Approximately 20 million children suffer from at least one chronic health condition. Of the 200 chronic conditions and disabilities that affect young people, AHRQ's current research focuses most predominantly on diabetes, cancer, cerebral palsy, respiratory problems, and traumatic brain injury.
For a description of projects and findings on other chronic illnesses, go to the sections on asthma and mental health in this program brief.
Children with type 1 diabetes can safely use the continuous subcutaneous glucose monitoring system to monitor their blood glucose levels.
The accuracy and reliability of the continuous glucose monitoring system (CGMS) have been established in adults. According to this study involving 27 patients (18 intervention and 9 control patients), it is also safe for use by children with type 1 (insulin-dependent or juvenile) diabetes. The CGMS is a tiny glucose-sensing device that is inserted just under the skin of the abdomen where it measures levels of blood glucose every 10 seconds and sends information every 5 minutes to a device worn on a belt or the waistline of a garment. Information is transmitted to the doctor's office every 3 days, so that adjustments to the diabetes management plan can be made.
Children in this study who used the CGMS had significantly lower blood glucose levels after 6 months than children in the control group.
Lagarde, Barrows, Davenport, et al., Pediatr Diabetes 7:159-164, 2006 (AHRQ HS10397).
Diabetes screening practices vary widely among pediatricians.
The American Diabetes Association (ADA) recommends screening of children at moderate or high risk of type 2 diabetes, but this study found that only one-fifth of clinicians follow the ADA recommendation. Screening practices varied widely among pediatricians responding to this survey. When presented with three hypothetical vignettes of pediatric patients with low, moderately high, and high risk for type 2 diabetes, 21 percent adhered to the ADA recommendations, 35 percent screened only children at high risk, and 39 percent screened children at all risk levels (low, moderate, and high).
Rhodes, Finkelstein, Marshall, et al., Ambulatory Pediatr 6(2):110-114, 2006 (AHRQ grant T32 HS00063).
Study reveals racial disparities in receipt of vision care among children with special health care needs.
Nearly 6 percent of U.S. children with special health care needs (CSHCN) do not receive needed eyeglasses or other vision care. Black, Latino, and multiracial CSHCN are two to three times as likely to have an unmet need for vision care as white CSHCN, according to this study. These disparities in unmet needs persisted after controlling for differences in health status and other child and family characteristics such as insurance and income. Special needs children whose usual care provider was a generalist physician, nurse practitioner, or physician assistant were more likely to have an unmet need for vision care than children who saw a pediatrician for usual care.
Heslin, Casey, Shaheen, et al., Arch Ophthal 124:895-902, 2006 (AHRQ grant HS14022).
Making treatment decisions for children with cancer is difficult for physicians and families.
Pediatric cancer care usually involves difficult and emotionally troubling decisions for physicians and families. These researchers examined the decisionmaking process from the time a child is first diagnosed, during treatment, when there is a relapse, and when death is inevitable. Popular ethical theory holds that the family should make the decisions, but sometimes the physician takes the lead. Because cure is the ultimate goal, the physician is in a better position to assume decisional priority when a cure is possible or when there is one best medical choice. On the other hand, when there are two or more clinically reasonable choices, the family is better positioned to take the lead.
Whitney, Ethier, Fruge, et al., J Clin Oncol 24(1):1690-1695, 2006 (AHRQ grant HS11289).
Children living in public housing are at increased risk for chronic health problems.
Black and Hispanic children living in public housing are two to four times as likely as children in the general population to suffer from chronic physical and mental problems, according to this study. The top five chronic conditions reported by parents for one or more children in their households were:
Bazargan, Calderon, Heslin, et al., Ethn Dis 15(suppl 5):3-9, 2005 (AHRQ grant HS14022).
Children with diabetes who need surgery must be carefully managed to prevent serious complications.
