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Improving Quality in Child and Adolescent Health

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Recent Findings

Quality Improvement

School-based health centers enhance care for children with asthma.
Researchers evaluated whether the availability of school-based health center (SBHC) services measurably affected the health and school performance of 949 inner-city children with asthma. The rate of hospitalization was higher among children attending non-SBHC schools (17 vs. 11 percent), as was the number of school days missed (21 vs. 18 days). SBHCs may offer a practical response to the limited access that poor and uninsured children have to health care.
Webber, Carpiniello, and Oruwariye, et al., Arch Pediatr Adolesc Med 157:125-29, 2003 (AHRQ grant HS10136).

Parents of hospitalized children often change smoking behaviors.
The Stop Tobacco Outreach Program was offered to 71 parents who smoked and whose children were hospitalized for asthma, pneumonia, or other respiratory illness. Those who completed the counseling sessions, had a stop-smoking attempt that lasted at least 24 hours, and had not smoked a cigarette in the last 7 days were 80, 49, and 21 percent, respectively. Also, 71 percent of the parents prohibited smoking in the home after the program, compared with 29 percent at enrollment.
Winickoff, Hillis, Palfrey, et al., Pediatrics 111(1):140-45, 2003 (NRSA training grant T32 HS00063).

Team-based approach may improve detection of chlamydia.
A team-based approach to improving chlamydia screening was instituted at an HMO. The strategy involved organizing teams of medical and administrative staff, getting leadership buy-in, educating participants about chlamydia, holding monthly meetings to discuss problem-solving strategies, using urine-based testing instead of pelvic exams, and monitoring progress with clinic-specific screening rates. The approach increased the screening rate of sexually active 14- to 18-year-old females from 5 to 65 percent.
Shafer, Tebb, Pantell, et al., JAMA 288(22):2846-52, 2002 (AHRQ grant HS10537).

Poor children's dental health can improve with minimal cost.
Researchers conducted a cost-effectiveness analysis of a successful school-based dental sealant program for low-socioeconomic-status children in New York. The data revealed that the program could substantially improve the dental health of poor school-aged children at no cost or only slightly increased cost relative to ordinary dental care.
Zabos, Glied, Tobin, et al., J Health Care Poor Underserved 13(1):38-48, 2002 (AHRQ and HRSA, cooperative agreement).

Training helps ED nurses recognize children at risk of suicide.
Emergency department (ED) nurses attended educational sessions on psychiatric issues, including the Risk of Suicide Clinical Practice Guideline (CPG) and the Risk of Suicide Questionnaire. After the training, participants displayed a marked increase in knowledge about the CPG and care of ED mental health patients, and they were better equipped to manage potentially suicidal children in the ED.
Horowitz, Smith, Levin, et al., Pediatr Emerg Care 17(4):306-9, 2001 (NRSA training grant T32 HS00063).

An inner-city asthma intervention proves effective.
Following a baseline assessment of about 1,000 inner-city children with physician-diagnosed asthma, researchers randomly assigned them to an asthma counselor (AC) or usual care (UC) group and followed clinical outcomes and use of services for 2 years. The AC group had an average of 27 more symptom-free days, and the AC program improved outcomes at an average additional cost of $9.20 per symptom-free day gained.
Sullivan, Weiss, Lynn, et al., J Allergy Clin Immunol 110:576-81, 2002 (AHRQ Publication No. 03-R006)1 (Intramural).

Infants discharged 1 or 2 days after birth fare equally well.
Investigators studied discharge, readmission, and ER visit data on more than 20,000 pairs of mothers and newborn infants covered by a large Massachusetts HMO. Results showed that ER visits and readmission rates following discharge did not change after the State established a 48-hour minimum stay.
Madden, Soumerai, Lieu, et al., N Engl J Med 347(25):2031-8, 2002 (AHRQ grant HS10060).

Study tests the efficacy of asthma management guidelines.
This study involved a prospective cohort design of all children aged 1 to 18 seen in the Connecticut Children's Medical Center ER for an asthma exacerbation. Researchers examined the impact of using the National Heart, Lung and Blood Institute's clinical practice guidelines on the quality of asthma care.
Effectiveness of the NHLBI Guideline on Childhood Asthma Outcomes (NTIS Accession No. PB2002-104710),2 Philip V. Scribano, Principal Investigator (AHRQ grant HS09825).

