AHRQ's research indicates that as many as 11 million U.S. children ages birth to 18 are uninsured. 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.
Barriers faced by vulnerable children are being identified.
Description:
Researchers aim to measure modifiable barriers to care that affect the link between vulnerability factors and health care structures, processes, and outcomes for children with special health care needs. English and Spanish versions of a Barriers to Care Questionnaire also will be developed.
Principal Investigator: Michael Seid (AHRQ grant HS13058).
Study will examine family status and child mental health.
Description:
This project will examine the socioeconomic status of families, mental health conditions of children, and related services for children.
Principal Investigator: Michael Ganz (AHRQ grant HS13047).
Project assesses family experiences in managing health needs.
Description:
The goal of this project is to provide qualitative information about managing the health care needs of vulnerable children in San Diego. The focus will be on health needs, use of services, problems in using care, and proposals for improving health care services.
Principal Investigator: Michael Seid (AHRQ grant HS11751).
Study will evaluate risk-assessment instruments.
Description:
Investigators will determine the sensitivity of risk assessment models that identify expected costs and use of managed care plans, if disincentives for enrollment exist, and whether additional information improves the predictive performance of risk assessment instruments.
Principal Investigator: Paul Fishman (AHRQ grant HS11314).
Studies in the Child Health Insurance Research Initiative (CHIRI) are focusing on ways that public health insurance programs and health care delivery systems can improve quality and access for low-income children.
Description:
In 1999, AHRQ in partnership with the Health Resources and Services Administration and the David and Lucile Packard Foundation funded nine 3-year projects to examine ways to improve health care for low-income children receiving care through publicly funded programs, including the State Children's Health Insurance Program (SCHIP). Funding for these projects will total $9.1 million over 3 years. The projects, which are dispersed around the country, will identify which health insurance and delivery features work best for low-income, minority, and special-needs children. The projects and principal investigators are:
Adolescents in skipped-generation families are most likely to be uninsured.
Description:
A study of the health insurance status of a nationally representative sample of 17,670 middle and high school students reveals that adolescents who live outside of two-parent families are significantly more likely to have been uninsured than adolescents in two-parent families. Adolescents living in households headed by grandparents are most likely to be uninsured (Intramural).
Citation: Kirby and Kaneda. Med Care Res Rev 59(2):146-65, 2002 (AHRQ Publication No. 02-R073)
Available from: AHRQ Publications Clearinghouse.
Limited English proficiency hinders enrollment in State Medicaid programs.
Description:
Families who are not proficient in the English language have more difficulty enrolling in State Medicaid health insurance programs, according to a survey of 1,055 parents. Compared with English-proficient families, they were more likely not to know if they were eligible or how to enroll in Medicaid and to find the enrollment forms too difficult.
Citation: Feinberg, Swartz, Zaslavsky, et al. Maternal and Child Health Journal 6(1):5-18, 2002 (AHRQ grant HS10207).
Georgia's SCHIP enrollees have better access to care than its Medicaid-insured children.
Description:
Based on responses to the Consumer Assessment of Health Plans Study Medicaid-Managed Care Child Survey, researchers report that children enrolled in Georgia's Medicaid program have worse access to health care than children enrolled in Georgia's SCHIP. Both programs have nearly identical rules and providers, and results were corroborated by focus groups with physicians and parents.
Citation: Edwards, Bronstein, and Rein. Health Affairs 21(3):240-48, 2002 (AHRQ grant HS10435).
Passive reenrollment policies contribute to a lower SCHIP disenrollment rate.
Description:
Kansas, New York, and Oregon require parents to periodically verify their children's eligibility. Florida's passive policy requires notification only if changes occur that affect eligibility for SCHIP. At reenrollment, this study found only 5 percent of children in Florida's SCHIP were disenrolled compared with one-third to one-half of those in the other States (Intramural).
Citation: Dick, Allison, Haber, et al. Health Care Financing Review 23(3):65-88, 2002 (AHRQ Publication No. 02-R070)
Available from: AHRQ Publications Clearinghouse.
Expanding income eligibility does not increase unmet needs.
Description:
Researchers evaluated a State-financed health insurance program that provided coverage to children regardless of income before implementation of SCHIP. They found inclusion of higher income children benefits a larger group of children without substantially changing health service use in the program.
Citation: Feinberg, Swartz, Zaslavsky et al. Pediatrics 109(2):2002, online at www.pediatrics.org/cgi/content/full/109/2/e29 (AHRQ grant HS10207).
State insurance does not “crowd out” private insurers.
Description:
Telephone surveys of 996 parent/guardians of children enrolled in the Massachusetts Children's Medical Security Plan (CMSP) revealed that access to employer-sponsored insurance (ESI) was limited (19 percent), and uptake was low (13 percent). Few children who had ESI at enrollment dropped this coverage to enroll in CMSP.