Surgery can cause life-threatening complications for children who have diabetes, and they must be carefully managed prior to surgery to ensure their diabetes is under control. Elective surgery should be postponed until metabolic control is acceptable. Whenever possible, these surgeries should be scheduled as the first case in the morning to avoid prolonged fasting and permit optimum adjustment of diabetes treatment regimens. These authors describe a surgery management protocol for managing pediatric patients with diabetes.
Rhodes, Ferrari, and Wolfsdorf, Anesth Analg 101:986-999, 2005 (AHRQ grant HS00063).
Low-dose insulin does not affect weight or development of children at risk for type 1 diabetes.
The researchers compared differences in weight change, BMI, and physical development between two groups of children and adolescents aged 4 to 19 who had more than a 50 percent risk of developing type 1 diabetes within 5 years. One group (55 children) received injections of low-dose insulin twice daily and an annual intravenous insulin infusion. Children in the other group (n = 45) were closely monitored but did not receive either insulin or placebo. The researchers found no differences over 2 years between the two groups for changes in weight, height, BMI, or stage of growth and development.
Rhodes, Wolfsdorf, Cuthbertson, et al., Diabetes Care 28(8):1948-1953, 2005 (AHRQ grant HS00063).
Newer HIV therapies have led to a marked decrease in illness and death among HIV-infected children.
Children who receive highly active antiretroviral therapy (HAART) are less likely than adults to achieve HIV suppression, and HIV tends to progress more rapidly among children. Unlike adults who take HAART, most children are unable to reduce their viral load below detectable levels. Nevertheless, this study of 263 HIV-infected children receiving HAART found that the majority had near-normal CD4 counts, an indicator of good immune system function.
Rutstein, Gebo, Flynn, et al., Med Care 43(9 suppl):15-22, 2005 (AHRQ-supported HIV Research Network).
Researchers find an overall drop between 1991-1992 and 2000-2001 in pediatric HIV care.
This study revealed lower hospitalization rates and similar use of outpatient care among HIV-infected children in 2000-2001 compared with the pre-HAART era. This drop in care use can be attributed in part to the use of newer antiretroviral therapies, but it also corresponds with the general aging of the pediatric HIV-infected population, according to the researchers. In 1991-1992, 6 percent of pediatric patients were younger than 12 months, with no child older than 12 years. In 2000-2001, the children ranged from birth to 17 years, and less than 7 percent of children were younger than age 2.
Rutstein, Gebo, Siberry, et al., Med Care 43(9):31-39, 2005 (AHRQ-supported HIV Research Network).
Children who need special care often don't receive the services they need.
Only a small proportion of children with special health care needs receive needed therapy; assistive devices, such as wheelchairs, hearing aids, or glasses; and related services, according to this study. Medicaid enrollment increased access to assistive devices and other services for children with special needs.
Dusing, Skinner, and Mayer, Ambulatory Pediatr 4:448-454, 2004 (AHRQ grant HS11309).
Leukemia relapse is common among children, but most benefit from autologous stem-cell transplant.
Relapse is common among children with acute myeloid leukemia, regardless of treatment modality. This study found that a substantial proportion of children in second complete remission who underwent autologous stem-cell transplant achieved long-term, leukemia-free survival, especially those who were experiencing relapse after a long first complete remission. Treatment failure and mortality were higher for patients in second complete remission after a short first complete remission.
Godder, Eapen, Laver, et al., J Clin Oncol 22(18):3798-3804, 2004 (cosponsored by AHRQ, NCI, NIAID, and NHLBI).
Children with chronic illness see a specialist twice as often as other children.
About 26 percent of U.S. children with a chronic condition or disability saw a specialist during 1999. Specialist visits for these children varied by household income, insurance status, and race. Use of specialty care was 45 percent lower for children in families between 100 and 200 percent of the Federal poverty level. The likelihood of uninsured children seeing a specialist was 59 percent lower relative to children who had either private insurance or Medicaid. Finally, use of specialty care was 41 percent lower for blacks, 54 percent lower for Hispanics, and 39 percent lower for other ethnic groups compared with whites.
