Racial/ethnic differences in children's access to care

Understanding barriers to well-child visit attendance among racial and ethnic minority parents

OBJECTIVES

To assess racial and ethnic minority parents' perceptions about barriers to well-child visit attendance.

METHODS

For this cross-sectional qualitative study, we recruited parents of pediatric primary care patients who were overdue for a well-child visit from the largest safety net healthcare organization in central Massachusetts to participate in semi-structured interviews. The interviews focused on understanding potential knowledge, structural, and experiential barriers for well-child visit attendance. Interview content was inductively coded and directed content analysis was performed to identify themes.

RESULTS

Twenty-five racial and ethnic minority parents participated; 17 (68%) of whom identified Spanish as a primary language spoken at home. Nearly all participants identified the purpose, significance, and value of well-child visits. Structural barriers were most cited as challenges to attending well-child visits, including parking, transportation, language, appointment availability, and work/other competing priorities. While language emerged as a distinct barrier, it also exacerbated some of the structural barriers identified. Experiential barriers were cited less commonly than structural barriers and included interactions with office staff, racial/ethnic discrimination, appointment reminders, methods of communication, wait time, and interactions with providers.

CONCLUSIONS

Racial and ethnic minority parents recognize the value of well-child visits; however, they commonly encounter structural barriers that limit access to care. Furthermore, a non-English primary language compounds the impact of these structural barriers. Understanding these barriers is important to inform health system policies to enhance access and delivery of pediatric care with a lens toward reducing racial and ethnic-based inequities.

Delayed and Forgone Health Care Among Adults With Limited English Proficiency During the Early COVID-19 Pandemic

BACKGROUND

Individuals with limited English proficiency (LEP) have long faced barriers in navigating the health care system. More information is needed to understand whether their care was limited further during the early period of the COVID-19 pandemic.

OBJECTIVE

To assess the impact of English proficiency on delayed and forgone health care during the early COVID-19 pandemic.

RESEARCH DESIGN

Multivariate logistic regression analysis of National Health Interview Survey data (July-December 2020; n=16,941). Outcomes were self-reported delayed and forgone health care because of cost or the COVID-19 pandemic. Delayed health care included medical, dental, mental health, and pharmacy care. Forgone health care also included care at home from a health professional.

RESULTS

A greater percentage of LEP adults reported delayed (49%) and forgone (41%) health care than English-proficient adults (40% and 30%, respectively). However, English proficiency was not significantly associated with delayed or forgone health care, after adjusting for demographic, socioeconomic, and health factors. Among LEP adults, multivariate models showed that being uninsured, having a disability, and having chronic conditions increased the risk of delaying and forgoing health care. LEP adults of Asian race and Hispanic ethnicity were also more likely to forgo health care while those with 65+ years were less likely to forgo health care.

CONCLUSIONS

Adults with LEP were more likely to experience challenges accessing health care early in the pandemic. Delayed and forgone health care were explained by low socioeconomic status and poor health. These findings highlight how during a period of limited health resources, deficiencies in the health care system resulted in an already disadvantaged group being at greater risk of inequitable access to care.

Differences in Pertussis Incidence by Race and Ethnicity in the United States, 2010-2017

Background

An increased pertussis burden has been demonstrated among Hispanic or Latino and American Indian or Alaska Native (AI/AN) infants. However, data on potential disparities among other age and racial groups are limited.

Methods

We analyzed pertussis cases reported through Enhanced Pertussis Surveillance from 2010 to 2017. Pertussis and severe pertussis incidence were calculated by race (White, Black or African American, AI/AN, and Asian or Pacific Islanders), ethnicity (Hispanic or Latino and non-Hispanic or non-Latino), and age.

Results

Compared with White persons, overall incidence was lower among Black or African American (incidence rate ratio [IRR], .57; 95% confidence interval [CI], .53-.61), AI/AN (IRR, 0.65; 95% CI, .58-.72), and Asian or Pacific Islander persons (IRR, 0.39; 95% CI, .35-.43). Overall incidence of pertussis was higher (1.5-fold; 95% CI, 1.37-1.60) among Hispanic or Latino compared with non-Hispanic or non-Latino adults, potentially related to household size or lower pertussis vaccine uptake among adult Hispanic or Latino cases. Severe pertussis incidence was similar among Black or African American and AI/AN persons compared with White persons. Among infants, severe pertussis incidence was 1.4-fold higher (95% CI, 1.03-1.82) among Black or African American infants than among White infants, and 2.1-fold higher (95% CI, 1.67-2.57) among Hispanic or Latino infants than non-Hispanic or non-Latino infants.

Conclusions

The contrast between lower reported incidence but similar or higher severe pertussis incidence among Black or African American and AI/AN persons compared with White persons warrants further investigation and may reflect underdiagnosis or underreporting of mild disease.

Differences in Telemedicine, Emergency Department, and Hospital Utilization Among Nonelderly Adults with Limited English Proficiency Post-COVID-19 Pandemic: a Cross-Sectional Analysis

BACKGROUND

The unprecedented use of telemedicine during the COVID-19 pandemic provided an opportunity to examine its uptake among individuals with limited English proficiency (LEP).

OBJECTIVE

To assess telemedicine use among nonelderly adults with LEP and the association between use of telehealth and emergency department (ED) and hospital visits.

DESIGN

Cross-sectional study using the National Health Interview Survey (July 2020-December 2021) PARTICIPANTS: Adults (18-64 years), with LEP (N=1488) or English proficiency (EP) (N=25,873) MAIN MEASURES: Telemedicine, ED visits, and hospital visits in the past 12 months. We used multivariate logistic regression to assess (1) the association of English proficiency on having telemedicine visits; and (2) the association of English proficiency and telemedicine visits on having ED and hospital visits.

KEY RESULTS

Between July 2020 and December 2021, 22% of adults with LEP had a telemedicine visit compared to 35% of adults with EP. After controlling for predisposing, enabling, and need factors, adults with LEP had 20% lower odds of having a telemedicine visit than adults with EP (p=0.02). While English proficiency was not associated with ED or hospital visits during this time, adults with telemedicine visits had significantly greater odds of having any ED (aOR: 1.80, p<0.001) and hospital visits (aOR: 2.03, p<0.001) in the past 12 months.

CONCLUSIONS

While telemedicine use increased overall during the COVID-19 pandemic, its use remained much less likely among adults with LEP. Interventions targeting structural barriers are needed to address disparities in access to telemedicine. More research is needed to understand the relationship between English proficiency, telemedicine visits, and downstream ED and hospital visits.

Ankyloglossia: Clinical and Sociodemographic Predictors of Diagnosis and Management in the United States, 2004 to 2019

OBJECTIVE

The past 2 decades have seen a rapid increase in the diagnosis of ankyloglossia. Patients are often managed by lingual frenotomy. The objective is to define the clinical and socioeconomic factors that determine which patients receive frenotomy.

STUDY DESIGN

A retrospective analysis of commercially insured children.

SETTING

Optum Data Mart database.

METHODS

Trends in frenotomy including provider and setting were described. Multiple logistic regression was used to determine predictors of frenotomy.

RESULTS

Diagnosis of ankyloglossia increased from 2004 to 2019 (from 3377 in 2004 to 13,200 in 2019), while lingual frenotomy similarly increased from 1483 in 2004 to 6213 in 2019. The proportion of inpatient frenotomy procedures increased from 6.2% to 16.6% from 2004 to 2019, with pediatricians having the highest odds of performing inpatient frenotomies (odds ratio: 4.32, 95% confidence interval: 4.08, 4.57). Additionally, during the study period, the proportion of frenotomies performed by pediatricians increased from 13.01% in 2004 to 28.38% in 2019. In multivariate regression analyses, frenotomy was significantly associated with the male sex, white non-Hispanic ethnicity, higher parental income and education, and a greater number of siblings.

