oral health problems were fair or poor teeth condition, decayed teeth and cavities, toothaches, and bleeding gums. POH services were preventive dental visits, cleanings, tooth brushing and oral health care instructions, fluoride, and sealants. Bivariate and multivariable logistic regression analyses were conducted.

RESULTS

A higher proportion of CYSHCN than non-CYSHCN received a preventive dental visit in the past year (84% vs 78%, P < .0001). Similar patterns were found for the specific preventive services examined. However, CYSHCN had higher rates of oral health problems compared with non-CYSHCN. For example, decayed teeth and cavities were reported in 16% of CYSHCN versus 11% in non-CYSHCN (P < .0001). In adjusted analyses, several factors were significantly associated with decreased prevalence of receipt of POH services among CYSHCN, including younger or older age, lower household education, non-English language, lack of health insurance, lack of a medical home, and worse condition of teeth.

CONCLUSIONS

CYSHCN have higher rates of POH service use yet worse oral health status than non-CYSHCN. Ensuring appropriate use of POH services among CYSHCN is critical to the reduction of oral health problems.

Patterns of Primary, Specialty, Urgent Care, and Emergency Department Care in Children With Inflammatory Bowel Diseases

OBJECTIVES

Pediatric patients with inflammatory bowel diseases (IBD) require treatment, monitoring, and health maintenance services. We described patterns of primary, specialty, emergency department (ED) and urgent care delivery, and explored patient- and system-related variables that impact ED/urgent care utilization.

METHODS

We conducted a cross sectional survey of parents of children with IBD at a large tertiary children's hospital.

RESULTS

One hundred sixty-one parents completed the survey (75% response). Mean patient age 13.9 years (51% boys); 80% Crohn disease, 16% ulcerative colitis, 4% IBD-unspecified. Mean disease duration 4 years (standard deviation [SD] 2.7). Thirty percent had at least 1 other chronic disease, 31% had a history of IBD-related surgery. Parents were predominantly Caucasian (94%), well-educated (61% bachelor's degree/higher), part of a 2-parent household (79%) living in a suburban setting (57%). Seventy-seven percent of patients had private insurance. In the past year, most children had 1 to 2 IBD-related office visits (54%) with their gastroenterology (GI) doctor and no IBD-related hospitalizations (79%). Eighty-eight percent (N = 141) had a primary care provider (PCP), and most (70%) saw their PCP 1 to 2 times. Even so, 86% (N = 139) received medical care from places other than their PCP or GI doctor; 27% in the ED and 45% at urgent care. Children of parents with less than a bachelor's degree, families that lived further from their GI doctor, and children who saw their PCP more often were more likely to utilize ED/urgent care.

CONCLUSIONS

ED/urgent care utilization in pediatric patients with IBD was greater than expected, potentially contributing to fragmented, costly care and worse outcomes.

Preventive care services and health behaviors in children with fragile X syndrome

BACKGROUND

This is the first description of preventive care services specifically received by children and young adults with fragile X syndrome (FXS). We compare these rates to those of other pediatric populations and identify care disparities within our cohort.

OBJECTIVE

Describe the frequency of preventive care services and health behaviors by young people with FXS, and identify disparities in care.

METHODS

We assessed four preventive care outcomes and the total number of preventive care guidelines met among individuals under 21 years from the ongoing Fragile X Online Registry with Accessible Research Database (N = 406) using data from 2012 to 2015. We used adjusted odds ratios (AORs) from multiple logistic regression models to describe associations between demographic factors and preventive care outcomes.

RESULTS

Seventy-five percent of our sample met dental care guidelines, 55.4% met influenza vaccination guidelines, 92.1% met immunization guidelines, and 24.4% met physical activity (PA) guidelines. Compared to children six to 10 years, younger children were less likely to have seen a dentist as recommended (AOR: 0.26) and young adults aged 16-20 were less likely to have received immunizations (AOR: 0.14) or to have engaged in recommended PA (AOR: 0.29). Black participants (AOR: 0.25) were less likely to have received an influenza vaccination than white participants. Individuals with autism (AOR: 0.25) were less likely to have sufficient PA, while individuals with hypersensitivity were more likely to have sufficient PA (AOR: 2.37) than unaffected individuals.

CONCLUSIONS

The proportion of young people with FXS that meet basic recommendations in preventive care guidelines varies according to health condition and demographic characteristics. This proportion could be increased for some groups, particularly in the cases of influenza vaccination and physical activity.

Health Care Utilization and Unmet Need Among Youth With Special Health Care Needs

PURPOSE

To examine unmet health needs and health care utilization among youth with special health care needs (YSHCN).

METHODS

We analyzed data among youth aged 12-17 years using the 2016 National Survey of Children's Health. We conducted descriptive analyses comparing YSHCN with non-YSHCN, and bivariate and multivariable analyses examining associations between dependent and independent measures. Six dependent variables represented unmet needs and utilization. Adjusted analyses controlled for sociodemographic and health measures.