Kuhlthau, Nyman, Ferris, et al., Pediatrics 113(3), 2004 online at www.pediatrics.org (AHRQ grant HS13757).
An increase in B-type natriuretic peptide after heart transplant in children may signal rejection.
B-type natriuretic peptide (BNP) is a circulating hormone released by the heart. Plasma BNP concentration becomes elevated in children following orthotopic heart transplant (OHT) and decreases gradually over time. A disproportionate increase in BNP concentrations after an initial decrease may be a warning sign of rejection of the transplanted heart, according to this study of 44 pediatric patients at 1 month to 14 years after OHT.
Lan, Chang, Alejos, et al., J Heart Lung Transplant 23:558-563, 2004 (AHRQ grant HS13217).
Deaths among children with single ventricle congenital heart disease are common.
Children with two types of congenital heart disease—double-inlet left ventricle and tricuspid atresia with transposed great arteries—often have an associated aortic arch anomaly and may develop pulmonary vascular disease due to excessive blood flow. Even with improvements in surgery, only 52 percent of patients with a single left ventricle are expected to survive beyond 25 years.
Lan, Chang, and Laks, J Am Coll Cardiol 43(1):113-119, 2004 (AHRQ grant HS13217).
Many chronic and mental illnesses affecting adults are rooted in childhood.
According to these researchers, reducing exposure to environmental toxins, preventing childhood stress and obesity, curtailing adolescent smoking, and preventing sexual abuse of children will greatly reduce the incidence of chronic and mental disorders in adults. They discuss the life-course model of health which focuses on preventing the precursors of illness in later life.
Forrest and Riley, Health Aff 23(5):155-164, 2004 (AHRQ grant K02 HS00003).
Characteristics of managed care may explain variations in outpatient pediatric care.
The researchers examined the relationship between the composition of managed care provider networks (number of pediatricians, family practitioners, and pediatric subspecialists), strategies to coordinate or facilitate care for children with special health care needs, and the effects of reimbursement practices on access to care for 2,223 children with special needs enrolled in one of eight Florida managed care organizations (MCOs). MCO characteristics, not child-level factors, explained most of the variation in use of outpatient care by children in the eight MCOs.
Shenkman, We, Nackashi, and Sherman, Health Serv Res 38(6, Part I):1599-1624, 2003 (AHRQ grant HS09949).
Proper classification of disability in children with cerebral palsy may increase access to needed services.
The researchers assessed the reliability of classification of cerebral palsy (CP) in children aged 2 to 8 who had been low birthweight babies in the United States, the Netherlands, Canada, and Germany. Five pediatricians with expertise in CP diagnosis grouped children into three categories: disabling CP, non-disabling CP, and no CP. When information on motor function was used, children with CP could be identified more reliably from clinical records.
Paneth, Qui, Rosenbaum, et al., Develop Med Child Neurol 45(9):628-633, 2003 (AHRQ grant HS08385).
Children with certain forms of leukemia have a very high relapse rate.
This study identified 11 out of 470 children newly diagnosed with acute myelogenous leukemia (AML) and myelodysplastic syndrome who had certain complex chromosomal abnormalities. Nine of the 11 children relapsed within 12 months, an 82 percent relapse rate. This was higher than the 46 percent relapse rate of other AML children studied. However, survival and event-free survival at 6 years were not different from other children with AML studied.
Casillas, Woods, Hunger, et al., J Pediatr Hematol Oncol 25(8):594-600, 2003 (AHRQ grant T32 HS00020).
Many pediatric cancer patients receive complementary therapy.
Nearly half (46 percent) of the predominantly white, well-educated parents of children with cancer in this study used complementary therapy (CT) for their children, and 33 percent began using a new CT following their child's cancer diagnosis. These therapies ranged from acupuncture and magnets to dietary supplements and herbal remedies.