Citation: Feinberg, Swartz, Zaslavsky, et al. Health Serv Res 36(6) (online only), 2001 (AHRQ grant HS10207).
Medicaid expansions were relatively inexpensive.
Description:
Researchers analyzed 1984 to 1994 State Medicaid spending to determine the cost of Medicaid expansions for children. They found that the expansions had relatively low incremental costs per enrollee and were substantially below the average Medicaid expenditure for children (Intramural).
Citation: Gordon and Selden. Med Care Res Rev 58(4):482-95, 2001 (AHRQ Publication No. 02-R033)
Available from: AHRQ Publications Clearinghouse.
Market forces prompt evolution of children's hospitals.
Description:
Chief executive officers of 29 children's hospitals responded to a survey on the impact of market changes from 1991 through 1996. They note that hospitals experienced changes in mission, movement toward more outpatient care, a decline in lengths of stay, and an increase in marketplace competition.
Citation: Yee, Shelton, Girouard, et al. Ambulatory Pediatr 1(2):117-21, 2001 (NRSA training grant T32 HS00063).
A regular source of care helps to ensure appropriate service.
Description:
Middle and high school students in rural areas were surveyed regarding their health status and use of health care services. Those with no regular source of care were much less likely to obtain preventive or acute care than those with a regular source of care.
Citation: Ryan, Riley, Kang, et al. Arch Pediatr Adolesc Med 155:184-190, 2001 (AHRQ grant HS07045).
Use of health services involves significant out-of-pocket expenditures for some families.
Description:
Data from AHRQ's 1996-1998 Medical Expenditure Panel Survey (MEPS) were used to analyze insurance coverage and health expenditures for children and youths, newborn to age 17. Although private health insurance was the largest payer, nearly 21 percent of expenditures were covered directly by families (Intramural).
Citation: McCormick, Weinick, Elixhauser, et al. Ambulatory Pediatrics 1(1):3-15, 2001 (AHRQ Publication No. 01-R036)
Available from: AHRQ Publications Clearinghouse.
Children who are eligible for public insurance programs often are not enrolled.
Description:
Although nearly 90 percent of children had some form of health insurance in 1996, 15.4 percent of children were uninsured at any given point in time. White children were more likely to have insurance than minority children; Hispanic children were least likely to be insured. Many children who were eligible for public insurance (e.g., Medicaid) were not enrolled (Intramural).
Citation: McCormick, Kass, Elixhauser, et al. Pediatrics 105:219-30, 2000 (AHRQ Publication No.00-R014)
Available from: AHRQ Publications Clearinghouse.
Costs of treating Medicaid-insured and commercially insured children are similar.
Description:
Researchers compared the use of services and costs for treating Medicaid-insured children and commercially insured children in a large nonprofit health maintenance organization. They concluded that treatment costs did not differ significantly between the two groups, and that States enrolling Medicaid recipients in managed care plans may need to adopt reimbursement levels comparable to rates for commercially insured patients.
Citation: Ray, Lieu, Weinick, et al. Am J Managed Care 6:753-60, 2000 (AHRQ Publication No. 00- R044)
Available from: AHRQ Publications Clearinghouse. (Intramural).
Changes in State rules and processes for public insurance could improve coordination and outreach.
Description:
Two reports examine efforts to increase enrollment in public health insurance programs that serve children. The first report describes administrative strategies that could promote coordination between Medicaid and SCHIP. The second report presents the results of a review of evidence on pre-SCHIP outreach efforts.
Citations: Mann, Cox, and Cohen-Ross, Making the Link: Strategies for Coordinating Publicly Funded Health Care Coverage for Children (AHRQ Publication No. 00-0014); and Barents Group, Review of the Literature on Evaluations of Outreach for Public Health Insurance and Selected Other Programs (AHRQ Publication No. OM 00-0006)
Available from: AHRQ Publications Clearinghouse. (AHRQ contracts 290-96-0004 and 290-98-0009).
Proportion of privately insured children declined between 1977 and 1996.
Description:
Between 1977 and 1996, the proportion of publicly insured children grew from 13.5 to 19.7 percent, the proportion with no insurance increased from 12.7 to 15.1 percent, and the proportion of children with private coverage decreased from 73.8 to 65.2 percent (Intramural).
Citation: Weinick and Monheit. Med Care Res Rev 56(1):55-73, 1999 (AHRQ Publication No. 99-R051)
Available from: AHRQ Publications Clearinghouse.
The daily practice of children's primary care is changing.
Description:
Using data from the National Ambulatory Care Surveys from 1979 to 1994 (58,000 visits), investigators concluded that primary care physicians were spending slightly more time with young patients in 1994 than they did in 1979. They also are providing increased preventive services and counseling and are prescribing antibiotics and the stimulant Ritalin more often.