RESULTS

A total of 5,862 individuals were identified as YSHCN, and nearly 70% had three or more comorbid conditions. Over 90% used medical care, preventive care, or dental care in the past 12 months, while 8% reported having unmet health needs (compared with 2.8% of non-YSHCN). Using a typology of qualifying criteria for special health care needs, we found that YSHCN with increasing complexity of needs were more likely to report unmet health needs, use of mental health care services, and emergency department use, compared with YSHCN using medication only to manage their conditions. All YSHCN living in households below 400% federal poverty level were less likely to utilize nearly all types of health care examined, with the exception of mental health care use, compared with those at or above 400% federal poverty level.

CONCLUSIONS

Differences in complexity of needs, race/ethnicity, and poverty status highlight existing gaps in health care utilization and persistent unmet health needs among YSHCN. Efforts should focus on strengthening coordinated systems of care that optimally meet the needs of YSHCN so they may thrive in their families and communities.

Parental or Teacher Education and Coaching to Support Function and Participation of Children and Youth With Sensory Processing and Sensory Integration Challenges: A Systematic Review

This systematic review examines the literature published from January 2007 through May 2015 related to the effectiveness of occupational therapy interventions using parental or teacher education and coaching with children with challenges in sensory processing and sensory integration (SP-SI). Of more than 11,000 abstracts and 86 articles that were considered, only 4 met the criteria and were included in this review. Studies of parental training and coaching for children with challenges in SP-SI and comorbid autism spectrum disorder have suggested that educational or coaching programs could result in positive outcomes for both parents and children, often in a relatively short time period. Recommendations include a greater focus on providing educational interventions for parents and teachers and including specific assessment of SP-SI before implementing interventions meant to address those issues. Specific recommendations for future research are provided.

Parent perceptions of health promotion for school-age children with spina bifida

PURPOSE

To gain insight into how parents develop their beliefs of health promotion for their children with spina bifida (SB) and how they develop and promote health promotion practices for their children.

DESIGN

Qualitative, exploratory design with semi-structured interviews of parents of children between 6 and 12 years of age diagnosed with SB was used for this study.

RESULTS

Perceptions of health promotion were maintaining healthy bowel function and managing SB care. Good bowel function and SB management is health promotion and adequate bowel function is viewed as a marker of health. Maintaining healthy bowel function was identified by parents as the key marker of health for their children with SB. Further, the term health promotion brought up plans, concerns, and goals more related to their child's physiologic functioning and health care needs rather than promoting health and avoiding preventable disease.

PRACTICE IMPLICATIONS

Nurses and healthcare providers are in unique and powerful positions for strategizing with parents on how to integrate health promotion into the lives of children with SB. Team-based, whole-person, holistic assessment and teaching inclusive of promoting healthy lifestyle behaviors in addition to providing excellent care related to their physiologic systems affected by SB can improve how we promote health for these children.

The Child Health Care System in Italy

Pediatric care in Italy has been based during the last 40 years on the increased awareness of the importance of meeting the psychosocial and developmental needs of children and of the role of families in promoting the health and well-being of their children. The pediatric health care system in Italy is part of the national health system. It is made up of 3 main levels of intervention: first access/primary care, secondary care/hospital care, and tertiary care based on specialty hospital care. This overview will also include a brief report on neonatal care, pediatric preventive health care, health service accreditation programs, and postgraduate training in pediatrics. The quality of the Italian child health care system is now considered to be in serious danger because of the restriction of investments in public health caused both by the 2008 global and national economic crisis and by a reduction of the pediatric workforce as a result of progressively insufficient replacement of specialists in pediatrics.

Safety-Related Concerns of Parents for Children with Disabilities and Chronic Conditions

OBJECTIVE

The aim of this study was to explore the safety-related concerns of parents of children with a variety of disabilities and chronic conditions. We sought to examine concerns common to parents as they related to their children's delayed development, behavioral difficulties, and chronic conditions.

METHOD

A qualitative approach guided by grounded theory was used. Participants included parents of children between 1 and 5 years with a disability or chronic condition who resided in British Columbia, Canada. Data were collected using in-depth in-person interviews and analysis conducted using constant comparative methods.

RESULTS

Three themes were identified that reflected parental safety concerns. These included concerns about: (1) Child's level of understanding about danger; (2) Child interactions with physical environment (concerns about child movement, concerns about ingestions); (3) Child interactions with social environment. Difficult-to-manage behaviors and cognitive limitations exacerbated parents' safety concerns. Parents were found to share safety concerns about movement and ingestions across a range of types of child health conditions.

CONCLUSION

For themes of child movement and child ingestions, findings supported the utility of a noncategorical approach for the design of injury prevention strategies for these types of concerns. Parent concerns about child lack of understanding about risk and social safety concerns were linked to a smaller number of conditions and supported a more tailored approach. Flexible approaches may be needed that can offer both generic and specific information and to meet the needs of parents and clinicians.

Correlates of wellness among youth with functional disabilities

BACKGROUND

The literature is more informative on the impediments to wellness among youth with functional limitations and less instructive on the state of wellness for this population.

OBJECTIVE

To explore overall wellness, and each sub-dimension of wellness, in a national sample of youth with functional limitations and to determine how demographic characteristics are associated with wellness.

METHODS

Using a previously validated screening instrument, we identify youth with functional limitations aged 12 to 17 represented in the 2011/12 National Survey of Children's Health. Survey items were coded to operationalize an overall wellness score comprised of four sub-dimensions of wellness (i.e., physical, intellectual, emotional, and social).