Gagnon and Recklitis, Psycho-Oncology 12:442-452, 2003 (AHRQ grant T32 HS00063).
AHRQ's research indicates that more than 10 million U.S. children ages birth to 17 were uninsured all year in 2004. Obtaining adequate access to care and maintaining a usual source of care are special challenges for these young people and their families. There also are significant racial and ethnic differences in children's access to health care that cannot be explained by insurance and socioeconomic factors alone.
Medical injuries among children result in longer hospital stays and higher charges.
This study found that 3.4 percent of children hospitalized between 2000 and 2002 in Wisconsin suffered a medical injury while in the hospital. These injuries were due to problems with medications, procedures, and medical devices. Injured children had a longer hospital stay (0.5 day) and higher charges ($1,614) than children who were not injured. The study involved more than 318,000 children admitted to 1 of 134 Wisconsin hospitals between 2000 and 2002.
Meurer, Yang, Guse, et al., Quality Safety Health Care 15:202-207, 2006 (AHRQ grant HS11893).
Immunocompromised children who acquire fungal infections have higher costs, longer hospital stays, and an elevated risk of death.
Some children's immune systems are compromised by diseases such as cancer or treatments such as bone marrow transplantation. During 2000, 0.5 percent of hospitalized immunocompromised children developed invasive aspergillosis (IA), the most common fungal infection to strike immunocompromised children. Nearly one in five (18 percent) of the children died in the hospital; children with cancer and IA had a 13.5 percent higher risk of dying in the hospital than children who had cancer but were not infected with IA. Median length of stay was over five times as long for immunocompromised children with IA (16 days) as for children who were not infected with IA (3 days), and their total hospital charges were also five times as high ($49,309 vs. $9,035).
Zaoutis, Heydon, Chu, et al., Pediatrics 117:711-716, 2006 (AHRQ grant HS10399).
Uninsured children' access to care is affected by the availability and capacity of the local safety net.
Researchers examined data on a nationally representative sample of more than 2,600 children aged 2 to 17 who were uninsured for at least 1 year during 1996 to 2000. They found that 60 percent of uninsured children did not visit a physician's office during the year, and more than half had no care from a provider of any type in an office-based setting. Uninsured children in rural areas were more likely to make physician visits if they lived closer to a safety net provider or in an area with a larger supply of primary care physicians. Although proximity to safety net providers was not found to be a determinant of access to care among uninsured urban children, the researchers caution that other factors affecting accessibility to care (e.g., availability of public transportation, ER crowding) were not measured and may influence the services that urban uninsured children receive.
Gresenz, Rogowski, and Escarce, Pediatrics 117:509-517, 2006 (AHRQ grant HS10770).
Non-English-speaking parents report better care and access for their children when interpreters are present during doctor visits.
Hispanic and Asian/Pacific Islander parents who always use an interpreter when their child has an outpatient medical visit report enhanced care access and quality, compared with parents who don't always use interpreters. They also report better service from their health plan when compared with parents who do not use interpreters.
Morales, Elliott, Weech-Maldonado, and Hays, Med Care Res Rev 63(1):110-128, 2006 (AHRQ grant HS09204).
Having health insurance coverage greatly increases children's access to care and use of services.
Researchers pooled 1996-2002 data from the Medical Expenditure Panel Survey (MEPS) to estimate the impact of insurance coverage on children's access to and use of care. Like other researchers, they found that public and private coverage were both associated with large increases in care access and use. The large differences between public and private coverage were reduced (and often reversed) when the researchers accounted for other characteristics of children and their families that could affect health care access and use.
Selden and Hudson, Medical Care 44(5 Suppl):19-26, 2006 (AHRQ Publication No. OM-06-0074, for single copies of the journal)* (Intramural).
Medicaid primary care case management reduces children's access to primary and preventive care.