Citation: Ferris, Saglam, Stafford, et al. Arch Pediatr Adolesc Med 152:227-33, 1998 (AHRQ grant HS07892).
Outpatient capacity and access to primary care play a role in out-of-area hospitalizations.
Description:
Children who live in areas with more primary care physicians and hospital-based outpatient services are less likely to go to hospitals outside their local area for ambulatory-care-sensitive conditions such as asthma and diabetes. Greater severity of illness, distance to a metropolitan area, and a higher county median income increase the likelihood of out-of-county care (Intramural).
Citation: Basu and Friedman. Health Econ 10:67-78, 2001 (AHRQ Publication No. 01-R033)
Available from: AHRQ Publications Clearinghouse.
Parental inability to speak English creates a substantial barrier to health care.
Description:
Researchers found that parents' inability to speak English well enough to fully interact with health care providers creates disadvantages for their children in accessing care. Interpreters or bilingual providers and office staff would help to help reduce disparities (Intramural).
Citation: Weinick and Krauss. Am J Public Health 90:11-14, 2000 (AHRQ Publication No. 01-R008)
Available from: AHRQ Publications Clearinghouse.
Doctors with many patients in gatekeeping plans tend to refer their patients to specialists.
Description:
Researchers found that gatekeeping arrangements nearly double the odds of patient referrals from pediatricians' offices to specialty care, even though coordinating referrals made during office visits is more difficult for patients in gatekeeping plans.
Citation: Forrest, Glade, Starfield, et al. Pediatrics 104(1):28-34, 1999 (AHRQ grant HS08430).
Current studies are focused on evaluating specific units within hospitals and identifying commonalities between frequent users of these facilities. Researchers also hope to expedite decisionmaking by providing evidence-based solutions.
Conference aims to improve practice through research.
Description:
Pediatric emergency medicine investigators learned about concepts in outcomes research, reviewed measures, determined their applicability, identified where new measures are needed, and promoted dialogue with researchers of other disciplines. Several conference papers were published in Ambulatory Pediatrics, July 2002, volume 2, number 4, including the paper “The importance of outcomes research in pediatric emergency medicine” (AHRQ Publication No. 02-R087) by AHRQ's Carolyn Clancy, Denise Dougherty, and Elinor Walker.
Principal Investigator: Ellen Crain (AHRQ grant HS10942).
Available from: AHRQ Publications Clearinghouse.
Researchers are developing a triage instrument.
Description:
The Pediatric Emergency Assessment Tool, now under development, is intended to help emergency room clinicians triage pediatric patients to the appropriate level of emergency care.
Principal Investigator: Marc Gorelick (AHRQ grant HS11028).
Findings on quality and severity are being applied in a pediatric emergency setting.
Description:
A pediatric emergency department severity system is being validated and applied to a quality-of-care evaluation.
Principal Investigator: Murray M. Pollack (AHRQ grant HS10238).
Researchers examine adolescents' functional outcomes after trauma.
Description:
This study is identifying risk factors for functional limitations after major trauma in adolescents and assessing their degree of disability, quality of life, and psychological well-being.
Principal Investigator: Troy Holbrook (AHRQ grant HS09707).
Three factors predict severity of car crash injuries.
Description:
Emergency medical technicians can identify seriously injured children and properly triage them to trauma centers if at the car crash site they evaluate a child's degree of consciousness, extent of passenger space intrusion, and appropriate use of a seatbelt or other restraint.
Citation: Newgard, Lewis, and Jolly. Ann Emerg Med 39(1):481-91, 2002 (NRSA grant F32 HS00148).
Nurses can be trained to recognize suicide risk in an emergency department.
Description:
After attending educational sessions on psychiatric issues and learning about the Suicide Risk Questionnaire, nurses were better equipped to manage potentially suicidal children in the emergency department. Horowitz, Smith, Levin, et al. Pediatr Emerg Care 17(4):306-9, 2001 (NRSA training grant T32 HS00063). Four simple questions based on a standard 30-item Suicide Ideation Questionnaire helped the ER triage nurses identify 98 percent of children at risk for suicide.
Citation: Horowitz, Wang, Koocher, et al. Pediatrics 107(5):1133-37, 2001 (NRSA training grant T32 HS00063).
Quality and research are key themes of conference.
Description:
This report describes a national conference on childhood emergencies. Participants emphasized quality improvement and research.
Citation: Jane Ball (AHRQ grant HS10084), National Congress on Childhood Emergencies, 2000 (Final Report, NTIS Accession No. PB2001-102808).
Available from: The National Technical Information Service.
Children with special health care needs are much more likely to use emergency medical services than other children.