RESULTS

The mean overall wellness score was 26.7 (out of 40) and had an approximate normal distribution. Mean raw scores for each sub-dimension were as follows: social = 2.79 (out of 4; 69.7%); emotional = 4.09 (out of 6; 68.2%); intellectual = 3.79 (out of 8; 47.4%); and physical = 6.30 (out of 8; 78.7%). Lower wellness scores were associated with older age among youth, increasing number of chronic health conditions, lower income, single mother homes, and youth whose mother reported fair or poor mental health status (all p < 0.05). Higher wellness scores were positively associated with mother's education (p < 0.001).

CONCLUSIONS

Program planners should consider interventions that target youth with functional limitations shown to be at particular risk for lower overall wellness and promote family involvement and comprehensive supports, including maternal educational attainment, mental health screening, and referral.

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.

Oral health care utilization in children with disabilities

OBJECTIVES

The objectives of this report were to survey the utilization of oral health care in children and adolescents with disabilities over a 7-year period and to compare these data with the utilization pattern of their peers without disabilities. For most countries, these data have not been published in the international literature so far.

MATERIAL AND METHODS

The cohort used was the Permanent Sample of Socially Insured Persons, an anonymous representative sample of Belgian residents. The database comprised prospective data on oral and general health care utilization and sociodemographic variables collected from 2002 up to 2008.

RESULTS

Data were available from 326 children and adolescents with and 53,589 without disabilities. Dental attendance rates were low in both subgroups: only 50 % had a dental visit in four or more of the seven observation years. Emergency oral and medical care was recorded significantly more often in children with disabilities whereas radiographs, restorations, and orthodontic assessments and treatments more frequently in children without disabilities.

CONCLUSION

The present study demonstrated that dental attendance rates in both subgroups were low and that in those who attended, preventive oral health care was only infrequently attested. Further research is needed to elucidate whether the lower number of radiographs and restorations and the higher number of emergency visits observed in the subgroup with disabilities reflect unmet oral treatment needs.

CLINICAL RELEVANCE

Objective data on health care utilization are essential to enable governments and stakeholders to devise appropriate care and to optimize access to care for persons with disabilities.

Assessing the health, functional characteristics, and health needs of youth attending a noncategorical transition support program

PURPOSE

To assess the health, functional characteristics, and health care service needs of youth and young adults with special health care needs attending a comprehensive, noncategorical transition program.

METHODS

A self-administered survey was developed from national health surveys and clinical experience to assess concepts identified as important for successful transition to adulthood. Surveys were mailed to 198 parents of youth and young adults with special health care needs attending the transition clinic. Parents were asked about the youth's health, functional status, and health care services needed. The clinical database provided demographic and patient health characteristics. Results were compared against the 2005-2006 National Survey of Children with Special Health Care Needs.

RESULTS

Forty-four percent of surveys were returned. Average age of youth was 17.5 (11-22) years old and diagnoses included cerebral palsy (36%), spina bifida (10%), developmental delay or Down syndrome (17%), and autism (6%). Most youth needed assistance with personal care (69%) and routine needs (91%) and used assistive devices (59%). Compared with the 2005-2006 National Survey of Children with Special Health Care Needs, parents reported higher needs for all services except mental health care and tobacco or substance use counseling. Forty three percent reported at least one unmet health need. Few parents reported the need for counseling on substance use (1%), sexual health screening (16%), nutrition (34%), and exercise (41%).

CONCLUSIONS

Youth attending our transition program had more functional limitations, poorer reported health status, different diagnosis distribution, and higher levels of needed health services. Few parents identified needs for other recommended adolescent preventive services. Transition programs should assess patient health characteristics and service needs to design effective patient-centered services.

Family-centered care: current applications and future directions in pediatric health care

Family-centered care (FCC) is a partnership approach to health care decision-making between the family and health care provider. FCC is considered the standard of pediatric health care by many clinical practices, hospitals, and health care groups. Despite widespread endorsement, FCC continues to be insufficiently implemented into clinical practice. In this paper we enumerate the core principles of FCC in pediatric health care, describe recent advances applying FCC principles to clinical practice, and propose an agenda for practitioners, hospitals, and health care groups to translate FCC into improved health outcomes, health care delivery, and health care system transformation.

Quality measures for primary care of complex pediatric patients

OBJECTIVES

A well-recognized gap exists in assessing and improving the quality of care for medically complex patients. Our objective was to examine evidence for primary care based on the patient-centered medical home model and to identify valid and meaningful quality measures for use in complex pediatric patients.

METHODS

We conducted literature searches on Medline and the National Quality Measures Clearinghouse for existing measures, as well as evidence to inform the development of new quality measures. We used a 3-step process to select relevant sources from published literature: (1) the titles were screened by 2 independent reviewers; (2) the abstracts were reviewed for quality-of-care contents or constructs; and (3) full-text articles were obtained and reviewed for measure specification. All materials were reviewed for the Oxford Centre For Evidence-Based Medicine level of evidence and for relevance to primary care of complex pediatric patients. A national expert panel was convened to evaluate and rate the measures by using the Rand/University of California Los Angeles Appropriateness Method.