Researchers examine the literature on QI.
Researchers interviewed experts and reviewed the published literature (1985-1997) on QI activities in child health. Barriers to pediatric QI were similar to those for adult populations and were complicated by limited resources and difficulties in measuring health outcomes, among other factors. However, research has shown that some QI strategies are effective.
Ferris, Dougherty, Blumenthal et al., Pediatrics 107:143-55, 2001 (AHRQ Publication No. 01-R020)1 (Intramural).

Embedding guidelines in a computer charting system does not improve quality of care.
Researchers examined the impact of clinical guidelines for managing the care of 830 children aged 3 or younger with high fevers. There were no changes in appropriateness of care or hospital charges for children managed with or without guidelines.
Schriger, Baraff, Buller, et al., J Am Med Inform Assoc 7(2):186-95, 2000 (AHRQ grant HS06284).

Feedback and financial incentives do not improve pediatric preventive care.
According to this study, providing pediatricians in Medicaid managed care organizations with feedback on compliance with recommendations for preventive health services and financial bonuses did not increase their provision of these services.
Hillman, Ripley, Goldfarb, et al., Pediatrics 104(5):931-35, 1999 (AHRQ grant HS07634).

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Quality Measurement

Parents provide views of inpatient care quality.
Responding to the Pediatric Inpatient Survey, 6,030 parents of children treated at one of 38 hospitals rated their child's care as very good. Parents reported problems with 27 percent of the survey's hospital process measures. They had the most problems with poor information to the child and coordination of care.
Co, Ferris, Marino, et al., Pediatrics 111(2):308-14, 2003 (NRSA training grant T32 HS00063).

Cannister counts yield more accurate profiles of medication underuse.
This study compared two methods for counting the use of bronchodilators and antiinflammatory medication among adult and pediatric asthma patients. The canister-equivalent method for counting dispensed asthma medications resulted in a 40 percent increase in the population identified as having high bronchodilator and chronic antiinflammatory medication use than simple asthma medication counts.
Glauber and Fuhlbrigge, Ann Allergy Asthma Immunol 88:451-6, 2002 (NRSA training grant T32 HS00063).

Do adult and child quality assessments differ?
Using data from 136 health plans, this study examined how the adult and child versions of CAHPS® differed in ranking health plans. There was fair to moderate agreement between adult and child mean scores in ranking health plans. Also, CAHPS® scores for children were significantly higher than those for adults, except for customer service and specialist ratings.
Zahn, Sangl, Meyer, et al., Med Care 40(2):145-54, 2002 (AHRQ Publication No. 02-R047)1 (Intramural).

Health plan quality information for adults is not a proxy for children.
Researchers used CAHPS® to assess responses from nearly 220,000 adults and more than 55,000 parents of children. The analysis found marked variation between the care provided by specialists and primary care physicians to adults and children within the same plan; however, there was little variation regarding health plan activities (health plan ratings and claims processing).
Bost, Thompson, Shih, et al., Ambulatory Pediatr 2(3):224-9, 2002 (AHRQ grant HS09205).

Researchers assess interpersonal aspects of pediatric care.
This project involved development of a set of domains that focus on patient interaction with the health care delivery system (such as communication with providers, courtesy of staff, getting needed care, and getting care quickly). A review of the literature also resulted in ways to improve interpersonal interaction with children and their parents in the ER.
Darby, Ambulatory Pediatr 2(4):345-8, 2002 (AHRQ Publication No. 02-R088)1 (Intramural).

Study assesses parents' source and quality of advice.
Using a self-administered survey of 1,108 subjects, researchers determined sources and quality of medical advice and information used by parents. Half of the respondents reported using the Internet for medical information, 30 percent used it to obtain information about a specific acute or chronic medical illness, and 15 percent had communicated with a physician by E-mail. Respondents also rated physician advice by phone or visit and information obtained via the Internet as very good or excellent (76 and 47 percent, respectively).
Pediatric Internet Medical Advice and Triage (NTIS Accession No. PB2002-108738),2 Larry J. Baraff, Principal Investigator (AHRQ grant HS10604).

