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Authors: Basu J, Friedman B, and Burstin H.
Title: Primary Care, HMO Enrollment and Hospitalization for ACS Conditions: A New Approach.
Publication: Medical Care 40(12) 1260-69.
Date: 2002.
Abstract: The study tests the association of primary care availability, HMO enrollment, and other person and location variables with potentially preventable hospitalization for adults in New York State, comparing preventable admissions to other types of admissions. The study population is all hospital stays of New York residents in the age group 20-64 hospitalized either in New York or in three contiguous states: New Jersey, Pennsylvania, or Connecticut using 1995 statewide discharge files from the Healthcare Cost and Utilization Project (HCUP) maintained by the Agency for Healthcare Research and Quality. A multinomial logit model uses the individual discharge as the unit of analysis. ACS admissions are compared with "marker" admissions (urgent but non-ACS), and "referral sensitive" surgeries (more discretionary), controlling for severity of illness. Higher primary care density was associated with a lower likelihood of ACS admission, compared with marker admissions, and without increasing referral-sensitive admissions. The study also supports the hypothesis of ACS admissions being less likely for private HMO enrollees than for other insured adults. This result was not found for Medicaid HMO enrollees, even by comparison to other Medicaid enrollees. A key policy-relevant result is the negative association of primary care physicians per capita with the likelihood of ACS admissions, without an offsetting association with resource costs via referral-sensitive admissions. This type of analysis could be strengthened in several ways for a defined population when better data on individual patients and several time periods are used.


Authors: Elixhauser A, Macklin S, Zodet MW, et al.
Title: Health care for children and youth in the United States: 2001 annual report on access, utilization, quality, and expenditures.
Publication: Ambulatory Pediatrics 2(6):419-37.
Date: 2001.
Abstract: This report provides an update on insurance coverage, use of health care services and health expenditures for children and youth in the United States. In addition the report provides information on variation in hospitalization for children from a new 22-state hospital discharge data source specifically designed to study children. The study uses the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (HCUP) Database for Pediatric Studies (DPS), later renamed the Kids' Inpatient Database (KID), both of which are maintained by the Agency for Healthcare Research and Quality. Children's use of health care services varies considerably by what type of health insurance coverage they have. Expenditures for children entail a substantial out-of-pocket component, which may be quite large for children with major health problems and which may have a significant burden on low-income families. The data also show substantial differences in average length of hospitalization across states in the U.S., ranging from 2.7 to 4.0 days, and rates of hospitalization through the ED vary from 9% to 23%. Injuries are a major reason for hospitalization, accounting for 1 in 6 stays among 10-14 year olds. In the 10-17 age group, over 1 in 7 stays are due to mental disorders. Among 15-17 year olds, over one-third of all hospital stays are related to childbirth and pregnancy.

Authors: Friedman B., Devers K., Steiner C., Fox, S.
Title: The Use of Expensive Health Technologies in the Era of Managed Care: The Remarkable Case of Neonatal Intensive Care.
Publication: Journal of Health Politics, Policy and Law 27(3)441-64
Date: 2002.
Abstract: The use of neonatal intensive care (NIC) continued to rise rapidly in the 1990s despite the concerns of observers about cost-effectiveness of NIC in some cases and better outcomes in facilities with high volume and capabilities. The study tested the effects of insurance type, competition among hospitals, and market pressure from managed care plans on the supply and cost of NIC. Key findings are that the decision of a hospital to offer NIC was associated with teaching status, the proportion of infants in the market area with high documented risk, and the market concentration of major competitors. The market share of managed care plans, and the concentration of enrollment, was not associated with NIC being offered or the standardized charges. Whether a particular patient was admitted to a NICU depended on patient risk factors, whether a NICU was present, but not on payer group. The results are consistent with the hypothesis that young insured parents (with the advice of their obstetricians) prefer hospitals with NIC, and also are relatively profitable enrollees for health plans.

Authors: Dick AW, Allison RA, Haber SG, Brach C, Shenkman B
Title: Consequences of States' Policies for SCHIP Disenrollment.
Publication: Health Care Financing Review 23(3):65-88.
Date: 2002.
Abstract: Policymakers are concerned about disenrollment from the State Children's Health Insurance Program (SCHIP). We describe disenrollment in Florida, Kansas, New York, and Oregon and assess the links between disenrollment and states' SCHIP policies. We find that SCHIP is used on a long-term basis (at least 2 years) for a significant group of new enrollees and as temporary coverage (fewer than 12 months) for many others. Recertification generates large disenrollments (about half of children still enrolled at the time), but as many as 25 percent return within 2 months. The increased disenrollment rate at recertification is completely eliminated by a policy of passive re-enrollment.
Availability: AHRQ Publication No. 02-R070 is available from the AHRQ Publications Clearinghouse.