RESULTS

We presented 74 quality measures to the expert panel for review and discussion. The panel rated and accepted 35 measures as valid and feasible for assessing primary care quality in complex pediatric patients. The final set of quality measures was grouped in the following domains: primary care-general (14), patient/family-centered care (8), chronic care (2), coordination of care (9), and transition of care (2).

CONCLUSIONS

By using the patient-centered medical home framework of accessible, continuous, family-centered, coordinated, and culturally effective care, a national expert panel selected 35 primary care quality measures for complex pediatric patients.

Disparities in the use of preventive health care among children with disabilities in Taiwan

Children with disabilities face more barriers accessing preventive health services. Prior research has documented disparities in the receipt of these services. However, most are limited to specific types of disability or care. This study investigates disparities in the use of preventive health care among children with disabilities in Taiwan. Three nationwide databases from the Ministry of the Interior, Bureau of Health Promotion, and National Health Research Institutes were linked to gather related information between 2006 and 2008. A total of 8572 children with disabilities aged 1-7 years were included in this study. Multivariate logistic regression analysis was conducted to adjust for covariates. Nationally, only 37.58% of children with disabilities received preventive health care in 2008. Children with severe and very severe disabilities were less likely to use preventive care than those with mild severity. Children with disabilities from the lowest income family were less likely to have preventive care than other income groups. Urbanization was strongly associated with the receipt of preventive health care. However, surprisingly, urban children with disabilities were less likely to receive preventive care than all others. Under universal health insurance coverage, the overall usage of preventive health care is still low among children with disabilities. The study also identified several disparities in their usage. Potential factors affecting the lack of use deserve additional research. Policymakers should target low socioeconomic brackets and foster education about the importance of preventive care. Mobile health services should be continually provided in those areas in need. Capitation reimbursement and other incentives should be considered in improving the utilization among children with disabilities.

A qualitative assessment of reasons for nonurgent visits to the emergency department: parent and health professional opinions

OBJECTIVE

Each day, children incur more than 69,000 emergency department (ED) visits, with 58% to 82% of them for nonurgent reasons. The objectives of this study were to elicit and to describe guardians' and health professionals' opinions on reasons for nonurgent pediatric ED visits.

METHODS

Focus groups sessions were held with 3 groups of guardians, 2 groups of primary care practitioners, and 1 group of pediatric emergency medicine physicians. Participants identified unique factors and their importance related to nonurgent ED use.

RESULTS

A total of 25 guardians and 42 health professionals participated. Guardians had at least 1 child younger than 5 years, most were self-identified racial/ethnic minorities, and nearly all had taken a child to an ED. Guardians focused on perceived illness severity in their children and needs for diagnostic testing or other interventions, as well as accessibility and availability at times of day that worked for them. Professionals focused on systems issues concerning availability of appointments, as well as parents' lack of knowledge of medical conditions and sense of when use of the ED was appropriate.

CONCLUSIONS

Guardians' concerns about perceptions of severity of illness in children and their schedules must be considered to effectively reduce nonurgent ED use, which may differ from the perceptions of professionals. Health professionals and systems seeking ways to decrease ED utilization may be able to better match capacity to demand both by increasing accessibility to primary care and by working to overcome guardians' perceptions that only EDs can handle acute illnesses or injuries.

Association of family-centered care with improved anticipatory guidance delivery and reduced unmet needs in child health care

Little is known about the association of family-centered care (FCC) with the quality of pediatric primary care. The objectives were to assess (1) associations between family-centered care (FCC), receipt of anticipatory guidance, and unmet need for health care; and (2) whether these associations vary for children with special health care needs (CSHCN). The study, a secondary data analysis of the 2004 Medical Expenditure Panel Survey, used a nationally representative sample of family members of children 0-17 years. We measured receipt of FCC in the last 12 months with a composite score average>3.5 on a 4 point Likert scale from 4 Consumer Assessment of Healthcare Providers and Systems questions. Outcome measures were six anticipatory guidance and six unmet health care service needs items. FCC was reported by 69.6% of family members. One-fifth (22.1%) were CSHCN. Thirty percent of parents reported≥4 of 6 anticipatory guidance topics discussed and 32.5% reported≥1 unmet need. FCC was positively associated with anticipatory guidance for all children (OR=1.45; 95% CI 1.19, 1.76), but no relation was found for CSHCN in stratified analyses (OR=1.01; 95% CI .75, 1.37). FCC was associated with reduced unmet needs (OR=.38; 95% CI .31, .46), with consistent findings for both non-CSHCN and CSHCN subgroups. Family-centered care is associated with greater receipt of anticipatory guidance and reduced unmet needs. The association between FCC and anticipatory guidance did not persist for CSHCN, suggesting the need for enhanced understanding of appropriate anticipatory guidance for this population.

Preschool vision testing by health providers in the United States: findings from the 2006-2007 Medical Expenditure Panel Survey

BACKGROUND

Few data are available regarding the rate of preschool vision screening. The purpose of this study is to estimate the current rate of vision testing among children ages 3 through 6 years by any health care provider and to the characterize the children reported to have been tested.