Adolescents accurately characterize the care they receive.
To develop quality measures for adolescent care, researchers recruited 400 adolescents, audiotaped their visits with physicians, and conducted phone surveys to assess their recollection of the preventive health care they received. Adolescents' recall of the care they received was good.
Klein, Graff, Santelli, et al., Health Serv Res 34(1):391-404, 1999 (AHRQ grant HS08192).

Different measures are needed to assess the quality of health care provided to children and adults.
Because children differ from adults in their health care needs and in the way they use care, researchers should use measures of health care quality that are appropriate to children. Future research should address specific methodologic challenges involved in measuring quality of pediatric health care.
Palmer and Miller, Ambulatory Pediatrics 1(1):39-52, 2001 (AHRQ Publication No. 01-R037)1 (Intramural).

Measuring quality for vulnerable children requires a special approach.
These authors point out that pediatric quality measurement is distinct from that for adults because of factors related to children's development and dependence, differential epidemiology, demographic factors, and differences between the child and adult health service systems. A noncategorical approach, rather than one based on illness status or specific condition, is indicated.
Seid, Varni, and Kurtin, Am J Med Qual 15(4):182-8, 2000 (AHRQ grant HS10317).

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Quality Problem Identification

Misconceptions contribute to parental demand for antibiotics.
Thirty-six day care centers and 398 parents were surveyed about their beliefs and the centers' policies for excluding children, requiring physician clearance, and/or enforcing their policies regarding symptoms of upper respiratory tract infection. Responses revealed that only 4 percent of parents felt pressured by staff to see a doctor or obtain an antibiotic (2 percent). However, 20 percent believed most colds and flu illnesses are caused by bacteria and improve faster with antibiotics.
Friedman, Lee, Kleinman, et al., Arch Pediatr Adolesc Med 157:369-74, 2003 (NRSA training grant HS00063).

Doctors succumb to overt pressure for antibiotic treatment.
By analyzing audiotaped and videotaped conversations of 295 acute care visits, researchers found that parents pressure pediatricians to prescribe antibiotics for their children. Doctors prescribed antibiotics for nearly half of all cases involving some form of overt pressure (15 out of 31).
Stivers, Soc Sci Med 54(7):1111-30, 2002 (AHRQ grant HS10577).

Medical errors affect 2 to 3 of every 100 hospitalized children.
Researchers used HCUP data to calculate hospital-reported medical errors among non-newborn pediatric inpatients up to 18 years of age. Results show the national medical error rate in hospitalized children ranged from 1.81 to 2.96 per 100 discharges. The error rate increased from 1988 to 1991 but remained stable from 1991 to 1997.
Slonim, LaFleur, Ahmed, et al., Pediatrics 111(3):617-21, 2003 (AHRQ grant HS11022).

Many children are using asthma medication inappropriately.
Parents of 638 children with asthma who were cared for at 1 of 42 primary managed care practices in three U.S. regions were interviewed. Researchers found that 64 percent of the children with persistent asthma were inadequately controlled. Older age, minority race, and household poverty were significantly associated with inadequate control.
Lozano, Finkelstein, Hecht, et al., Arch Pediatr Adolesc Med 157:81-8, 2003 (AHRQ grant HS08368).

Reviewers question reproductive care resource distribution.
This study finds that the United States has substantially greater NICU resources per capita than Australia, Canada, and the United Kingdom without having better infant survival. The researchers call into question the effectiveness of the current distribution of U.S. reproductive care resources and call for improved funding for preconception and prenatal care.
Thompson, Goodman, and Little, Pediatrics 109(6):1036-43, 2002 (NRSA training grant T32 HS00070).

New methods for educating parents about asthma are needed.
This study of 638 children with asthma found that 78 percent had bedroom carpeting. Most lived in households that had furry pets, a smoker, and cockroaches or mice (59, 30, and 18 percent, respectively). Although 45 percent of the parents had received written instructions about avoiding asthma triggers, receipt of instructions was not associated with efforts to do so.
Finkelstein, Fuhlbrigge, Lozano, et al., Arch Pediatr Adolesc Med 156:258-64, 2002 (AHRQ grant HS08368).