CONCLUSION

Ankyloglossia has been increasingly diagnosed in the past 2 decades, and among patients with ankyloglossia, frenotomy is increasingly performed. This trend was driven at least in part due to increasing rates of pediatricians as proceduralists. After accounting for maternal and patient-level clinical factors, socioeconomic differences in the management of ankyloglossia were observed.

The Impact of Interpretation Services Training on Contact Tracing Efforts During the COVID-19 Pandemic

There is limited research regarding interpretation services training and its benefit in contact tracing programs. This study seeks to assess the impact of optional formal interpretation services training on contact tracers and identify specific barriers tracers face when contacting patients with limited English proficiency, who have been disproportionately impacted by the COVID-19 pandemic.

Children’s health insurance coverage and adequacy from 2016 to 2018: Racial/ethnic disparities under the ACA

Background:

This study advances health disparities research by documenting the racial/ethnic disparities in children’s health insurance coverage and health insurance adequacy under the implementation and revisions of the Affordable Care Act between 2016 and 2018 in America.

Design and methods:

Combining the nation-wide repeated cross-sectional data from 2016 to 2018 Children’s Health National Survey (NSCH), we examined the changes and trends of health insurance coverage and health insurance adequacy among children age 0–17 across different racial/ethnic groups from 2016 to 2018. Multivariate logistic regression models stratified by race-ethnicity were further analyzed to examine the association between children’s health insurance adequacy, their health insurance coverage, and their socio-demographic background factors.

Results:

Our analyses indicate that generally children’s enrollment in Medicaid or other government aided health care programs had been increasing whereas children’s enrollment in the employer-based had been decreasing from 2016 to 2018. At the same time, the number of children who said that they always had adequate health insurance to meet their health care needs has slightly dropped from 2016 to 2018, except for AIAN children. Our analyses further revealed that the risk of inadequate health insurance appears to be stronger for children in disadvantaged situation, socially and economically.

Conclusions:

The ACA has contributed to expanding childhood health insurance coverage. But racial/ethnic disparities continue to exist in children’s health insurance coverage and health insurance adequacy. To achieve equity in childhood health care, more outreach and appropriate programs are needed for children who are socially and economically disadvantaged.

The Influence of Socioeconomic Status (SES) and Processing Speed on the Psychological Adjustment and Wellbeing of Pediatric Brain Tumor Survivors

Simple Summary

Processing speed (PS) is one of the most impaired functions in pediatric brain tumor survivors (PBTSs) and it has been linked to difficulties in their psychological functioning, together with other non-insult-related risk factors, such as socio-economic status (SES). Given the psychological adjustment difficulties observed in PBTS, the aim of the current study was to explore the relationship between SES and psychological functioning, measured with the Child Behavioral Checklist (CBCL) and the Strengths and Difficulties Questionnaire, and considering the contribution of PS as a mediator. The results demonstrated that the influence of SES on the CBCL total index was mediated by PS. Furthermore, PS was found to have a mediating effect on the SES–internalizing problems relationship but not on the SES–externalizing problems relationship. These findings suggest that PS may be a rehabilitation target to prevent psychological distress and should be addressed, especially for PBTSs who live in a disadvantaged situation.

Abstract

(1) Background: The relationship between processing speed (PS) and psychological adjustment in the healthy population is well established, as is that between low socio-economic status (SES) and psychological distress. While PS is one of the most impaired functions in pediatric brain tumor survivors (PBTSs), previous research has demonstrated that low SES may be a predictor of increased psychosocial risk in PBTSs. Given the psychological adjustment difficulties observed in PBTS, in the current study we aimed to explore the relationship between SES and psychological functioning, considering the contribution of PS as a mediator. (2) Methods: demographic and clinical data of 80 children (age range: 4–17 y.o.) were retrospectively collected. Psychological measures were the parent-compiled versions of the Child Behavioral Checklist (CBCL) and the Strengths and Difficulties Questionnaire (SDQ). Mediation analysis models were performed on psychological measures with and without the inclusion of covariates. (3) Results: The influence of SES on the CBCL total index was mediated by PS. Furthermore, PS was found to have a mediating effect on the relationship between SES and internalizing problems but not on the relationship between SES and externalizing problems. (4) Conclusions: The results suggest that PS may be a rehabilitation target for the prevention of psychological distress and should be addressed especially for PBTSs who live in a disadvantaged situation.

A qualitative inquiry of communication based barriers to the diagnosis of pediatric cancer: Perceptions of primarily Spanish-speaking caregivers

BACKGROUND

Primarily Spanish-speaking cancer patients and caregivers often experience non-congruence with healthcare providers about beliefs, values, and knowledge of cancer. Our goal was to describe how communication related to the diagnosis of cancer was influenced by culture and language among primarily Spanish-speaking caregivers of pediatric cancer patients.

METHODS

Caregivers participated in three focus groups about their experiences with their child's diagnosis, communication issues, and understanding of their child's diagnosis and treatment plan. Focus groups were audio recorded, transcribed, and qualitatively analyzed using interpretive description.

RESULTS

Three themes emerged: 1) Negative experiences and barriers during the cancer diagnosis and treatment, 2) Miscommunication and system complexity, and 3) Language barriers throughout the diagnostic process. Due to barriers and negative experiences, some caregivers reported that their child's diagnosis was delayed, that providers sometimes used dehumanizing language, and that they were confused about diagnostic testing and treatment.

CONCLUSION

Cultural and linguistic disparities in pediatric oncology must be systematically addressed at the provider, clinic, and system level.

PRACTICE IMPLICATIONS

High-quality cancer care delivered by oncologists and cancer care teams should include cultural humility when discussing the cancer diagnosis and prognosis.

Factors that contribute to disparities in time to acute leukemia diagnosis in young people: an in depth qualitative interview study

BACKGROUND

Racial and ethnic disparities in outcomes for Black and Hispanic children with acute leukemia have been well documented, however little is known about the determinants of diagnostic delays in pediatric leukemia in the United States. The primary objective of this study is to identify factors contributing to delays preceding a pediatric leukemia diagnosis.

METHODS

This qualitative study utilized in-depth semi-structured interviews. Parents and/or patients within two years of receiving a new acute leukemia diagnosis were asked to reflect upon their family's experiences preceding the patient's diagnosis. Subjects were purposively sampled for maximum variation in race, ethnicity, income, and language. Interviews were analyzed using inductive theory-building and the constant comparative method to understand the process of diagnosis. Chart review was conducted to complement qualitative data.

RESULTS

Thirty-two interviews were conducted with a diverse population of English and Spanish speaking participants from two tertiary care pediatric cancer centers. Parents reported feeling frustrated when their intuition conflicted with providers' management decisions. Many felt laboratory testing was not performed soon enough. Additional contributors to delays included misattribution of vague symptoms to more common diagnoses, difficulties in obtaining appointments, and financial disincentives to seek urgent or emergent care. Reports of difficulty obtaining timely appointments and financial concerns were disproportionately raised among low-income Black and Hispanic participants. Comparatively, parents with prior healthcare experiences felt better able to navigate the system and advocate for additional testing at symptom onset.

CONCLUSIONS

While there are disease-related factors contributing to delays in diagnosis, it is important to recognize there are multiple non-disease-related factors that also contribute to delays. Evidence-based approaches to reduce outcome disparities in pediatric cancer likely need to start in the primary care setting where timeliness of diagnosis can be addressed.

Language Proficiency and Survival in Pancreatic Cancer: a Propensity Score-Matched Analysis

BACKGROUND

Limited English proficiency has been shown to negatively affect health outcomes. However, as of now, little is known about survival rates of patients with limited English proficiency (LEP) and pancreatic ductal adenocarcinoma (PDAC) when compared to patients with English proficiency (EP) in an urban, non-safety net setting. We aimed to compare survival rates between patients with LEP and those with EP who had a diagnosis of PDAC.