METHODS

We conducted a cross-sectional analysis of the 4,237 children aged 3 through 6 years included in either the 2006 or 2007 Medical Expenditure Panel Survey. Household respondents were asked whether selected children ever had vision testing by a doctor or other health provider. Data were weighted to make estimates representative of the civilian noninstitutionalized population.

RESULTS

Overall, 64.9% (95% CI, 62.9%-66.9%) of children 3 through 6 years of age were reported to have ever had vision testing. The likelihood of previous reported testing increased with age, from 42.9% among 3-year-olds to 79.4% among 6-year-olds (P < 0.001). After adjusting for age, family income, insurance status, whether the child had a regular health care provider, and whether the child had special health care needs, we found that lower odds of testing were reported among non-Hispanic white children (odds ratio [OR], 0.73; 95% CI, 0.55-0.97) and among Hispanic children (OR, 0.62; 95% CI, 0.47-0.82) compared with non-Hispanic black children (OR, 1).

CONCLUSIONS

These findings highlight the gaps in the delivery of preschool vision screening. Improved population-level surveillance of children's vision and methods to track use of vision-related health services are needed to inform policy makers to develop new strategies to improve care.

Predictors of well child care adherence over time in a cohort of urban Medicaid-eligible infants

BACKGROUND

Changes in well child care (WCC) adherence over time have not previously been examined. Our objective is to describe adherence rates to WCC over time in a low-income urban population of infants 0-24 months of age, and to identify predictors of WCC adherence in this population.

METHODS

This is a secondary analysis of a cohort of Medicaid-eligible children followed from birth to 2 years between 2005 and 2008 with structured telephone surveys to assess maternal well-being, social support, and household and demographic information. For the 260 children attending 4 urban pediatric practices, WCC adherence was assessed based on visit data abstracted from electronic medical records. A random-intercept mixed effects logit model clustered on subject was used.

RESULTS

92% of the mothers were African-American, 27% had not finished high school, 87% were single, and 43% earned<$500/month; mean age was 23. WCC adherence decreased from 88% at 6 months to 47% (12 mo), 44% (18 mo), and 67% (24 mo). The difference across time periods was statistically significant (p<0.001). Married (OR 1.71, p=0.02) and primiparous (OR 1.89, p<0.001) mothers had significantly greater odds of adherence, along with women who reported having been adherent to prenatal care visits (OR 1.49, p=0.03) and those with the lowest household income (OR 1.40, p=0.03).

CONCLUSIONS

Maternal education efforts should emphasize the importance of establishing WCC, especially for mothers of more than one child. Further studies using larger, more broadly defined populations are needed to confirm our findings that efforts to increase WCC adherence should be intensified after 6 months of age, particularly for children at higher risk.

The use of fluoride varnish and its determining factors among children with disability in Taiwan

The oral health of children with disability is often not as good as that of other children. In view of improving their oral health, this study aims to explore the utilization of fluoride varnish services among children with disability in Taiwan and its relevant influencing factors. With children under the age of 5 as subjects, this study is conducted based on the database of Ministry of the Interior, Executive Yuan, ROC in 2008, coupled with information gathered between 2006 and 2008 on preventive health care and health insurance from the Bureau of Health Promotion and the National Health Research Institute, respectively. In addition to descriptive statistics and bivariate analysis, this study examined the factors determining the use of fluoride varnish with logistic regression analysis. Research revealed that fluoride varnish is used by up to 9.84% of children with disability; the use increases with age and decreases with increased level of disability, but is remarkably higher in those with catastrophic illness/injury. The probability of fluoride varnish use is lower among those living in areas of lower urbanization (levels 5-7) and higher among those whose parents have higher premium-based monthly salaries. Recommendations include (1) providing a differential pricing scheme for fluoride varnish based on the level of disability of the child, (2) promoting proactively among dentists to carry out regular fluoride varnish in rural areas and collaboration with pediatricians to provide convenient services and (3) targeting families in low socioeconomic brackets, improving knowledge of fluoride varnish.

Health care services and the transition to young adulthood: challenges and opportunities

OBJECTIVE

The aim of this study was to examine the potential role of the health care system in the successful transition to young adulthood for all adolescents, with emphasis on adolescents with special health care needs (ASHCN), and to evaluate the system's status in filling that role.

METHOD

Research and conceptual frameworks addressing successful transitions and functioning were reviewed. A framework describing a role for health care services in the transition was presented. The health care system's status in promoting healthy transitions was evaluated, including National Survey of Children with Special Health Care Needs 2005-2006 analyses of key outcomes for ASHCN.

RESULTS

Although most national efforts to define skills needed for the transition have focused on career/vocational skills, a few frameworks integrate broader issues such as health, psychosocial development, and civic engagement. Adolescent transitional issues have generally received little attention; however, these have been articulated for ASHCN. Nevertheless, only 2 in 5 ASHCN receive transitional care, and ASHCN fare poorly on other core outcomes. ASHCN with mental health conditions fare worse on outcomes than those with physical health conditions. Our framework for healthy transitions includes the following: 1) adolescents can access a comprehensive health care system, 2) preventable problems are avoided, and 3) chronic problems are managed. The present health care system falls short of accomplishing these.