Primary care case management (PCCM) programs reimburse providers on a fee-for-service basis. However, they assign Medicaid patients to gatekeeper providers who must make specific referrals for specialty, emergency, and inpatient care. This arrangement resulted in disruptions in established patterns of care use in Alabama and Georgia and had an unexpected negative effect on children, especially minority children, according to this study.
PCCM was associated with lower use of primary care for all children (except for white children) in urban Georgia and reduced preventive care for white children in urban Alabama and for black and white children in urban Georgia. Implementation of PCCM without fee increases may affect provider decisions about Medicaid participation and ultimately may reduce provider availability, note the researchers.
Adams, Bronstein, and Florence, Med Care Res Rev 63(1):58-87, 2006 (AHRQ grant HS10435).
Nearly one-quarter of Latino children living in the United States lack health insurance.
Despite State Medicaid health insurance programs for the poor and the State Children's Health Insurance Program (SCHIP), more than 8 million U.S. children are uninsured. Latino children, in particular, are likely to be uninsured. This study found that nearly one-quarter (3 million) Latino children lack health insurance. Even in States where all low-income children are eligible for health insurance, current SCHIP and Medicaid outreach and enrollment efforts are not reaching many uninsured Latino children.
Latino parents need better information about the programs, including eligibility requirements and application processes. Major obstacles to enrollment of these children include lack of knowledge about the application process and eligibility, language barriers, family mobility, and misinformation from insurance representatives.
Flores, Abreu, Brown, and Tomany-Korman, Ambulatory Pediatr 5(6):332-340, 2005 (AHRQ grant HS11305).
Researchers examine factors that affect children's primary care experiences.
This study found that having a regular provider and obtaining needed care have a greater impact on children's primary care experiences than having health insurance. After accounting for other factors that affect the primary care experience—such as the parent's language and the mother's education level—gaining or losing insurance during the 1-year study period did not have a significant effect on primary care experiences. Gaining a regular physician also did not have a significant effect on primary care experiences, but losing a regular physician was associated with much lower parental satisfaction scores.
Seid and Stevens, Health Services Res 40(6):1758-1780, 2005 (AHRQ grant HS10317).
SCHIP decreases uninsurance among children from low-income families.
During the period 1996-2002, SCHIP significantly increased public insurance for poor children, from 21.5 percent in 1996 to 26.3 percent in 2002. During the same period, uninsurance declined for this group by more than 3 percentage points, from 16.4 percent to 13.1 percent. Further study is needed to quantify the potential benefits to these children and their families from lower premiums and out-of-pocket expenditures, as well as improved access to care.
Hudson, Selden, and Banthin, Inquiry 42:232-254, 2005 (AHRQ Publication No. 06-R018)* (Intramural).
Expanding public health insurance for children lessens the financial burden on low-income families.
Expansions in public health insurance programs (e.g., Medicaid, SCHIP) between 1980 and 2000 have reduced out-of-pocket medical expenses for low-income families, according to this study. The researchers compared out-of-pocket health care expenditures and the associated financial burden for children aged 0 to 18 in six poverty level groups. They found that out-of-pocket expenses and financial burden decreased for all groups studied, ranging from a reduction of 36.5 percent for those below 100 percent of the Federal poverty level to 46.7 percent for those at or above 300 percent (four times the Federal poverty level).
Wong, Galbraith, Kim, and Newacheck, Arch Pediatr Adolesc Med 159:1008-1013, 2005 (AHRQ grant HS11662).
Researchers examine methods for predicting Medicaid child health expenditures.
In this study, researchers found that models with either pharmacy-based or diagnosis-based risk adjustment improved the prediction of Medicaid child health expenditures compared with demographic models without risk adjustment. They used Medicaid claims data from the mid-1990s for children in three States who were not covered by managed care.
Kuhlthau, Ferris, Davis, et al., Med Care 43(11):1155-1159, 2005 (AHRQ grant HS10152).
Premium subsidy programs can help low-income families obtain health insurance.