METHODS

A single-institution retrospective propensity-matched cohort study of patients with biopsy-proven PDAC was undertaken. Demographics, clinical characteristics, and language information were collected for all participants. Patients were classified as having LEP or EP based on their preferred speaking language at the time of admission and matched on baseline characteristics using propensity scores. Survival analysis methods were used to study survival rates in patients with PDAC based on their EP status.

RESULTS

Of 739 included patients, 71 (9.48%) had LEP, mean age was 68.4 ± 10.9, and 51.8% were female. Both groups of patients were comparable for age, gender, marital status, and time to treatment. LEP status was associated with higher odds of death in both unmatched (HR 1.65, 95% CI 1.22-2.22) and matched (HR 1.60, 95% CI 1.03-2.47) analyses. Additionally, patients with LEP had significantly decreased odds of receiving cancer-directed treatment and increased odds of advanced stage cancer at presentation.

CONCLUSIONS

In this cohort of patients with PDAC, LEP predicted worse survival. The results of this study suggest that, after accounting for interpreter use, other factors contribute to this disparity. Such factors, as yet unmeasured, may include health literacy and cultural expectations, for which further investigation is warranted to better understand and limit this survival disparity.

Prescription of antibiotics in the medical care of newly arrived refugees and migrants

PURPOSE

Unnecessary and inappropriate use of antibiotics is a widespread problem in primary care. However, current data on the care of refugees and migrants in initial reception centers is pending. This article provides data on prescription frequencies of various antibiotics and associated diagnoses.

METHODS

In this retrospective observational study, patient data of 3255 patients with 6376 medical contacts in two initial reception centers in Germany were analyzed. Patient data, collected by chart review, included sociodemographic characteristics, diagnoses, and prescriptions. Antibiotic prescription behavior and corresponding physician-coded diagnoses were analyzed.

RESULTS

Nineteen percent of all patients in our study received systemic antibiotics during the observation period, with children below the age of 10 years receiving antibiotics most frequently (24%). The most commonly prescribed antibiotics were penicillins (65%), macrolides (12%), and cephalosporins (7%). The most frequent diagnoses associated with antibiotic prescription were acute tonsillitis (26%), bronchitis (21%), infections of the upper respiratory tract (14%), and urinary tract infections (10%). In case of acute bronchitis 74% of the antibiotic prescriptions were probably not indicated. In addition, we found a significant number of inappropriate prescriptions such as amoxicillin for tonsillitis (67%), and ciprofloxacin and cotrimoxazol for urinary tract infections (49%).

CONCLUSION

Regarding inappropriate prescription of antibiotics in refugee healthcare, this study shows a rate ranging from 8% for upper respiratory tract infections to 75% for acute bronchitis. Unnecessary use of antibiotics is a global problem contributing to gratuitous costs, side effects, and antimicrobial resistance. This research contributes to the development of stringent antibiotic stewardship regiments in the particularly vulnerable population of migrants and refugees.

Factors Associated With Delay in Cleft Surgery at a Tertiary Children's Hospital in a Major US Metropolitan City

OBJECTIVE

To identify factors associated with late cleft repair at a US tertiary children's hospital.

DESIGN

Retrospective study of children with CL/P using Children's Hospital Los Angeles (CHLA) records.

SETTING

US tertiary children's hospital.

PATIENTS/PARTICIPANTS

Patients undergoing primary CL or CP repair at CHLA from 2009 to 2018.

MAIN OUTCOME MEASURES

Proportion of children who had delayed primary CL repair or CP repair using CHLA and American Cleft Palate-Craniofacial Association (ACPA) guidelines and factors associated with late surgery.

RESULTS

In total, 805 patients-503 (62.5%) who had CL repair, 302 (37.5%) CP repair-were included. Using CHLA protocol, 14.3% of patients seeking CL repair had delayed surgery. Delay was significantly associated with female gender, non-Hispanic ethnicity, Spanish primary language, government insurance, bilateral cleft, cleft lip and palate (CLP), and syndromic diagnosis. Using ACPA guidelines, 5.4% had delayed surgery. Female gender and syndromic diagnosis were significantly associated with delay and remained significant after adjustment for confounders in multivariate models. For CP repair, 60.3% of patients had delayed surgery using CHLA protocol. Cleft lip and palate diagnosis, complete cleft, syndromic diagnosis, and longer travel distance were significantly associated with delay. Using ACPA guidelines, 28.5% had delayed surgery; however, significant association with patient variables was not consistently observed.

CONCLUSIONS

Delay in cleft surgery occurs most often for patients seeking CP repair and is associated with female gender, non-Hispanic ethnicity, Spanish language, government insurance, and bilateral CL, CLP, or syndromic diagnoses. Initiatives should aim to optimize cleft surgery delivery for these subpopulations.

Language Barriers to Healthcare for Linguistic Minorities: The Case of Second Language-specific Health Communication Anxiety

In this study we examined health communication anxiety (HCA) associated with language-discordant situations - that is, where people have to use their second language (L2) to communicate with health providers who are using their first language (L1). We adapted existing HCA scales in order to (1) assess L2 HCA in such situations separately for physical and mental/emotional health contexts and (2) control for potential confounds, such as HCA not related to L2 use and L2 communication anxiety not related to health, allowing us to obtain L2-specific measures of HCA. We examined the relationship between L2-specific HCA and willingness to use health services in language-discordant situations. English-speaking linguistic minority participants (N = 314) living in Québec, a predominantly French-speaking area of Canada, were recruited for online testing. The results revealed that, separately for both physical and mental/emotional health contexts, there were significant and meaningful L2-specific relations between HCA and willingness to use L2 health services - i.e., over and above general anxiety and discomfort about using an L2, and over and above general health communication anxiety. The effect was stronger for mental/emotional health contexts. The results are discussed in terms of their implications for understanding barriers to health services for linguistic minorities.

Transcultural Differences in Risk Factors and in Triggering Reasons of Suicidal and Self-Harming Behaviour in Young People with and without a Migration Background

Minors with and without migration background can have different risk factors and triggering reasons for self-harming and suicidal behaviour. We retrospectively analysed the data of 192 children and adolescents to investigate the transcultural differences in self-harming, as well as suicidal behaviour in Austrian, Turkish, and Bosnian/Croatian/Serbian (BCS)-speaking patients, who were treated in an emergency out-patient clinic in Vienna. Our results showed transcultural differences in both behaviours. In all groups, females had higher rates of suicide attempts and self-harming behaviour than males. While Turkish-speaking patients received treatment more often, after attempted suicide, Austrians and BCS-speaking patients needed treatment more often for acute stress disorder. Suicide attempts and self-harming behaviours were triggered most frequently by intrafamilial problems, but more frequently in migrant patients. Turkish-speaking patients were at a more than 2 times (OR = 2.21, 95%CI: 1.408–3.477) higher risk for suicide attempts, and were triggered almost 3 times (OR = 2.94, 95%CI: 1.632–5.304) more often by interfamilial conflicts. The suicide attempts of BCS-speaking minors were more often caused by relationship and separation crises (OR = 2.56, 95%CI: 1.148–5.705). These transcultural differences in suicidal and self-harming behaviour of minors, demand an increase of transcultural competence to provide optimal treatment of migrant children.

Supply and Demand: Association Between Non-English Language-Speaking First Year Resident Physicians and Areas of Need in the USA

BACKGROUND

Over 25 million US inhabitants are limited English proficient (LEP). It is unknown whether physicians fluent in non-English languages are training in geographic areas with the highest proportion of LEP people. Diversity of language ability in the physician workforce is an important complement to language assistance services for providing quality care to LEP patients.