CONCLUSIONS

Health care services can potentially play a role in facilitating a healthy transition to young adulthood; however, many gaps exist. Although the health care reform act addresses some gaps, efforts that integrate adolescents' developmental needs and address mental health issues are needed.

Delivery of well-child care: a look inside the door

OBJECTIVE

To describe the delivery of well-child care and its components; to compare that delivery with recommendations in Bright Futures; and to compare delivery of well-child care for children with special health care needs with that for children without special needs.

METHODS

Over a 10-week period, 2 medical students observed and documented characteristics of well-child care visits by general pediatricians and midlevel pediatric providers. Parents completed a demographic questionnaire and a screener for children with special health care needs.

RESULTS

A total of 483 visits by 43 pediatricians and 9 midlevel providers with patients from 0 to 19 years of age were observed. Adjusted mean visit duration was 20.3 minutes; 38.9% of visits began with an open-ended question about parent/child concerns. A mean of 7.2 health supervision/anticipatory guidance topics were addressed per visit. Clinicians addressed a mean of 42% of Bright Futures-recommended age-specific health supervision/anticipatory guidance topics. Topics addressed less frequently than recommended included family support, parental well-being, behavior/discipline, physical activity, media screen time, risk reduction/substance use, puberty/sex, social-peer interactions, and violence. Shorter visits were associated with asking about parent/child concerns and with addressing greater proportions of recommended health supervision/anticipatory guidance topics. Well-child care visits with children with special health care needs were 36% longer than those with children without special needs and addressed similar numbers of age-specific health supervision/anticipatory guidance topics. More time was spent with children with special health care needs addressing health supervision/anticipatory guidance topics, other conditions (usually their chronic condition), and testing, prescriptions, and referrals.

CONCLUSIONS

Utilizing direct observation of visits with pediatric clinicians, we found that solicitation of parent/child concerns occurred less frequently than recommended. Fewer than half of recommended visit-specific health supervision/anticipatory guidance topics were addressed, and there was little congruence with some Bright Futures age group-specific recommendations. Notably, both solicitation of patient/parent concerns and greater adherence to health supervision/anticipatory guidance recommendations were associated with shorter visits. Well-child care visits with children with special health care needs were longer than those with children without special needs; more time was spent addressing similar numbers of health supervision/anticipatory guidance topics as well as their chronic conditions.

The medical home, preventive care screenings, and counseling for children: evidence from the Medical Expenditure Panel Survey

OBJECTIVE

Little is known about the role of the medical home in promoting essential preventive health care services in the general pediatric population. This study examined associations between having a medical home and receipt of health screenings and anticipatory guidance.

METHODS

We conducted a cross-sectional analysis of the 2004-2006 Medical Expenditure Panel Survey (MEPS). Our sample included 21 055 children aged 0 to 17 years who visited a health care provider in the year prior to the survey. A binary indicator of the medical home was developed from 22 questions in MEPS, reflecting 4 of the 7 American Academy of Pediatrics' recommended components of the medical home: accessible, family-centered, comprehensive, and compassionate care. Multivariable logistic regression was used to examine the association between the medical home and receipt of specific health screenings and anticipatory guidance, controlling for confounding variables.

RESULTS

Approximately 49% of our study sample has a medical home. The medical home, defined when the usual source of care is a person or facility, is significantly associated with 3 health screenings (ie, weight, height, and blood pressure) and several anticipatory guidance topics (ie, advice about dental checkups, diet, exercise, car and bike safety), with odds ratios ranging from 1.26 to 1.54.

CONCLUSIONS

The medical home is associated with increased odds of children receiving some health screenings and anticipatory guidance. The medical home may provide an opportunity to improve the delivery of these services for children.

The impact of insurance on satisfaction and family-centered care for CSHCN

BACKGROUND

Children with special health care needs (CSHCN) have worse health outcomes and satisfaction compared with children with typical needs. Although individual characteristics influence satisfaction and family-centered care, additional effects of health insurance and state child health policies are unknown.

OBJECTIVES

To determine if satisfaction and family-centered care varied among CSHCN, after adjusting for individual characteristics, according to insurance type and state child health policies.

METHODS

We performed descriptive and multivariate analyses by using demographic, insurance, and satisfaction data from the 2006 National Survey of Children With Special Health Care Needs (N = 40723). Additional state data included Medicaid and State Children's Health Insurance Program (SCHIP) characteristics and the supply of pediatricians. We supplemented the national findings with survey data from Florida's SCHIP comprehensive care program (CMS-Duval ["Ped-I-Care"]) for CSHCN (N = 300).

RESULTS

Nationally, 59.8% of parents were satisfied with their child's health services, and two thirds (65.7%) received family-centered care. Adjusting for individual predictors, those uninsured and those with public insurance were less satisfied (odds ratios [ORs]: 0.45 and 0.83, respectively) and received less family-centered care (ORs: 0.43 and 0.80, respectively) than privately insured children. Of note, satisfaction increased with state Medicaid spending. Survey data from Ped-I-Care yielded significantly higher satisfaction (91.7%) compared with national levels of satisfaction in the SCHIP (54.2%) and similar rates of family-centered care (65.6%). These results suggest that satisfaction is based more on experiences with health systems, whereas family-centered care reflects more on provider encounters.