Medicaid-insured children with asthma underuse controller medications.
Researchers surveyed the parents of 1,648 children and adolescents with asthma. Of the 1,083 children with persistent asthma, 73 percent underused controller therapy, 49 percent reported no controller use, and 24 percent reported less than daily use. Blacks and Hispanics were at substantially increased risk of underuse; however, parental education beyond high school reduced the risk by 40 percent.
Finkelstein, Lozano, Farber, et al., Arch Pediatr Adolesc Med 156:562-7, 2002 (AHRQ grant HS09935).

Extra care by pharmacists does not improve asthma outcomes.
This study examined asthma outcomes and use of health care services of 153 and 177 children who filled asthma medication prescriptions at 14 intervention or 18 usual care sites, respectively. Although intervention site pharmacists were trained to provide individualized asthma management services, researchers found no differences between sites in pulmonary function, functional status, quality of life, asthma management, satisfaction with care, use of antiinflammatory medications, total asthma-related medical care use, or school days lost.
Stergachis, Gardner, Anderson, et al., J Am Pharm Assoc 42:743-52, 2002, and Pharmaceutical Care and Pediatric Asthma Outcomes, Final Report (NTIS Accession No. PB2000-101828),2 Andreas S. Stergachis, Principal Investigator (AHRQ grant HS07834).

Erythromycin therapy in newborns increases the risk of gastric outlet obstruction.
Tennessee Medicaid files from 1985 to 1997 were analyzed to examine the link between erythromycin use and infantile hypertrophic pyloric stenosis (IHPS). Infants who received erythromycin between 3 and 13 days of life were at a substantially increased risk of developing IHPS, which results in gastric outlet obstruction that requires surgery.
Cooper, Griffin, Arbogast, et al., Arch Pediatr Adolesc Med 156:647-50, 2002 (AHRQ grant HS10384).

Experts offer blueprint for improving asthma outcomes.
A committee of experts and leaders in childhood asthma outlined policy recommendations to improve childhood asthma outcomes. Their recommendations address ways to improve health care delivery and financing, enhance access to and quality of health care services for asthma, increase knowledge about asthma, and ensure asthma-safe schools.
Lara, Rosenbaum, Rachelefsky, et al, Pediatrics 109(5):919-30, 2002 (AHRQ grant HS00008).

Perceptions that parents expect antibiotics are often wrong.
Researchers surveyed 306 parents prior to an audiotaped visit to two private practices for their child's symptoms of upper respiratory tract infection, asked doctors after the visits what they believed the parents expected, and analyzed communication behaviors used by parents and physicians' perceptions of parental expectations. When parents suggested a candidate diagnosis or resisted a viral diagnosis, it increased by five and nearly three times, respectively, the odds that a doctor would perceive that parents expected antibiotics. However, there was no association between communication behaviors and parents' reports of expectations for antibiotics.
Stivers, Mangione-Smith, Elliott, et al., J Fam Pract 52(2):140-8, 2003 (AHRQ grant HS10577).

Girls are more likely than boys to die in the hospital following heart surgery.
Investigators identified 6,593 children who underwent cardiac surgery for congenital heart disease from California hospital discharge data for 1995 to 1997. After controlling for variables affecting mortality, girls had a 51 percent higher odds of death than boys.
Chang, Chen, and Klitzner, Circulation 106:1514-22, 2002 (NRSA training grant T32 HS00028).

Use of oral steroids is common among children in TennCare.
In 1998, 7 percent of children enrolled in Tennessee's managed health care program for Medicaid-eligible people (TennCare) had at least one oral corticosteroid prescription filled. The rate of corticosteroid use from birth to 2 years was three to four times that of older children, and only 80 percent of new users had a possible indication for steroid use.
Cooper, Staffa, Renfrew, et al., Ambulatory Pediatr 2(5):375-81, 2002 (AHRQ grant HS10384).

When pediatricians perceive parental pressure to prescribe antibiotics, most do.
Conversations between parents and pediatricians from 295 audiotaped acute care visits and 65 videotaped well-child and acute care visits were analyzed and used to examine how pediatricians responded to interaction with parents. When parents only discussed their children's symptoms, pediatricians perceived parents wanted a medical evaluation and complied. When parents offered a candidate diagnosis (in 16 percent of cases), 82 percent of the cases were treated with antibiotics.
Stivers, Health Commun 14(3):299-338, 2002 (AHRQ grant HS10577).