OBJECTIVE

To determine whether non-English language-speaking resident physicians matched in the geographic areas where language skills are needed.

DESIGN

Cross-sectional study.

PARTICIPANTS

Postgraduate medical training applicants to the Association of American Medical College's Electronic Residency Application Service in 2013-2014 (n = 50,766). We included data from the Graduate Medical Education Track database, mapped against American Community Survey data.

INTERVENTIONS

N/A.

MAIN MEASURES

We assessed the geographic alignment of non-English language-speaking resident physicians relative to the distribution of the LEP-speaking population.

KEY RESULTS

While 37% of resident physicians spoke at least one non-English language, in most cases the languages they spoke were not those in greatest need by the US LEP population. LEP speakers' potential exposure to non-English language-speaking residents varied. For Spanish, the language with the lowest national resident physician to Spanish LEP patient ratio, the ratio was most favorable in New York at 23.7/100,000 LEP population versus 5.1 in Los Angeles. For Tagalog, the group with the highest geographic mismatch, the ratio was 70.4 in New York but 0 in San Diego, San Jose, and Seattle. Among the top five LEP languages in the USA, Chinese-speaking resident physicians were the most geographically matched.

CONCLUSIONS

We found considerable misalignment of the geographic distribution of non-English language-speaking resident physicians relative to the distribution of the LEP-speaking population. Residency programs in areas of high need could consider better matching the non-English language needs of their community with the language abilities of the resident physicians they are recruiting.

Impact of Socioeconomic Status on Outcomes of Patients with Kawasaki Disease

OBJECTIVE

To evaluate the association of neighborhood socioeconomic status (SES) with time to intravenous immunoglobulin treatment, length of stay (LOS), and coronary artery aneurysms (CAAs) in patients with Kawasaki disease.

STUDY DESIGN

We examined the relationship of SES in 915 patients treated at a large academic center between 2000 and 2017. Neighborhood SES was measured using a US census-based score derived from 6 measures related to income, education, and occupation. Linear and logistic regression were used to examine the association of SES with number of days of fever at time of treatment, LOS, and CAA.

RESULTS

Patients in the lowest SES quartile were treated later than patients with greater SES (7 [IQR 5, 9] vs 6 [IQR 5, 8] days, P = .01). Patients in the lowest SES quartile were more likely to be treated after 10 days of illness, with an OR 1.9 (95% CI 1.3-2.8). In multivariable analysis, SES remained an independent predictor of the number of days of fever at time of treatment (P = .01). Patients in the lowest SES quartile had longer LOS than patients with greater SES (3 [IQR 2, 5] vs 3 [IQR 2, 4], P = .007). In subgroup analysis of white children, those in the lowest SES quartile vs quartiles 2-4 were more likely to develop large/giant CAA 17 (12%) vs 30 (6%), P = .03.

CONCLUSIONS

Lower SES is associated with delayed treatment, prolonged LOS, and increased risk of large/giant CAA. Novel approaches to diagnosis and education are needed for children living in low-SES neighborhoods.

RETRACTED: Factors Affecting Readmission After Pediatric Thyroid Resection: A National Surgical Quality Improvement Program-Pediatric Evaluation

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the authors because of an error involving the dataset which doubled the reported sample size, thereby invalidating the analysis. The authors reported this error immediately upon discovering the problem. The authors regret the error.

Racial and Ethnic Disparities in Provider-Related Barriers to Health Care for Children in California After the ACA

The aim of this study was to examine disparities in provider-related barriers to health care by race and ethnicity of children in California after the implementation of the Affordable Care Act (ACA). California Health Interview Survey child (0-11 years) survey data from 2014 to 2016 were used to conduct multivariable logistic regressions to estimate the odds of reporting any provider-related barrier, trouble finding a doctor, child’s health insurance not accepted by provider, and child not being accepted as a new patient. Compared with parents of non-Latino white children, parents of non-Latino black, Latino, Asian, and other/multiracial children were not more likely to report experiencing any of the 4 provider-related barrier measures. The associations between children’s race and ethnicity and parents’ reports of provider-related barriers were nonsignificant. Findings demonstrate that there are no significant racial/ethnic differences in provider-related barriers to health care for children in California in the post-ACA era.

Objectively measured pediatric obesity prevalence using the OneFlorida Clinical Research Consortium

We characterized the prevalence of obesity among Florida children 2-19years old using electronic health records (EHRs). The obesity prevalence for 331,641 children was 16.9%. Obesity prevalence at 6-11years (19.5%) and 12-19years (18.9%) were approximately double the prevalence of obesity among children 2-5years (9.9%). The highest prevalence of severe obesity occurred in rural Florida (21.7%) and non-Hispanic children with multiple races had the highest obesity prevalence (21.1%) across all racial/ethnic groups. Our results highlight EHR as a low-cost alternative to estimate the prevalence of obesity and severe obesity in Florida children, both overall and within subpopulations.

Determinants of having no general practitioner in Germany and the influence of a migration background: results of the German health interview and examination survey for adults (DEGS1)

BACKGROUND

It is aspired in the German healthcare system that general practitioners (GPs) act as initial contact for patients and guide through at all steps of medical treatment. This study aims at identifying factors associated with the odds of having no GP within the general population and especially among people with migration background.

METHODS

This cross-sectional analysis was based on the "German Health Interview and Examination Survey for Adults" (DEGS1) conducted by the Robert Koch Institute. Descriptive analyses as well as multiple logistic regression models were performed to analyse the impact of a migration background, age, gender, residential area, socioeconomic status (SES) and other factors on having no GP among 7755 participants.

RESULTS

9.5% of the total study population and 14.8% of people with a migration background had no GP, especially men, adults living in big cities and without chronic diseases. The odds of not having a GP were higher for people with a two-sided migration background (aOR: 1.90, 95% CI: 1.42-2.55). Among the population with a migration background, particularly young adults, men, people living in big cities and having a private health insurance showed higher odds to have no GP.

CONCLUSIONS

It is necessary to investigate the causes of the differing utilization of healthcare of people with a migration background and, if necessary, to take measures for an equal access to healthcare for all population groups. Further research needs to be done to evaluate how to get young people into contact with a GP.

Nativity, Duration of Residence, Citizenship, and Access to Health Care for Hispanic Children

This article examines differences in access to a regular source of health care for children of Hispanic subgroups within the United States. Particular attention is paid to the impact of the immigration status of the mother –including nativity, duration in the United States, and citizenship status – and its affect on access to health care for Hispanic children. Data are pooled from the National Health Interview Survey for 1999–2001 and logistic regression models are estimated to compare Mexican American, Puerto Rican, Cuban, and Other Hispanic children with non-Hispanic whites and blacks. While initial disparities are recorded among the race/ethnic groups, in the final model, only Mexican American children display significantly less access to health care than non-Hispanic whites. The combined influence of the mother's nativity, duration, and citizenship status explains much of the differentials in access to a regular source of care among children of Hispanic subgroups in comparison to non-Hispanic whites.

Reduced Severity of Pertussis in Persons With Age-Appropriate Pertussis Vaccination-United States, 2010-2012

Background

In 2012, >48000 pertussis cases were reported in the United States. Many cases occurred in vaccinated persons, showing that pertussis vaccination does not prevent all pertussis cases. However, pertussis vaccination may have an impact on disease severity.

Methods

We analyzed data on probable and confirmed pertussis cases reported through Enhanced Pertussis Surveillance (Emerging Infections Program Network) between 2010 and 2012. Surveillance data were collected through physician and patient interview and vaccine registries. We assessed whether having received an age-appropriate number of pertussis vaccines (AAV) (for persons aged ≥3 months) was associated with reduced odds of posttussive vomiting, a marker of more clinically significant illness, or of severe pertussis (seizure, encephalopathy, pneumonia, and/or hospitalization). Adjusted odds ratios were calculated using multivariable logistic regression.