CONCLUSIONS

Insurance type affects both satisfaction and family-centered care for CSHCN, and certain state-level health care characteristics affect satisfaction. Future studies should focus on interventions in the health care system to improve satisfaction and patient encounters for family-centered care.

The use of internet-based technology to tailor well-child care encounters

OBJECTIVE

The goal was to evaluate the feasibility and acceptance of a new model for well-child care (WCC) in a large health maintenance organization.

METHODS

We designed a new model of WCC that engages families in Internet-based developmental and behavioral screening, allows for review of the results before the visit, and allows for selection of the appropriate visit type (e-visit, e-visit with brief provider visit, or extended encounter). The new model was pilot-tested in 2 practices within a large health maintenance organization. Seven providers and 70 parents participated in the study. Parents and providers were surveyed regarding their experience and satisfaction with the encounter.

RESULTS

Seventy-five percent of parents thought that the online previsit assessment improved or very much improved the WCC visit. However, 12% of parents found the online assessment somewhat or very difficult to use. All of the parents found the e-visit or the e-visit with brief provider visit acceptable or very acceptable, compared with a standard WCC visit. All 7 providers thought that use of the new model helped focus the visit and that they would continue or definitely continue to use the model.

CONCLUSIONS

We demonstrated the feasibility of a new model of WCC that engaged parents in previsit assessment and used alternative visit types to tailor care to the needs of the family. Future research will be needed to examine the impact of this model on important WCC outcomes.

Access to the medical home: new findings from the 2005-2006 National Survey of Children with Special Health Care Needs

OBJECTIVE

This article reports new findings from the 2005-2006 National Survey of Children with Special Health Care Needs (NS-CSHCN) regarding parental perceptions of the extent to which children with special health care needs (CSHCN) have access to a medical home.

METHODS

Five criteria were analyzed to describe the extent to which CSHCN receive care characteristic of the medical home concept. Data on 40840 children included in the NS-CSHCN were used to assess the presence of a medical home, as indicated by achieving each of the 5 criteria.

RESULTS

Results of the survey indicate that (1) approximately one half of CSHCN receive care that meets all 5 criteria established for a medical home; (2) access to a medical home is affected significantly by race/ethnicity, income, health insurance status, and severity of the child's condition; (3) parents of children who do have a medical home report significantly less delayed or forgone care and significantly fewer unmet needs for health care and family support services; and (4) limited improvements have occurred since success rates were first measured by using the 2001 NS-CSHCN.

CONCLUSIONS

The findings suggest that, although some components of the medical home concept have been achieved for most CSHCN, care synonymous with the principles underlying the medical home is not yet in place for a significant number of CSHCN and their families.

Adolescent preventive services: rates and disparities in preventive health topics covered during routine medical care in a California sample

PURPOSE

The objective was to examine rates and disparities in preventive health topics covered during routine medical care for adolescents, using a California sample.

METHODS

Utilizing 2003 California Health Interview Survey data, the sample included 2192 adolescents attending a physical exam within the past 6 months. Adolescents reported whether nine health topics: tobacco, alcohol, drugs, seatbelts, helmets, violence, exercise, nutrition, and sexually transmitted diseases (STDs) were discussed during their most recent physical exam. Outcomes were rates of health topics discussed and disparities in rates based on age, gender, race/ethnicity, income level, and insurance status.

RESULTS

Rates ranged from 15% (violence) to 76% (nutrition, exercise). Compared to older teens, younger teens reported discussing safety more, but substances, nutrition, and STDs less. Compared to males, females reported discussing tobacco and helmets less, but exercise and STDs more. Compared to white youths, Hispanic youths reported more discussion of most topics, black youths reported more discussion of nutrition and less of violence, and Asian youths reported more discussion of seatbelts and helmets. Lower income and uninsured groups reported more discussion of health topics compared to higher income and insured groups.

CONCLUSIONS

Rates of coverage of health topics are below recommended levels. Contrary to expectations, minority, uninsured, and lower income groups reported higher rates of discussing health topics. Strategies to increase the coverage of preventive health topics during routine medical care should address these findings.

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.

Preventive care for adolescents: few get visits and fewer get services

OBJECTIVE

Professional guidelines for adolescents recommend annual preventive visits with screening and anticipatory guidance for health-related behaviors. The objective of this study was to examine receipt of preventive services, including disparities in services received, by using a nationally representative sample of adolescents.

METHODS

Using data from the 2001-2004 Medical Expenditure Panel Survey (ages 10-17; N = 8464), we examined receipt of preventive care visits and several measures of the content of care, based on caregiver's reports, among adolescents who received a preventive care visit during the past 12 months. Content of care outcomes included physical parameters measurement (height, weight, and blood pressure); receipt of anticipatory guidance (dental care, seat belts, helmets, exercise, healthy eating, and secondhand smoke exposure); and, for 12- to 17-year-olds, whether adolescents had time alone with their provider during their most recent visit, a proxy for confidential services. We conducted logistic regression analyses to test for disparities in the outcomes on the basis of race/ethnicity, income, and insurance status.