Ventilation of low birthweight infants increases the risk of disabling cerebral palsy (DCP).
Researchers examined a cohort of 1,105 infants with a birthweight of 500 to 2,000 grams and constructed an index of exposure to hypocapnia (low levels of carbon dioxide in the blood). Of the 902 survivors to age 2 years, 657 had neurodevelopmental assessments and blood gas measurements in their first week of life. DCP was diagnosed in 2.3 percent of the 257 unventilated newborns, 9.4 percent of the 320 ventilated newborns without exposure to unusual levels of hypocapnia, and 27.5 percent of the 80 ventilated infants with exposure to significant hypocapnia.
Collins, Lorenz, Jetton, et al., Pediatr Res 50(6):712-9, 2001 (AHRQ grant HS08385).

Universal versus selective initiation of intensive care for premature newborns remains a moral dilemma.
Researchers examined perinatal management, mortality, prevalence of disabling cerebral palsy, and costs for extremely premature infants born in the mid-1980s in New Jersey and the Netherlands. When intensive care is used for all (U.S. neonatologists' approach) rather than selected extremely premature babies (European approach), it increases survival. However, costs (including disability and increased resource use) are high.
Lorenz, Paneth, Jetton, et al., Pediatrics 108(6):1269-74, 2001 (AHRQ grant HS08385).

Reducing emergency room (ER) errors in treating febrile infants may require system changes.
A research team found that 7 percent of infants arriving at the ER with a high fever were treated inappropriately. They either were given antibiotics they did not need or did not receive antibiotics they actually did need.
Glauber, Goldmann, Homer, et al., Pediatrics 105(6):1330-32, 2000 (NRSA grant T32 HS00063).

Caregivers should pay more attention to palliative care.
A review of medical records of children who had died of cancer showed that parents were more likely than physicians to report that their child had fatigue, poor appetite, constipation, and diarrhea and that these symptoms were not recognized by the medical team. Also, suffering from pain was nearly three times more likely in children whose parents reported that the physician was not actively involved in end-of-life care.
Wolfe, Grier, Klar, et al., N Engl J Med 342:326-33, 2000 (NRSA training grant T32 HS00063).

Providers often do not address major injury-prevention issues during well-child visits.
A survey of 465 pediatricians, family physicians, and pediatric nurse practitioners found that attitudes about certain childhood injuries, rather than knowledge about the prevalence of particular injuries, affected which counseling topics the clinicians discussed with their patients.
Barkin, Fink, and Gelberg, Arch Pediatr Adolesc Med 153:1226-31, 1999 (NRSA training grant T32 HS00046).

Clinicians often do not counsel parents on drowning prevention.
Despite the high incidence of drowning injuries in Los Angeles County, only one-third of a random sample of primary care providers (PCPs) counseled parents about drowning prevention. Two-thirds of the PCPs surveyed did not know that deaths of young children due to drowning are more common than deaths due to poisoning and firearm injury.
Barkin and Gelberg, Pediatrics 104(5):1217-19, 1999 (NRSA training grant T32 HS00046).

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Quality Determinants

Severity model uncovers source of errors at admission.
Using a nationally applicable model to control for severity of illness in the emergency department (ED), investigators examined 11,664 hospital records to determine the factors associated with quality of pediatric care. Total errors were strongly associated with residents; there was no association with other care factors.
Pediatric Emergency Care: Severity and Quality (NTIS Accession No. PB2003-101524),2 Murray M. Pollack, Principal Investigator (AHRQ grant HS10238).

Pastoral care providers explain spiritual care needs.
Pastoral care providers from 115 hospitals in 42 States responded to a survey about their perceptions of the spiritual care needs of hospitalized children and their parents, barriers to better care, and the quality of spiritual care in children's hospitals. Most agreed that empathetic listening, praying with children and families, touch and silent communication, and religious rituals or rites were very effective. Respondents estimated that their hospitals provide 60 percent of the ideal spiritual care.
Feudtner, Haney, and Dimmers, Pediatrics 111(1):e67, 2003 (AHRQ grant HS0002).

Parents prefer an on-call pediatrician to a nurse advice service.
After-hours medical advice calls from parents or guardians of about 6,000 children seen at the pediatrics practice of an urban university medical center were randomized to a nurse advice service (566 callers) or the on-call pediatrician (616 callers). Parents rated call satisfaction as very good or excellent significantly more often for the on-call pediatrician, were more likely to comply with advice given for an office visit within 72 hours, and made repeat calls for advice less frequently than those in the nurse advice group.
Lee, Guzy, Johnson, et al., Pediatrics 110(5):865-72, 2002 (AHRQ grant HS10604).