Results

Among 9801 pertussis patients aged ≥3 months, 77.6% were AAV. AAV status was associated with a 60% reduction in odds of severe disease in children aged 7 months-6 years in multivariable logistic regression and a 30% reduction in odds of posttussive vomiting in persons aged 19 months-64 years.

Conclusions

Serious pertussis symptoms and complications are less common among AAV pertussis patients, demonstrating that the positive impact of pertussis vaccination extends beyond decreasing risk of disease.

Neighborhood Socioeconomic Status and Outcomes Following the Norwood Procedure: An Analysis of the Pediatric Heart Network Single Ventricle Reconstruction Trial Public Data Set

BACKGROUND

Children with single ventricle heart disease require frequent interventions and follow-up. Low socioeconomic status (SES) may limit access to high-quality care and place these children at risk for poor long-term outcomes.

METHODS AND RESULTS

Data from the SVR (Pediatric Heart Network Single Ventricle Reconstruction Trial Public Use) data set were used to examine the relationship of US neighborhood SES with 30-day and 1-year mortality or cardiac transplantation and length of stay among neonates undergoing the Norwood procedure (n=525). Crude rates of death or transplantation at 1 year after Norwood were highest for patients living in neighborhoods with low SES (lowest tertile 37.0% versus middle tertile 31.0% versus highest tertile 23.6%, P=0.024). After adjustment for patient demographics, birth characteristics, and anatomy, patients in the highest SES tertile had significantly lower risk of death or transplant than patients in the lowest SES tertile (hazard ratio 0.62, 95% confidence interval, 0.40, 0.96). When SES was examined continuously, the hazard of 1-year death or transplant decreased steadily with increasing neighborhood SES. Hazard ratios for 30-day transplant-free survival and 1-year transplant-free survival were similar in magnitude. There were no significant differences in length of stay following the Norwood procedure by SES.

CONCLUSIONS

Low neighborhood SES is associated with worse 1-year transplant-free survival after the Norwood procedure, suggesting that socioeconomic and environmental factors may be important determinants of outcome in critical congenital heart disease. Future studies should investigate aspects of SES and environment amenable to intervention.

CLINICAL TRIAL REGISTRATION

URL:http://www.clinicaltrials.gov> http://www.clinicaltrials.gov. Unique identifier: NCT00115934.

Factors associated with patients' satisfaction in Brazilian dental primary health care

Objective

To assess factors associated with patients’ satisfaction with the treatment by dentists in primary health care (PHC) in Brazil.

Materials and methods

The dataset was part of a nationwide cross-sectional survey for evaluating PHC teams conducted by the Brazilian Ministry of Health. Patients from each of 16,202 oral health teams were interviewed. In addition to sociodemographic information, the questionnaire included information about patient experience domains: access and booking of dental appointments, bonding and accountability, welcoming of the patient, and their perception of dental facilities.

Statistical analysis

The dependent variable was the answer to the question ‘From 0 to 10, how would you grade your satisfaction with treatment received from the dentist?’ Negative binomial regression models were used to estimate the unadjusted and adjusted rate ratios and corresponding 95% confidence interval.

Results

The mean patient satisfaction was 9.4 (±2.3). Higher patient satisfaction with PHC was associated with lower education and the patient’s perception of the clinic conditions. Moreover, higher satisfaction was associated with positive reception and hospitality, enough time for treatment, and instructions that met patients’ needs. Lower satisfaction with PHC was associated with patients who have jobs compared to those who do not work.

Conclusion

Patient satisfaction is increased with friendly and understanding PHC staff. Moreover, meeting patient expectations by taking time to understand the needs and giving the right instructions is associated with higher satisfaction.

Understanding Hearing and Hearing Loss in Children With Down Syndrome

PURPOSE

This study evaluated the prevalence of permanent and transient hearing loss, the use of hearing aids as a recommendation, and middle ear dysfunction in children with Down syndrome (DS) through a large multiage and ethnically diverse sample, using current audiologic testing practices.

METHOD

Retrospective analysis of data collected on 308 children with DS (168 boys, 140 girls; average age = 5.99 ± 4.88 years) who received an audiological evaluation during 2013 as part of their medical care at a large pediatric hospital.

RESULTS

Permanent hearing loss was identified in 24.9% of the children, among whom bilateral (75.4%) and conductive (33.3%) hearing losses occurred most often. Of children with DS, 22%-30% experienced a transient hearing loss, with a high incidence of middle ear pathologies from infancy until early adulthood. There were no statistical differences between ethnicity and permanent/transient hearing loss diagnosis. Twenty-three percent were current hearing aid users or had them recommended in a treatment plan.

CONCLUSIONS

The prevalence of hearing loss and abnormal middle ear status is high in the pediatric population with DS. Audiologic evaluations should follow the American Academy of Pediatrics practice guidelines to monitor this high-risk population, and amplification should be considered as an appropriate intervention option if repeated audiologic examinations reveal hearing loss.

Infection-related mortality in Hispanic and non-Hispanic children with cancer

BACKGROUND

Hispanic children with cancer experience poorer survival than their White counterparts. Infection is a known cause of cancer-related mortality; however, little is known about the risk of infection-related death among Hispanic children with cancer. We examine the association of Hispanic ethnicity with infection-related mortality and life-threatening events among children with cancer.

PROCEDURE

For a cohort of all pediatric cancer patients diagnosed from 1986 to 2012 and treated at a single tertiary care center, we obtained national death records to determine all-cause mortality and infection-related mortality, as well as intensive care unit (ICU) admissions as a surrogate for life-threatening events. Cox proportional hazard models assessed all-cause mortality and infection-related mortality using ethnicity as the main independent variable. ICU admission rates were modeled using a zero-inflated Poisson regression model. Models were adjusted for gender, diagnosis year, age, residential location, and diagnosis.

RESULTS

Of 6,198 patients, 741 (12%) were Hispanic. Mean follow-up was 11 years (SD = 8.04). There were 1,205 deaths, with 193 attributable to infection. Differences in all-cause mortality between Hispanic and non-Hispanic patients did not reach significance (hazard ratio [HR] = 1.14, 95% confidence interval [CI]: 0.96-1.36). However, Hispanic patients were 68% (HR = 1.68, 95% CI: 1.16-2.43) more likely to have an infection-related cause of death. Hispanic ethnicity was statistically associated with a higher rate of ICU admissions (rate ratio = 1.32, 95% CI: 1.12-1.56).

CONCLUSION

Hispanic pediatric cancer patients were more likely to have an infection-related death and higher rates of ICU admissions than non-Hispanic patients. Infection may be an overlooked contributor to poorer outcomes among Hispanic patients.

Dietary and Physical Activity Counseling Trends in U.S. Children, 2002-2011

INTRODUCTION

In 2007 and 2010, Expert Committee and U.S. Preventive Services Task Force guidelines were released, respectively, urging U.S. practitioners to deliver preventive obesity counseling for children. This study determined the frequency and evaluated predictors of receiving counseling for diet and physical activity among a national sample of children from 2002 to 2011.

METHODS

Children aged 6-17 years were used from the 2002-2011 Medical Expenditure Panel Surveys and analyzed in 2016. Parental report of two questions assessed whether children received both dietary and exercise counseling from the provider. Children were grouped by weight category. Bivariate analyses compared the frequency of receiving counseling; logistic regression evaluated predictors of receiving counseling.

RESULTS

The sample included 36,114 children; <50% of children received counseling. Across all time periods, children were more likely to receive counseling with increasing weight. Logistic regression models showed that obese children had greater odds of receiving counseling versus normal-weight children, even after adjusting for covariates. Additional significant positive correlates of receiving counseling were Hispanic ethnicity, living in an urban setting, and being in the highest income stratum. Being uninsured was associated with lower odds of counseling. Years 2007-2009 and 2010-2011 were associated with increased counseling versus the benchmark year category in the multivariable model.