A growing number of States have begun to explore the use of premium subsidy programs to help low-income families purchase health insurance through the workplace or private plans. Three recent studies examined the benefits and difficulties encountered in several of these programs. All three studies are part of AHRQ's Child Health Insurance Research Initiative (CHIRI™). The first study examined the factors that led parents to choose Oregon's premium subsidy program over SCHIP to cover their children and compared the children's experiences with regard to access, use of services, and satisfaction. The second study found that SCHIP can improve care for vulnerable children and reduce racial/ethnic disparities in health care. The third study found that families have difficulty shifting to Medicaid primary care case management programs, which limit the providers enrollees can use for routine care.
Mitchell, Haber, and Hoover, Health Aff 24(5):1344-1355, 2005 (AHRQ
grant HS10463).
Also: Shone, Dick, Klein, et al., Pediatrics 115(6), 2005, online
at www.pediatrics.org (AHRQ grant HS10465).
Also: Bronstein, Adams, Florence, et al., Health Care Financ Rev 26(4):95-107,
2005 (AHRQ grant HS10435).
MEPS statistical brief details health insurance status of U.S. children.
Data from the 2004 Medical Expenditure Panel Survey (MEPS) Household Component indicate that nearly 12 percent (8.5 million) of children under age 18 were uninsured in 2004. This estimate is significantly lower than estimates from the previous decade, mostly due to expansions in public insurance (Medicaid and SCHIP). The data also show that young adults aged 19-24 were at greatest risk of being uninsured.
MEPS Statistical Brief #85 at www.meps.ahrq.gov (Intramural).*
Certain features of managed care increase access to specialists for low-income children with chronic illnesses.
This study linked certain features of managed care—having more in-network pediatricians and offering financial incentives for meeting quality of care standards—with greater access to specialty care for low-income children with chronic conditions. The study involved 2,333 children with conditions such as asthma, diabetes, and cystic fibrosis who were enrolled in an SCHIP program. The study also identified disparities in access to care; overall, black children were only half as likely as white children to receive specialty care.
Shenkman, Tian, Nackashi, and Schatz, Pediatrics 115(6):1547-1554, 2005 (AHRQ grant HS09949).
Improving access and quality for low-income and minority children may require more than expanding coverage.
Although low-income children account for nearly 40 percent of the U.S. child population, only about one-quarter of total pediatric medical expenditures are for these children. Factors other than health insurance coverage that affect access to care and quality for these children include: problems in accessing necessary care, difficulty in getting referrals for specialty care, and lack of effective communication with physicians and other care providers. Regardless of income, black children had lower health care use and expenditures than white children, according to these researchers.
Simpson, Owens, Zodet, et al., Ambul Pediatr 5(1):6-44, 2005 (AHRQ Publication No. 05-R048)* (Intramural).
One in five Latino children in the United States is uninsured.
This study examined the use of bilingual community-based case managers to assist Latino children with public insurance enrollment in two Boston-area communities. Children aged 18 and younger were divided into two groups: one group received help from trained case managers, and the other group (control) received traditional Medicaid and SCHIP outreach and enrollment. The researchers found that 96 percent of children in the intervention group enrolled in either Medicaid or SCHIP between May 2002 and September 2003, compared with 57 percent of children in the control group.
Flores, Abreu, Chaisson, et al., Pediatrics 116(6):1433-1441, 2005 (AHRQ grant HS11305).
Study strengthens argument against rollbacks in SCHIP.
High enrollment and reduced Federal allocations for SCHIP have led a number of States to begin reversing the expansion in public coverage for children. However, this study by AHRQ researchers found that rollbacks in SCHIP will not save much money. The net cost of SCHIP—both to States and to the Federal Government—is substantially less than the average spending per enrollee would suggest, according to the researchers. They conducted a variety of simulations and found that budgetary data greatly overstate the true net costs of SCHIP and consequently the potential savings from rollbacks to reduce enrollment.
Selden and Hudson, Inquiry 42:16-28, 2005 (AHRQ Publication No. 05-R063)* (Intramural).