Characteristics of hospital deaths suggest need for onsite palliative care.
Investigators used discharge data from 60 hospitals to identify all deaths of patients younger than 24 during 1991, 1994, and 1997. Patients who had chronic conditions were more likely than those who did not to have been mechanically ventilated and to have been ventilated longer. These findings suggest that palliative care services for chronically ill children need to be at least partially hospital-based.
Feudtner, Christakis, Zimmerman, et al., Pediatrics 109(5):887-93, 2002 (AHRQ grant HS00002).

Nutritional intake of extremely premature infants varies by site.
Researchers examined the weight growth velocity of 564 extremely premature infants at six neonatal intensive care units (NICUs) and found weight growth velocities varied significantly. Control for calories (especially protein intake) accounted for much of this variability.
Olsen, Richardson, Schmid, et al., Pediatrics 110(6):1125-32, 2002 (AHRQ grant HS07015).

Regionalization decreases the number of deaths from pediatric cardiac surgery.
This study evaluated discharge data from California hospitals that performed 10 or more pediatric cardiac surgeries, and simulated regionalization of surgery by redistributing patients from low-volume hospitals to high-volume hospitals. Results show that regionalization of pediatric cardiac surgery did not reduce surgical deaths until patients were sent to the nearest high-volume hospitals.
Chang and Klitzner, Pediatrics 109(2):173-81, 2002 (NRSA training grant T32 HS00028).

Type of delivery affects bleeding problems in newborns.
This prospective study examined the incidence of neonatal thrombocytopenia (NT) and intraventricular hemorrhage (IVH) and delivery method of 1,283 low birthweight infants admitted to six NICUs. Although there is debate over which delivery method is safer (vaginal or cesarean), this study shows that vaginal delivery substantially increased the risk of IVH and severe NT during an infant's first day in the NICU.
Kahn, Richardson, Billett, Am J Obstet Gynecol 186:109-16, 2002 (AHRQ grant HS07015).

Birth in a regional NICU offers LBW infants best chance of survival.
This study linked birth certificates of 16,732 low birthweight infants with hospital discharge abstracts and death certificates. According to the researchers, birth in a regional NICU offered the best chance to survive. Further, the level of care available at the hospital of birth was more important for survival than the level of care ultimately received.
Cifuentes, Bronstein, Phibbs, et al., Pediatrics 109(5):745-51, 2002 (AHRQ contract 290-92-0055).

Children in Medicaid managed care receive care equal to that of privately insured children.
Researchers used administrative data and a telephone survey to obtain data on access to, satisfaction with, and use of services for enrollees of Kaiser Permanente of Northern California. They found that Medicaid-enrolled children received care at least equal to that of their commercially enrolled peers.
Newacheck, Lieu, Kalkbrenner, et al., Ambulatory Pediatrics 1(1):28-35, 2001 (AHRQ Publication No. 01-R039)1 (Intramural).

High-volume PICUs have better outcomes than low-volume units.
A study of patient volume and its relationship to risk of death and length of stay in 16 pediatric intensive care units (PICUs) revealed that higher patient volume is consistent with lower mortality rates and shorter stays.
Tilford, Simpson, Green, et al., Pediatrics 106:289-94, 2000 (AHRQ grant HS09055).

Parents stress the importance of parent-doctor and child-doctor communication.
The CAHPS® Child Core Survey was used to assess the interpersonal care of children based on parental responses. The most important factors—according to 3,083 assessments of overall care and of personal doctors—are parent-doctor communication, child-doctor communication, and sufficient time spent with the child.
Homer, Fowler, Gallagher, et al., Jt Comm J Qual Improv 25(7):369-77, 1999 (AHRQ grant HS09205).

Monthly recertification of Medicaid eligibility may undermine health care quality.
Twelve months of continuous Medicaid enrollment and an assigned primary care physician (PCP) improved the care of children with middle ear infections, say researchers. Children who are continuously enrolled are far less likely to visit the ER for middle ear infections, more apt to receive antibiotics for the condition, and more likely to be referred for ear surgery than those who are discontinuously enrolled (due to monthly recertification) and lack a PCP.
Berman, Bondy, Lezotte, et al., Pediatrics 104(5):1192-97, 1999 (AHRQ grant HS07816).