Authors: Luce BR, Zangwill KM, Palmer CS, et al.
Title: Cost-effectiveness analysis of an intranasal influenza vaccine for the prevention of influenza in healthy children.
Publication: Pediatrics 108(2):e24.
Date: 2001.
Abstract: This study determined the potential cost-effectiveness of intranasal influenza vaccine among young, healthy children. The analysis included prospectively collected 2-year clinical trial data supplemented with data from the literature. Results indicated that routine use of intranasal influenza vaccine among healthy children may be cost-effective and cost-effectiveness may be maximized by using group-based vaccination approaches.

Authors: Simonsen L, Morens DM, Elixhauser A, et al.
Title: Effect of rotavirus vaccination program on trends in admission of infants to hospital for intussusception.
Publication: Lancet 358:1224-29.
Date: 2001.
Abstract: The effect of Rotashield vaccination use on intussusception admissions in 10 U.S. States was investigated. We analyzed electronic databases containing 100 percent hospital discharge records for 1993-99 from 10 States, where an estimated 28 percent of the birth cohort had received Rotashield. Records of infants admitted to hospital (<365 days old) with any mention of intussusception were examined (ICD-9-CM code 560·0). Excess admissions for intussusception during the period of Rotashield availability (October 1998-June 1999) were estimated by direct comparison with the corresponding period of October 1997 to June 1998 (before Rotashield was available) and with adjustment for secular trends during 1993-98 by Poisson regression. Among infants ages 45-210 days, an increase in intussusception admissions of 1 percent (one excess admission) was estimated by direct comparison and 4 percent (4·6 excess admissions) by trend comparison, (PAR range of one excess admission in 66,000-302,000). No evidence of increased infant intussusception admissions was found during Rotashield availability.

Authors: Friedman B., Basu J.
Title: Health Insurance, Primary Care, and Preventable Hospitalization of Children in a Large State.
Publication: American Journal of Managed Care 7(5):473-81.
Date: 2001.
Abstract: The study analyzes variations of the admission rate to hospitals of children with ambulatory care-sensitive (ACS) conditions, testing the relationship to insurance coverage, HMO enrollment, availability of primary care, severity of illness, distance to hospital, and a number of other factors. Hypotheses are derived from basic considerations of demand and use of primary care and preventive services, and then tested with a weighted linear regression model of the ACS admission rate for children residing in each county of New York. The principal data are all hospital discharges for New York resident children admitted to hospitals in New York, Pennsylvania, New Jersey, or Conecticut in 1994. The data and methodology are noteworthy for including out-of-area hospital admissions. One key result is a substantial negative association of the ACS rate with private HMO coverage. There are also sizable negative effects of the availability of primary care services in physician offices and distance traveled. Large differences related to racial and ethnic composition of the population are found, independent of other determinants. There was a positive association with the proportion of admissions for all conditions covered by Medicaid or self-pay. Severity of illness and use of emergency departments were controlled. There was no independent effect of a location in New York City. The results are consistent with smaller-scale studies, suggesting that improved health insurance for children could reduce hospital admissions. Contracting with HMOs also appears to be attractive. Independently, programs to increase the availability of primary and preventive services could substantially reduce ACS admissions. Some disparities remain that deserve more detailed attention at a local level.