Children of working poor parents continue to be at a disadvantage for health care access and use.
Researchers used data from the 2001 California Health Interview Survey to compare health insurance coverage, access to care, and use of health care services for three groups of children: the working poor, nonworking poor, and nonpoor. They found that despite public health insurance, children from poor working families in California were less likely to be insured than other poor and nonpoor children in 2001. Children of the working poor also were more likely to be Latino and less likely to be black or Asian, more likely to be undocumented, and more likely to live in two-parent or larger households.
Guendelman, Angulo, and Oman, Med Care 43(1):68-78, 2005 (AHRQ grant HS13411).
Children with special needs use more health services and have higher costs than other children.
Children who have special health care needs (CSHCN) are those who have chronic physical, developmental, behavioral, or emotional problems and require more or more complex care than other children. This study found that in 2000, CSHCN had three times the health care expenditures of other children ($2,099 vs. $628). Although CSHCN make up less than 16 percent of U.S. children, they accounted for 42 percent of total medical costs and 52.5 percent of children's hospital days in 2000. Also, CSHCN used five times as many prescription drugs and substantially more home health care days than other children.
Newacheck and Kim, Arch Pediatr Adolesc Med 159:10-17, 2005 (AHRQ/HRSA
cooperative agreement).
Also: Jaffee, Liu, Canty-Mitchell, et al., Psychiatr Serv 56(1):63-69, 2005
(AHRQ grant HS10453).
SCHIP benefits low-income and vulnerable children.
According to this study of children newly enrolled in the State Children's Health Insurance Program (SCHIP), more children had a usual source of care, received a preventive health visit, and had fewer unmet health care needs as a result of being enrolled in SCHIP for 1 year. Families were more satisfied with the health care their children received after enrollment as compared with before SCHIP. SCHIP minimized many, but not all, racial/ethnic health care disparities.
Dick, Brach, Allison, et al., Health Affairs 23(5):63-75, 2004 (AHRQ Publication No. 04-R066)* (Intramural).
SCHIP has led to improvements in public coverage for children.
According to this study, the percentage of children who were eligible for free or highly subsidized health insurance rose from 29 percent in 1996 to 45 percent in 2002, primarily due to enactment of SCHIP. However, the problem of uninsurance among children continues, with a total of 10 million uninsured children in 2002; 62 percent of these uninsured children were eligible for public coverage but were not enrolled.
Selden, Hudson, and Banthin, Health Affairs 23(5):39-50, 2004 (AHRQ Publication No. 04-R067).* (Intramural)
Researchers track children's health insurance coverage over a 25-year period.
According to this study, the percentage of children without health insurance of any type increased sharply between 1977 and 1987, but by 2001, it had dropped back to near the 1977 level of coverage. Also, the percentage of children with public coverage rose significantly during the period, while the percentage of children with private health insurance declined.
Cunningham and Kirby, Health Affairs 23(5):27-38, 2004 (AHRQ Publication No. 04-R065).* (Intramural)
Study describes trends in children's health insurance coverage, principal care sites, and expenditures.
From 1987 to 2001, insurance coverage for U.S. children improved, the site of care shifted toward outpatient sites, hospital use declined, and expenditures for children as a proportion of total health expenditures decreased. Several of the observed trends varied significantly by type of health insurance coverage, poverty status, and geographic region.
Simpson, Zodet, Chevarley, et al., Ambulatory Pediatr 4(2):131-153, 2004 (AHRQ Publication No. 04-R042).* (Intramural)
Inner city parents often have limited knowledge of managed care rules and procedures.
A survey of urban parents living in Boston found that most of them, especially those who were disadvantaged or had limited English, knew little about managed care rules and policies. Most of the parents were poor, minority, and covered by public health insurance; more than half of their children were covered by managed care. For the study, researchers interviewed 1,100 parents at inner city community sites—including supermarkets, hair salons, and laundromats—about care access, insurance, and managed care.