A number of variables affect assessments of managed care for children.
A review of the research found that access to, satisfaction with, and quality of managed care depend on a range of variables. Future research should focus on specific features of managed care, managed care providers, and poor and chronically ill children.
Simpson and Fraser, Med Care Res Rev 56(Suppl. 2), 13-36, 1999 (AHRQ Publication No. 99-R062)1 (Intramural).

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Addressing Racial and Ethnic Disparities

Ethnic disparities in prescribing of asthma medication exist in private practice.
Researchers analyzed information from patient-reported questionnaires and prescription, demographic, provider, and other data on a community sample of 1,000 asthmatic children and their families. The analysis of private practices revealed significantly lower inhaled steroid use among Hispanic children. Also, most of the children had not used inhaled steroids in the past year: 73, 88, and 94 percent of whites, blacks, and Hispanics, respectively.
Ortega, Gergen, Paltiel, et al., Pediatrics 109(1):e1, 2002 (AHRQ Publication No. 02-R046)1 (Intramural).

Increasing use of preventive medications may reduce disparities in asthma burden.
Researchers analyzed data on Medicaid-insured children with asthma in five managed care organizations and interviewed parents to gauge asthma status and evaluate racial/ethnic variations in the processes of asthma care. Despite having worse asthma than white children, black and Hispanic children were 31 and 42 percent less likely to be using inhaled antiinflammatory medication.
Lieu, Lozano, Finkelstein, et al., Pediatrics 109(5):857-65, 2002 (AHRQ grant HS09935).

Reviewers uncover insights to medical cultural competency.
Based on a literature review of studies on culture and language in the emergency care of children, researchers recommend use of cultural code cards to help emergency room clinicians quickly identify and treat pediatric problems in ways that are acceptable to parents.
Flores, Rabke-Verani, Pine, et al., Pediatr Emerg Care 18(4):271-84, 2002 (AHRQ grant HS11305).

Experts identify research priorities in Latino child health.
The Latino Consortium of the American Academy of Pediatrics Center for Child Health Research published a series of recommendations to improve and eliminate barriers to the health care of Latino children. Priority recommendations include that Latino children be better represented in medical research, that study data be analyzed by Latino subgroups, and that studies focus on identifying the social and economic determinants of Latino child health and use of health services.
Flores, Fuentes-Afflick, Barbot, et al., JAMA 288(1):82-90, 2002 (AHRQ grant K02 HS11305).

Barriers to dental care for minority children are revealed.
Researchers examined comments from a diverse group of 77 caregivers who participated in 11 focus groups to discuss problems in obtaining dental care for their Medicaid-insured children. Caregivers described language barriers; frustrating and time-consuming searches for dentists who would accept Medicaid patients; problems caused by appointment restrictions; and navigating formidable barriers (such as long waiting times and judgmental, disrespectful, and discriminatory behavior from staff and providers).
Mofidi, Rozier, and King, Am J Public Health 92(1):53-8, 2002 (NRSA training grant T32 HS00032).

Investigators find disparities in pediatric dental care.
An analysis of the 1996 MEPS data revealed substantial disparities in the level of dental services obtained by poor and minority youth. For every type of dental service, use was higher among white children than black and Hispanic children and between non-poor and poor children. State Medicaid health insurance programs fail to assure comprehensive dental services for eligible children.
Macek, Edelstein, and Manski, Pediatr Dent 23(5):383-9, 2001 (AHRQ Publication No. 02-R045)1 (Intramural).

Commentary summarizes AHRQ's efforts to address inequities in health care.
In partnership with other agencies and foundations, AHRQ is funding nine Excellence Centers to Eliminate Ethnic/Racial Disparities; supporting six Translating Research into Practice II studies; and developing other programs (i.e., practice-based research networks and the Minority Research Infrastructure Support Program) to augment research to improve the health of underserved and vulnerable populations.
Stryer, Clancy, and Simpson, Health Promotion Practice 3(2):125-9, 2002 (AHRQ Publication No. 02-R061)1 (Intramural).

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