Authors: Basu J, Friedman B.
Title: Hospitalization of children for ambulatory care sensitive conditions: Determinants of patient flows in a large State.
Publication: Health Economics 10(1)67-78.
Date: 2001.
Abstract: The study examines the influence of key policy variables such as types of insurance, and local supply of primary care, and patient characteristics such as race, and severity of illness, among others, on out-of-area use of hospitals by children with diagnoses defined as ambulatory care sensitive (ACS) conditions. Hospital discharge data for New York residents admitted to hospitals in New York, Pennsylvania, New Jersey or Connecticut in 1994 are used. Patient-level data are merged with the Area Resource file (ARF), and American Hospital Association (AHA) surveys. Hypotheses are developed from a model that links the choices of families residing in a local area, supply considerations of ambulatory care providers, HMOs and hospitals, determining the admissions to hospitals for ACS conditions in an out-of-area hospital. The study uses logistic regression to predict travel out of the local area for ACS admission. The study finds that HMOs do not especially take members outside the area when hospital care is needed. Inadequate primary care could cause significant patient flows. Severity of illness significantly affects flows out of the local area and children with nonwhite race tend to stay in. The implications of these findings might be that a greater availability of local primary care physicians could reduce the movement of children outside the county. This could be more effective in areas with more nonwhites and Medicaid patients because those are the areas associated with higher occurrence rates, and a higher likelihood of patients to stay locally. Future research will compare patient flows for ACS conditions with other conditions such as those treated with elective procedures, use other age groups, and examine the time trends for ACS conditions.

Authors: Elixhauser A, Leidy NK, Halpern M.
Title: Cost and outcome implications for prevention.
Publication: In: Weiss KB, Buist AS, Sullivan SD. Asthma's Impact on Society: The Social and Economic Burden. New York: Marcel Dekker, Inc.
Date: 2000.
Abstract: This chapter examines the health and economic implications of interventions aimed at the primary prevention of asthma. Research into these areas is a relatively recent phenomenon; many of the conclusions about the effectiveness of preventive interventions are speculative. This chapter provides alternative typologies of prevention for asthma and provides a conceptual framework for evaluating the costs and outcomes of interventions for the primary prevention of asthma.

Authors: McCormick MC, Kass B, Elixhauser A, et al.
Title: Annual report on access to and utilization of health care for children and youth in the United States—1999.
Publication: Pediatrics 105(1 Pt 3):219-30.
Date: 2000.
Abstract: This report is the first in what is anticipated to be an annual series of reports on access to and use of health care services by America's children and youth. The report capitalizes on the existence of two national datasets, the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (HCUP), which have not been widely used by the child health services research community. As background to these new sources of data, the authors have provided a detailed description of the datasets, and reviewed some fundamental tabulations. In future years, as more data are accumulated, these reports will focus on delineation of key trends and analyses addressing policy issues.
Availability: AHRQ Publication No. 00-R014 is available from the AHRQ Publications Clearinghouse.

Authors: Friedman B, Jee J., Steiner C, et al.
Title: Tracking the State Children's Health Insurance Program with hospital data: National baselines, State variations, and some cautions.
Publication: Medical Care Research and Review 56(4):440-55.
Date: 1999.
Abstract: State and Federal agencies are concerned with the impact of the State Children's Health Insurance Program (SCHIP) on the health care of enrolled children. As part of a broad program evaluation, and at relatively low cost, analysts can track data on hospital admissions for ambulatory care sensitive (ACS) conditions. This article uses hospital data for 19 states to calculate baseline ACS rates and to discuss trends and cross-state variations just prior to the start of SCHIP. A few cautions and limitations are discussed. An unexpected result in the explorations was a substantial increase in the rate of ACS admissions for self-pay and Medicaid-enrolled children during the period of 1990-1995. During that same period, the admission rate for other insured children fell by more than a third. The comparisons across states are meant to be illustrative; they do reveal a relationship between the rate of asthma admissions and the proportion of self-pay plus Medicaid-enrolled cases.
Availability: AHRQ Pub. No. 00-R009 is available from the AHRQ Publications Clearinghouse.

Authors: Simpson L, Fraser I.
Title: Children and managed care: What research can, can't, and should tell us about impact.
Publication: Medical Care Research and Review 56(Suppl 2):13-36.
Date: 1999.
Abstract: The speed and ubiquity of the move from fee-for-service to managed care raises questions about how these changes affect children. This article examines: (1) The pace and context of the move to managed care for children. (2) Potential opportunities and challenges emerging from these changes. (3) Research findings on how managed care affects children. (4) Next steps for learning more. The research review provides a consistent answer to whether managed care is good for children: it depends on what kind of managed care, which children, and under what circumstances. This finding suggests lessons for future research: (1) Focus on particular features of managed care. (2) Get inside the "black box" of managed care and examine providers. (3) Expand the portfolio of research on children; research on adults cannot "trickle down" to children. (4) Foster research partnerships and networks. (5) Focus on poor and chronically ill children.
Availability: AHCPR Publication No. 99-R062 is available from the AHRQ Publications Clearinghouse.