Flores, Abreu, Sun, and Tomany, Med Care 42(4):336-345, 2004 (AHRQ grant K02 HS11305).
Enrollment in certain Medicaid managed care plans increases access to services for children with special needs.
Children with special needs who qualified for Supplemental Security Income (SSI) and were enrolled in a partially capitated Medicaid managed care plan had fewer unmet health care needs compared with similar children enrolled in Medicaid fee-for-service plans. The managed care plan was specifically designed for children who qualify for Medicaid because they receive SSI due to a disability. The researchers attribute the children's enhanced access to care to the plan's comprehensive care plan assessment, ongoing case management, primary care providers' gatekeeping role, and higher physician reimbursement.
Mitchell and Gaskin, Pediatrics 114(1):196-204, 2004 (AHRQ grant HS10912).
ED use varies among children enrolled in both Medicaid and a State-run plan for children with special needs.
Researchers found that some Michigan children who were enrolled in both Medicaid and the State's Children's Special Health Care Services plan had especially high rates of emergency department use. The children were younger than age 1 and/or had diagnoses of anemia, hemophilia, asthma, epilepsy, or juvenile diabetes.
Pollack, Dombkowski, Zimmerman, et al., Health Serv Res 39(3):665-692, 2004 (AHRQ grant HS10441).
Instrument measures access to care for children with special needs.
The researchers developed and validated the 39-item Barriers to Care Questionnaire (BCQ). The instrument was field tested in three samples of children with special health care needs. BCQ scores were higher (indicating fewer barriers) for children with a primary care physician and for those who reported no problems getting care.
Seid, Sobo, Gelhard, and Varni, Ambulatory Pediatr 4(4):323-331, 2004 (AHRQ grant HS13058).
Telemedicine can increase access to health care, but there may be problems with diagnostic accuracy.
This project assessed the usefulness of telemedicine links for increasing access to quality health care. Children who were ill were examined by an experienced pediatrician in a hospital-based primary care clinic and then assigned to receive an in-person or telemedicine duplicate exam. Children needing skilled palpation or x-rays were excluded. Among the 492 remaining children, there was a disagreement between the two exams on primary diagnosis for 54 (11 percent) of children. Disagreement was marginally more common among telemedicine cases compared with in-person exams.
Kenneth M. McConnochie, PI (AHRQ grant HS10753), Reliability and Efficacy of Telemedicine in Routine Pediatric Practice (Final Report, NTIS Accession No. PB2003-104249).**
Determinants of access to care are similar for rural, suburban, and urban children.
Rural children tend to have less access to health care than urban and suburban children due in part to time and distance to care sites, lack of transportation, and fewer doctors. According to this study, the most important determinants of care use—health insurance coverage, household income, and a parent's perceptions of a child's pain—apply to all children, regardless of where they live. Programs in rural areas that strengthen health insurance coverage and reduce poverty will have a direct impact on child health, according to these researchers.
Woods, Arcury, Powers, et al., Pediatrics 112(2), 2003 online at www.pediatrics.org (AHRQ grant HS09624).
U.S. children are more likely to be referred to specialists.
Investigators compared specialist referrals among 135,092 children in five U.S. managed health plans with 221,312 U.K. children. Compared with their U.K. counterparts, U.S. children were twice as likely to be referred to medical specialists, three times as likely to be referred to surgeons, and nearly three times as likely to be referred to psychiatrists.
Forrest, Majeed, Weiner, et al., Arch Pediatr Adolesc Med 157:279-285, 2003 (AHRQ grant HS00003).
Many migrant children receive health care in Mexico.
Nearly 70 percent of the 279 parents surveyed at Head Start preschool centers serving migrant farm workers in southern California had health insurance. However, their children received more than half of their health care in Mexico.
Seid, Castenada, Mize, et al., Ambulatory Pediatr 3(3):121-130, 2003 (AHRQ grant HS10317).