CONCLUSIONS

Counseling appears more likely with greater weight and increased after both guidelines in 2007 and 2010. Overall counseling rates for children remain low. Future work should focus on marginalized groups, such as racial and ethnic minorities and rural populations.

Which Health Cares Are Related to the Family Physician? A Critical Interpretive Synthesis of Literature

BACKGROUND

This study provided the theoretical basis for program development through a new conceptualization of the concept of family physician related health care.

METHODS

Critical interpretive synthesis (CIS) was used to carry out qualitative analysis and synthesis of the literature from 2006 until 2015. At the beginning of CIS, the search strategy was designed to access electronic databases such as CINAHL, Medline, Cochrane library, PsycINFO, Embase, EBMreviews, and Thomson scientific web of science database. The main review question was the clarification of the health care related to family physician in health system, which produced over related 750 articles; 60 articles related to the research objective were studied by purposive sampling. After identifying the main categories and sub-categories, synthesis of the contradictory findings in different studies was conducted. New concepts and relationships between concepts were created using CIS of documentation related to the place of family physician in health system.

RESULTS

To define the original position of family physician in health system, clarify its related health care and determine its boundaries from other health care providers, and its use in the design and development of family physician's educational program, a frame of concepts related to the main concept and question was created. A more useful means of understanding family physician is offered by the synthetic constructs of this framework.

CONCLUSION

The theoretical conceptualization of family physician position and duties in the health system can be an appropriate guide for educational program and curricula in our context.

"What We Have Here is a Failure to Communicate": Association of Preferred Language With the Rate of Psychiatric Consultation

BACKGROUND

In the United States, people with limited English proficiency (LEP) receive poorer medical care than those proficient in English. Few studies demonstrate how linguistic barriers complicate psychiatric care; in consultation-liaison (C-L) psychiatry, there are no published data about care disparities for patients with LEP or for whom English is not the preferred language (PL).

OBJECTIVE

We sought to determine if PL affects the psychiatric consultation rate.

METHODS

Among adult patients admitted during 1 year to a large urban academic medical center, we compared psychiatric consultation rates in English PL patients with non-English PL patients. PL was ascertained from demographics during the medical record. The occurrence of psychiatric consultation was ascertained from C-L service logs.

RESULTS

There were 54,534 admissions: the no-consultation group (N = 53,196) and the consultation group (N = 1,398). English as PL was more common in the consult group (72.0% of consult group, 62.0% of no-consult group, χ² = 92.98, p < 0.0001). Spanish speakers were underrepresented in the consult group (14.2% of consult, 25.8% of no-consult, χ² = 98.78, p < 0.0001).

CONCLUSION

Primary teams requested more consultations for patients whose PL was English than for patients with other PLs, suggesting that psychiatric needs of patients with non-English PL may be unaddressed. This is the first study to demonstrate a disproportionately low rate of general hospital psychiatric consultations in this population. Further study is necessary to confirm and understand this disparity. We recommend routine use of professional interpreters and low threshold for consultation in patients with non-English PL.

The Effect of Initiatives to Overcome Language Barriers and Improve Attendance: A Cross-Sectional Analysis of Adherence in an Inner City Chronic Pain Clinic

Language barriers can prevent pain physicians and patients from forming meaningful rapport and drive health care disparities. Non-adherence with scheduled pain clinic appointments deprives patients with chronic pain of needed specialist care.

Objective

We evaluated the benefit of comprehensive initiatives to overcome language barriers to improve patient adherence with initial scheduled chronic pain clinic appointments.

Design

After implementation of our initiative, we performed a retrospective cross-sectional analysis and fit logistic regression models to investigate the association between demographic factors and adherence.

Setting

We collected retrospective data from an observational cohort with a scheduled appointment at the adult inner-city underserved outpatient Pain Center at Montefiore Medical Center, Bronx, New York.

Patients

Between March 2012 and March 2014, 14,459 appointments were scheduled; 3,035 of these appointments represented initial first visits; patients had a mean age of 53 years; 15% were predominantly Spanish-speaking, 65% were female.

Interventions

Our initiative to overcome language barriers in our pain clinic included appointment reminders in the patient’s preferred language, Spanish-speaking staff, and unified locations with equitable access.

Outcome Measures

Our dependent variable was adherence with a first scheduled pain clinic appointment.

Results

We found that after implementation of our initiative, speaking Spanish was now statistically significantly associated with higher rates of adherence with appointments (Odds Ratio 1.32, 95% confidence interval [1.06–1.64]).

Conclusions

We infer from our results that coordinated initiatives to overcome language barriers can be beneficial in improving appointment adherence and access to care by enhancing rapport and communication between pain physicians and their patients.

Perspective

The results of this retrospective cross-sectional analysis of patients’ adherence with scheduled appointments in an inner-city chronic pain clinic suggests that targeted initiatives including a pre-clinic reminder phone call in the patient’s own language may help to overcome language barriers and improve access to care.

Racial and Ethnic Disparities in Unmet Need for Pediatric Therapy Services: The Role of Family-Centered Care

OBJECTIVE

To examine whether individual elements of family-centered care (FCC) mediate racial/ethnic disparities in parent-reported unmet therapy need.

METHODS

We conducted a secondary data analysis using the 2009-2010 National Survey of Children With Special Health Care Needs. A total of 6478 black, Hispanic, and white children ages 0 to 5 years had complete data on parent-reported unmet need and FCC. Five measured indicators of FCC included whether the child's health care provider spent enough time with the child (time), listened carefully to the child's parents (listening), was sensitive to family culture and values (sensitivity), delivered information specific to the child's health (information), and helped parents feel like partners (partnership). We performed staged multivariate logistic regression to test the association between race/ethnicity and parent-reported unmet therapy need, and to explore whether this association was mediated by elements of FCC using the Baron-Kenny mediation framework.

RESULTS

Eighteen percent of children with special health care needs 0 to 5 years old with reported therapy need experienced unmet need. Black and Hispanic children were more likely than white children to have parent-reported unmet therapy need (adjusted odds ratio 1.59, 95% confidence interval 1.08-2.36). This disparity was no longer significant after adjustment for the FCC elements of time, sensitivity, or partnership.

CONCLUSIONS

The provision of FCC is likely an important factor in meeting the therapy needs of children with developmental delay and in reducing racial/ethnic disparities in parent-reported unmet therapy need. Interventions aimed at fostering parent-provider relationships through improved cultural sensitivity and engagement of parents as partners are necessary to ensure equitable utilization of these services.

The impact of language barriers and immigration status on the care experience for Spanish-speaking caregivers of patients with pediatric cancer

BACKGROUND

An increasing proportion of pediatric cancer patients in the United States are Latino and many have Spanish-speaking immigrant parents with limited English proficiency (LEP). Little is known about how language or undocumented immigration status impacts their care experience.

PROCEDURE

A cross-sectional survey was administered to English (N = 310) and Spanish-speaking LEP (N = 56) caregivers of pediatric cancer patients. To assess differences in healthcare experiences between the language groups, t-tests and chi-square statistics were used. Multivariable logistic regression evaluated associations between primary language and knowledge of clinical trial status.

RESULTS

Spanish-speaking caregivers were more likely to report higher rates of quitting or changing jobs as a direct result of their child's cancer, and their children were more likely to experience a delay in education. Although Spanish-speaking caregivers reported higher satisfaction with care, 32% reported feeling that their child would have received better care if English was their primary language. Spanish-speaking caregivers were more likely to incorrectly identify whether their child was on a clinical trial compared with English-speaking caregivers. The majority of Spanish-speaking caregivers reported at least one undocumented caregiver in the household and 11% of them avoided or delayed medical care for their child due to concerns over their undocumented immigration status.