RESULTS

Thirty-eight percent of adolescents had a preventive care visit in the previous 12 months. Low-income and full-year uninsured status were associated with higher risk for not receiving this visit. Most adolescents had height (87%), weight (89%), and blood pressure (78%) assessed. Rates for height and weight were lower in poor and uninsured adolescents. Anticipatory guidance rates were much lower, ranging from 31% for seat belts, helmets, and secondhand smoke to 49% for healthy eating. Only 10% had all 6 areas addressed. Multivariate analyses yielded few disparities in receipt of anticipatory guidance. Forty percent had time alone with their providers. Hispanic and the lowest-income adolescents were the least likely to have time alone.

CONCLUSIONS

Few adolescents received a preventive visit; among those who received this visit, provision of recommended anticipatory guidance was very low. Strategies are required to improve delivery of recommended preventive services to adolescents.

Preventive care utilization among children with and without special health care needs: associations with unmet need

OBJECTIVE

To compare attendance at preventive medical and dental visits for children with special health care needs (CSHCN) and children without special health care needs, and associations between attending visits and unmet need.

METHODS

We analyzed data on 102 353 children aged 0 to 17 years from the National Survey of Children's Health. We examined associations between attending preventive medical or dental visits and CSHCN status, and unmet need for medical or preventive dental care and attending preventive medical or dental visits.

RESULTS

Medical care-CSHCN were more likely than other children to attend a well-child visit (odds ratio [95% confidence interval], 1.45 [1.12-1.93] for 0 to 5 years, 1.99 [1.74-2.28] for 6 to 11 years, 1.84 [1.64-2.06] for 12 to 17 years). CSHCN aged 12 to 17 years attending a well-child visit had lower odds of unmet medical need (0.48 [0.27-0.85]) than CSHCN not attending visits; well-child visits and unmet need were not associated for younger age groups. Dental care-CSHCN aged 3 to 5 years were more likely than other children of similar ages to attend a preventive dental visit (1.26 [1.04-1.52]). CSHCN attending a preventive dental visit had lower odds of unmet preventive dental needs than CSHCN not attending visits (0.52 [0.28-0.93] for 3 to 5 years, 0.18 [0.12-0.28] for 6 to 11 years, 0.12 [0.08-0.17] for 12 to 17 years).

CONCLUSIONS

CSHCN attend preventive medical and dental visits at similar or higher rates than other children. CSHCN who attend visits are less likely to have unmet needs. Further research should examine differences in visit content for CSHCN and mechanisms whereby preventive care may reduce unmet need.

[Health care needs of children and adolescents with chronic conditions]

Using data from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), we studied the association between chronic health conditions and specific health care needs among children and adolescents in Germany. A chronic health condition was defined based on standardized parent questionnaires and computer-assisted parent interviews regarding any lasting illness or health problem, congenital malformation or officially recognized disability. As part of the parent questionnaire, the validated German version of the Children with Special Health Care Needs (CSHCN) screener was used to assess special health care needs. Overall, 38.7% of the study population had at least one chronic health condition, as compared to 73.0% of children and adolescents who were identified as having specific health care needs. Only 25.8% of children and adolescents with chronic health conditions were found to have any special health care needs. However, this proportion varied considerably according to the type of health condition. Overall 3.7% of study participants screened positive for special health care needs, while no specific chronic health condition was reported by their parents. In multiple logistic regression analyses, factors independently associated with the absence of perceived health care needs among children and adolescents with chronic health conditions included female gender, migration background, a lower socioeconomic status, residence in former West Germany, a lower number of concomitant health problems, and the absence of behavioural problems. The identification of special health care needs among children and adolescents without any reported chronic health condition was determined by male gender, having no migration background, and evidence of behavioural problems. Further analyses are necessary to elucidate the relationship between chronic health conditions and health care needs among children and adolescents. These need to focus on specific health conditions and should include additional information on health-related quality of life, health care services use, and psychosocial resources.

Parental perceptions of dental/oral health among children with and without special health care needs

OBJECTIVES

The aims of this study were to determine the prevalence of parent-reported preventive dental care and better dental health in children with special health care needs (CSHCN) and to identify parent-reported dental problems, reasons for lack of preventive dental care, and factors associated with receiving preventive care and having better perceived dental health in CSHCN. A comparison group of children without special needs (CWOSN) was included.

METHODS

We analyzed the 2003 National Survey of Children's Health by using a sample of 17,001 CSHCN and a comparison group of CWOSN. Descriptive and between-group chi-square statistics were used to analyze child characteristics, parent-perceived dental problems, and reasons for lack of preventive dental care. Factors associated with receipt of preventive dental care and better reported dental health were examined using logistic regression.

RESULTS

Approximately 80% of CSHCN and 72% of CWOSN received preventive dental care. CSHCN parents reported more dental problems and fewer described their children as having good to excellent dental health compared to CWOSN, despite greater odds of having dental coverage and receiving preventive dental care. Disparities were evident in preventive dental care and dental health based on income, education, and insurance coverage.

CONCLUSIONS

Most parents of CSHCN and CWOSN report that their children receive preventive dental care and have good to excellent dental health; however, disparities in dental health and receipt of preventive dental care exist. Accessing care coordination by using the medical/dental home model, particularly for CSHCN, may alleviate the situation in which some of the most vulnerable children are experiencing the worst dental health.

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.