Authors: Brach C, Scallet L.
Title: Managed care challenges for children and family services.
Publication: In Humane Managed Care?, edited by Schamess G, and Lightburn A. Washington (DC): National Association of Social Workers Press.
Date: 1998.
Abstract: This chapter highlights five challenges facing those dedicated to the welfare of children and their families who also want to make the most of the opportunity managed care presents: (1) The speed with which managed care is moving through the various systems that serve children and families. (2) The emphasis that has been placed on outcomes. (3) The participation of clients in the design and implementation of managed care policies and programs and the importance of ensuring client protection. (4) The need for the development of culturally competent systems of care. (5) The potpourri of legal considerations that accompany managed care initiatives.

Authors: Simpson L, Kamerow D, Fraser I.
Title: Pediatric guidelines and managed care: Who is using what and what difference does it make?
Publication: Pediatric Annals 27(4):234-40.
Date: 1998.
Abstract: This article defines the use and value of guidelines, their role in improving the quality and outcomes of care, and the reasons some clinicians are skeptical of them. The article articulates the role of managed care organizations in driving the use of guidelines, and identifies the importance of the evidence base for child health interventions as well as efforts in progress to improve and expand this base.
Availability: AHCPR Publication No. 98-R081 is available from the AHRQ Publications Clearinghouse.

Authors: Brach C, Mauch D.
Title: Public sector responsibilities in managed care.
Publication: In Managed care: Challenges for children and family services, edited by L. Scallet, C. Brach and E. Steel. Baltimore, (MD): Annie E. Casey Foundation.
Date: 1996.
Abstract: This report poses the question: "What responsibilities must remain with the public sector?" The response comes in three parts. First, the public sector's objectives in caring for vulnerable children and families are defined. Second, core functions of government that cannot be delegated are articulated. Third, strategies are offered for executing core functions and securing the public sector's objectives. Public sector officials who think through these issues and plan accordingly can remain in control while using the private sector effectively to accomplish public objectives.

Authors: Brach C, Scallet L.
Title: Trends.
Publication: In Managed care: Challenges for children and family services, edited by Scallet L, Brach C, Steel E. Baltimore (MD): Annie E. Casey Foundation.
Date: 1996.
Abstract: This report was designed to educate the systems that serve children and families (e.g., child welfare, special education, juvenile justice) about managed care. Drawing upon knowledge from the sectors where managed care is relatively more advanced, such as the health and mental health sectors, the authors discuss the implications of the advancement of managed care techniques into child- and family-serving systems.

Author: Drissel A.
Title: Managed care and children and family services: A guide for State and local officials.
Publication: Baltimore (MD): Annie E. Casey Foundation. Edited by Brach C.
Date: 1996.
Abstract: This guide is the final product of a project for the Annie E. Casey Foundation, Managed care: Implications for children and family services. A major goal of the project was to provide a bridge from the sectors where managed care is relatively more advanced, such as the health and mental health care systems, to those where managed care is beginning to make inroads.

Authors: Harris DR, Andrews R, Elixhauser A.
Title: Race/Ethnicity and Treatment of Children and Adolescents, by Diagnosis.
Publication: Rockville (MD): AHCPR.
Date: 1996.
Abstract: A number of recent studies have identified racial differences in treatment for selected diagnoses among adults. However, relatively few studies have examined treatment differences among children of different racial and ethnic groups. This Research Note examines treatment differences among children and adolescents by race/ethnicity across a comprehensive list of diagnoses in order to foster more research in this important area. Descriptive statistics are provided for 75 conditions treated on an inpatient basis; information is presented overall and separately by race/ethnicity (white, black, Hispanic, and other). This study used discharge abstract data on nearly 700,000 discharges of children and adolescents from the 1986 Hospital Cost and Utilization Project, a sample of about 10 percent of short-term, general, non-Federal hospitals in the United States. For each condition, statistics are provided on age, type of procedure, presence of complications, discharge status, disease stage, expected primary payer, length of stay and charges. Detailed tables allow comparison of racial/ethnic groups on all these variables. Otitis media is used as a case study to illustrate how these descriptive statistics can be used to design future research projects.
Availability: AHCPR Publication No. 96-0012 is available from the AHRQ Publications Clearinghouse.

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