CONCLUSIONS

Language barriers and undocumented immigration status may negatively impact the quality of informed decision-making and the care experience for Spanish-speaking LEP caregivers of pediatric cancer patients. These families may benefit from culturally appropriate Spanish language resources to improve communication and open a dialogue regarding undocumented immigration status.

Spanish and English Language Symposia to Enhance Activation in Pediatric Inflammatory Bowel Disease

OBJECTIVES

Patient activation is an important consideration for improved health outcomes in the management of chronic diseases. Limited English proficiency among patients and primary care providers has been shown to be a predictor for worse health across disease states. We aimed to determine the baseline patient activation measure (PAM) among Spanish-speaking (SP) and English-speaking (ES) pediatric patients with IBD and parents, and to describe the feasibility and efficacy of a novel peer-group education symposium designed to enhance patient activation as measured with the PAM.

METHODS

Two separate half-day educational symposia in either Spanish or English were presented and moderated by 2 native SP physicians. Content for each of the presentations were highly standardized and interactive, designed to address each of the activation domains (self-management, collaboration with a health care provider, maintenance of function and prevention of disease exacerbation, and appropriate access to high-quality care). Descriptive statistics were used to describe changes between pre- and postsymposium PAM trends.

RESULTS

Eleven primarily SP and 21 ES families participated in their respective symposium. Paired pre- and post-PAM scores were available from 24 pediatric patients with IBD (8 SP, 16 ES) and 41 parents (15 SP, 26 ES). The mean age for SP and ES patients was 11.6 and 12.0 years, and female sex in 80% and 62%, respectively. Paired pre- and post-PAM scores for all participants (n = 65) were analyzed. PAM scores uniformly increased in all 4 groups after the symposia (SP patients 59.1-70.3, P = 0.05; SP parents 69.8-75.2, P = 0.2; ES patients 59.9-64.0, P = 0.08; ES parents 61.9-69.1, P = 0.002), although only the ES-parents group had sufficient sample size (n = 26) to achieve statistical significance. The overall cohort had an aggregate increase from pre-PAM of 62.9 (SD 14.5) to post-PAM of 69.4 (SD 13.9) (<0.001).

CONCLUSIONS

We describe a novel peer-group educational symposium presented in Spanish and English languages to increase patient and parent activation in pediatric patients with IBD and their caregiving parents. The use of PAM to assess levels of activation appears to be feasible and effective in these groups.

Contrasting Experiences With Child Health Care Services by Mothers and Professional Caregivers in Transitional Housing

The study examined experiences of mothers and health care providers with preventive child health care services using qualitative methods at a primary care clinic located in transitional housing for homeless families in an urban community with predominantly Black American residents. Participants were 20 mothers and 4 health care professionals. Three major domains emerged: (a) the infrastructure of the clinic and health care delivery poses barriers to mothers’ access and use of services for their children; (b) specialized, biomedical-driven care produces fragmented care delivery not responsive to the comprehensive nature of problems of mothers and their children; and (c) organizational strategies for improving access and use of health care services are directed by health care providers’ value orientations. Findings support existence of infrastructural characteristics of the health care system that maintains differential value orientations and power structure, and care delivery processes that are non responsive to racially diverse and poor mothers.

Nursing Unit Environment Associated with Provision of Language Services in Pediatric Hospices

BACKGROUND

Provision of language services in pediatric hospice enables nurses to communicate effectively with patients who have limited English proficiency. Language barriers contribute to ethnic disparities in health care. While language service use corresponds with improved patient comprehension of illness and care options, we lack an understanding of how the nurse work environment affects the provision of these services.

METHODS

Data were obtained from the 2007 National Home and Hospice Care Survey and included a study sample of 1251 pediatric hospice agencies. Variable selection was guided by structural contingency theory, which posits that organizational effectiveness is dependent upon how well an organization's structure relates to its context. Using multivariate logistic regression, we analyzed the extent to which nursing unit environment predicted provision of translation services and interpreter services.

RESULTS

The majority of hospices provided translation services (74.9 %) and interpreter services (87.1 %). Four variables predicted translation services: registered nurse (RN) unit size, RN leadership, RN medical expertise, and for-profit status. RN medical expertise and having a safety climate within the hospice corresponded with provision of interpreter services.

CONCLUSIONS

Findings indicate that nursing unit environment predicts provision of language services. Hospices with more specialized RNs and a stronger safety climate might include staffs who are dedicated to best care provision, including language services. This study provides valuable data on the nurse work environment as a predictor of language services provision, which can better serve patients with limited English proficiency and ultimately reduce ethnic disparities in end-of-life care for children and their families.

Race, disability, and grade: Social relationships in children with autism spectrum disorders

Race is associated with social relationships among typically developing children; however, studies rarely examine the impact of race on social outcomes for children with autism spectrum disorder. This study examined how race (African American, Latino, Asian, or White) in conjunction with disability status (autism spectrum disorders or typically developing) and grade (grades K-2 or 3-5) affects friendships and social networks. The sample comprises 85 children with autism spectrum disorders and 85 typically developing controls matched on race, gender, age/grade, and classroom (wherever possible). Race, disability, and grade each had an independent effect on friendship nominations, and there was an interaction among the three variables. Specifically, children with autism spectrum disorders who were African American or Latino in the upper elementary grades received fewer friendship nominations than typically developing White children in the lower elementary grades. Only the presence of autism spectrum disorders was associated with social network centrality. Our results also suggested that Latino children with autism spectrum disorders in the upper elementary grades were at the highest risk of social isolation. Implications for re-conceptualizing social skills interventions are discussed.

Capturing Unmet Therapy Need Among Young Children With Developmental Delay Using National Survey Data

OBJECTIVE

Estimates of unmet therapy need based on parent report overlook the unmet needs of children with developmental delay (DD) whose parents do not first recognize a need for therapy. Using national survey, data we: 1) identified children with DD who likely need physical, occupational, or speech therapy services; 2) estimated the prevalence of overall unmet therapy need; and 3) examined factors associated with unrecognized therapy need and parent-reported unmet therapy need.

METHODS

Criteria for DD were applied to children aged 0 to 4 years using the 2009-2010 National Survey of Children With Special Health Care Needs (NS-CSHCN). Multivariate logistic regression was used to identify factors associated with unrecognized or parent-reported unmet therapy need.

RESULTS

Among 5349 children with special health care needs aged 0 to 4 years, 50.2% met our inclusion criteria for DD, 21.6% had overall unmet therapy need, 15.4% had unrecognized therapy needs, and 6.2% had parent-reported unmet therapy need. The adjusted odds of unrecognized therapy need were higher among black and Hispanic children, and children from other racial or ethnic groups than among white children (adjusted odds ratio 1.78 [95% confidence interval 1.23-2.57]). The odds of parent-reported unmet therapy need were higher for children lacking special education services.

CONCLUSIONS

Relying on parent-reported unmet therapy need, without considering children with DD whose therapy needs go unrecognized, likely underestimates overall unmet therapy need among children with DD. Exploring the mechanisms underlying racial, ethnic, and socioeconomic disparities in overall unmet therapy need should facilitate the development of effective interventions aimed at improving therapy access for children with DD.

Adolescent Survival Expectations: Variations by Race, Ethnicity, and Nativity

Adolescent survival expectations are linked to a range of problem behaviors, poor health, and later socioeconomic disadvantage, yet scholars have not examined how survival expectations are differentially patterned by race, ethnicity, and/or nativity. This is a critical omission given that many risk factors for low survival expectations are themselves stratified by race and ethnicity. Using the National Longitudinal Study of Adolescent to Adult Health, we modeled racial, ethnic, and immigrant group differences in trajectories of adolescent survival expectations and assess whether these differences are accounted for by family, neighborhood, and/or other risk factors (e.g., health care access, substance use, exposure to violence). Findings indicated that most racial, ethnic, and immigrant groups were more pessimistic about their survival than were non-Hispanic whites, with the exception of Cuban youth, who were the most optimistic. Foreign-born Mexican youth had the lowest survival expectations, contrary to expectations from the "healthy-immigrant" hypothesis.

Early physical health conditions and school readiness skills in a prospective birth cohort of U.S. children

RATIONALE

Extant research identifies associations between early physical health disparities and impaired functioning in adulthood, but limited research examines the emergence of these associations in the early years of children's lives.

OBJECTIVE

This study draws on data from the Early Childhood Longitudinal Study Birth Cohort (ECLS-B; N = 5900) to assess whether a host of early health indicators measured from birth to age five are associated with children's cognitive and behavioral skills at age five.

RESULTS

After adjusting for child and family characteristics, results revealed that children's neonatal risks (prematurity or low birth weight) and reports of poor health and hospitalizations were associated with lower cognitive skills, and neonatal risks and poor health predicted lower behavioral functioning at age five. Some of the association between neonatal risks and school readiness skills were indirect, functioning through children's poor health and hospitalization. Analyses further found that associations between early physical health and children's school readiness skills were consistent across subgroups defined by family income and child race/ethnicity, suggesting generalizability of results.

CONCLUSIONS

Findings emphasize the need for more interdisciplinary research, practice, and policy related to optimizing child well-being across domains of physical health and development in the early years of life.

Age at Migration, Language Proficiency, and Socioeconomic Outcomes: Evidence From Australia

This study estimates the causal effects of language proficiency on the economic and social integration of Australian immigrants. Identifying the effects of languages on socioeconomic outcomes is inherently difficult owing to the endogeneity of language skills. Using the phenomenon that younger children learn languages more easily than older children, we construct an instrumental variable for language proficiency. To achieve this, we consider the age at arrival of immigrants who came as children from Anglophone and non-Anglophone countries. We find a significant positive effect of English proficiency on wages and promotions among adults who immigrated to Australia as children. Higher levels of English proficiency are associated with increased risk-taking, more smoking, and more exercise for men, but have considerable health benefits for women. English language proficiency has a significant influence on partner choice and a number of social outcomes, as well as on children’s outcomes, including their levels of academic achievement. The results are robust to alternative specifications, including accounting for between-sibling differences and alternative measures of English skills.

Factors associated with receiving treatment for dental decay among Medicaid-enrolled children younger than 12 years of age in Iowa, 2010

OBJECTIVES

The Iowa Department of Public Health I-Smile program provides dental screening and care coordination to over 23,000 low-income and Medicaid-enrolled children per year. The purposes of this study were to evaluate I-Smile program effectiveness to ensure that Medicaid-enrolled children obtained dental treatment after having been screened and to determine the factors associated with failure to receive dental care after screening through the I-Smile program.

METHODS

Based on I-Smile program priorities, we limited our sample to children younger than 12 years of age who screened positive for decay and who linked to a paid Medicaid claim for dental treatment (n = 1,816). We conducted bivariate analyses to examine associations between children's characteristics who screened positive for decay and received treatment within 6 months of their initial screening. We also performed multivariate logistic regression to assess the association of sociodemographic characteristics with receipt of treatment among children who screened positive for decay.

RESULTS

Eleven percent of children screened positive for decay. Nearly 24 percent of children with decay received treatment based on a Medicaid-paid claim. Being 5 years or older [adjusted odds ratio (aOR): 1.48, confidence interval (CI): 1.17, 1.88] and not having a dental home (aOR: 1.90, CI: 1.41, 2.58) were associated with higher odds of not receiving dental treatment.

CONCLUSIONS

Children 5 years and older and without a dental home were less likely to obtain dental treatment. Opportunities exist for the I-Smile program to increase the numbers of at-risk children with dental homes and who obtain dental care after screening.

Cardiovascular disease risk factors are elevated in urban minority children enrolled in head start

BACKGROUND

The prevalence of obesity and overweight persists in the preschool population, despite some prevention and treatment advances, particularly in minorities. Investigating the prevalence of dyslipidemia and the effect of family health may also guide the focus of intervention efforts.

METHODS

Anthropometric data were collected from urban minority preschool children (n=161; 42% female) enrolled in USDA Head Start. Blood was collected by finger prick and analyzed with the Cholestech LDX Analyzer (Cholestech Corporation, Hayward, CA). Caregivers provided a self-reported family health history for cardiovascular diseases (CVDs).

RESULTS

By BMI percentile, 8% of the children were underweight (UW), 54% healthy weight (HW), 10% overweight (OW), and 28% obese (OB). One of every 5 children had borderline or high-risk levels for total cholesterol (TC), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides based on the National Cholesterol Education Program categories. In OW/OB children only, BMI was positively correlated with TC (r(61)=0.428; p=0.001) and LDL (r(58)=0.395; p=0.005). Child BMI was also associated with family comorbid diseases (r(159)=0.177; p=0.025). UW/HW children with a family history of CVD had significantly higher LDL than UW/HW children without a family history of CVD (p=0.001). Step-wise regression analysis revealed that BMI (p=0.005) plus family history of heart attack (p=0.018) were significant predictors of blood TC levels.

CONCLUSION

Continued efforts to treat and prevent elevated weight are urgently needed for minority preschoolers. Attention to CVD screening may be an important target in school, community, and healthcare arenas for minority populations regardless of weight status.

Effect of Hispanic ethnicity and language barriers on appendiceal perforation rates and imaging in children

OBJECTIVE

To determine the association between Hispanic ethnicity and limited English proficiency (LEP) and the rates of appendiceal perforation and advanced radiologic imaging (computed tomography and ultrasound) in children with abdominal pain.

STUDY DESIGN

We performed a secondary analysis of a prospective, cross-sectional, multicenter study of children aged 3-18 years presenting with abdominal pain concerning for appendicitis between March 2009 and April 2010 at 10 tertiary care pediatric emergency departments in the US. Appendiceal perforation and advanced imaging rates were compared between ethnic and language proficiency groups using simple and multivariate regression models.

RESULTS

Of 2590 patients enrolled, 1001 (38%) had appendicitis, including 36% of non-Hispanics and 44% of Hispanics. In multivariate modeling, Hispanics with LEP had a significantly greater odds of appendiceal perforation (OR, 1.44; 95% CI, 1.20-1.74). Hispanics with LEP with appendiceal perforation of moderate clinical severity were less likely to undergo advanced imaging compared with English-speaking non-Hispanics (OR, 0.64; 95% CI, 0.43-0.95).

CONCLUSION

Hispanic ethnicity with LEP is an important risk factor for appendiceal perforation in pediatric patients brought to the emergency department with possible appendicitis. Among patients with moderate clinical severity, Hispanic ethnicity with LEP appears to be associated with lower imaging rates. This effect of English proficiency and Hispanic ethnicity warrants further investigation to understand and overcome barriers, which may lead to increased appendiceal perforation rates and differential diagnostic evaluation.

Implementing health reform: improved data collection and the monitoring of health disparities

The relative lack of standards for collecting data on population subgroups has not only limited our understanding of health disparities, but also impaired our ability to develop policies to eliminate them. This article provides background about past challenges to collecting data by race/ethnicity, primary language, sex, and disability status. It then discusses how passage of the Affordable Care Act has provided new opportunities to improve data-collection standards for the demographic variables of interest and, as such, a better understanding of the characteristics of populations served by the U.S. Department of Health and Human Services (HHS). The new standards have been formally adopted by the Secretary of HHS for application in all HHS-sponsored population health surveys involving self-reporting. The new data-collection standards will not only promote the uniform collection and utilization of demographic data, but also help the country shape future programs and policies to advance public health and to reduce disparities.