Description:
A study of how Utah children used emergency medical services (EMS) and related hospital care found that children with special health care needs—for example, congenital anomalies or birth-related conditions—use more EMS than other children, are more likely to be admitted to the hospital and have longer stays, and usually incur greater hospital charges.
Citation: Suruda, Vernon, Diller, et al. Prehosp Emerg Care 4(2):131-5, 2000 (AHRQ grant HS09057).
No significant differences in outcomes were found between two emergency breathing procedures—endotracheal intubation (ETI) and bag-valve-mask ventilation.
Description:
Nearly all (97 percent) paramedic training programs teach ETI. Until this study, however, there were no data associating improved patient survival or other positive outcomes with its use. These researchers compared pediatric ETI with bag-valve-mask ventilation in 830 children and found no significant differences in survival or neurological outcome between the two approaches.
Citations: Gausche-Hill, Lewis, Gunter, et al. Ann Emerg Med 36(4):356-65, 2000 and Gausche, Lewis, Stratton, et al. JAMA 283(6):783-90, 2000 (AHRQ grant HS09166).
Mortality and functional outcomes data are needed to evaluate pediatric intensive care units (PICUs).
Description:
Researchers examined the relationships between illness severity, length of stay, and functional outcomes among 11,106 patients at 16 PICUs across the United States. Because mortality is a relatively rare event, by itself it probably is not a sufficient indicator of outcomes for PICUs but should be combined with other findings.
Citation: Fiser, Tilford, and Roberson, Crit Care Med 28(4):1173-79, 2000 (AHRQ grant HS09055).
High-volume PICUs have better outcomes than low-volume units.
Description:
A study of patient volume and its relationship to risk of death and length of stay in 16 PICUs revealed that higher patient volume is consistent with lower mortality rates and shorter stays.
Citation: Tilford, Simpson, Green, et al. Pediatrics 106:289-94, 2000 (AHRQ grant HS09055).
Handlebars cause major abdominal injuries in minor bicycle falls.
Description:
Researchers studied the records of children age 18 and younger who had been treated for serious bicycle-related injuries at an urban pediatric trauma center. About 77 percent of the handlebar-related injuries resulted from minor crashes.
Citation: Winston, Shaw, Kreshak, et al. Pediatrics 102(3):596-601, 1998 (AHRQ grant HS09058).
Despite the debilitating nature and prevalence of mental health problems in children, many disorders continue to be under-diagnosed and inadequately treated. AHRQ-funded research focuses on improving delivery of mental health care in general health care.
Study evaluates an intervention for oppositional defiant disorder.
Description:
Researchers are evaluating the effectiveness of using a psychological intervention in primary care pediatric settings to help identify and treat preschool children with oppositional defiant disorder (ODD). The study also will evaluate how well a 10-week training program on parenting skills reduces the incidence of ODD and the use of ambulatory and ER care.
Principal Investigator: John V. Lavigne, (AHRQ/NIMH grant MH59462).
Investigators explore better ways to treat depressed teens.
Description:
This study is testing whether adolescents who receive psychotherapy and medication are more likely than those given medication alone to adhere to medication instructions, recover faster from initial depression, stay in remission longer, function better socially and academically, and be more satisfied with their treatment.
Principal Investigator: Gregory N. Clarke (AHRQ grant HS10535).
Researchers evaluate an intervention for depressed youths.
Description:
This study involves an intervention to treat depression in adolescents and young adults in primary care settings. Effects are being compared for indicators including usual care, quality of care, satisfaction with care, clinical symptoms, daily functioning, service use and cost, and parental psychological distress.
Principal Investigator: Joan Asarnow (AHRQ grant HS09908).
More primary care physicians are prescribing psychotropic medications.
Description:
An analysis of 1995-1999 claims data and calculation of the prevalence of antidepressant use for children with depression or attention deficit/hyperactivity disorder reveal an increase in use of serotonin selective reuptake inhibitors and central nervous system stimulants, a decrease in use of tricyclic antidepressants, and an increase in other antidepressants. Also, more pediatricians and family doctors are prescribing these drugs, despite their limited training in this area.
Citation: Shatin and Drinkard. Ambulatory Pediatrics 2:111-9, 2002 (AHRQ grant HS10397).
Affective disorders in children often go undetected and untreated in primary care.
Description:
Researchers examined how primary care providers treat affective disorders in children and adolescents. They found that pediatricians identified mental health needs in only 1 to 16 percent of children, even though 17 to 27 percent of pediatric primary care patients may need care.
Citation: Wells, Kataoka, and Asarnow, Biol Psychiatry 49(12):1111-20, 2001 (AHRQ grant HS09908).
Family stress contributes to the use of services.
Description:
In this study, mothers of 4,000 disabled children ages 6-17 reported on their children's health, psychosocial problems, and mental health services use, as well as the services provided by health care coordinators. Family stressors were found to be strongly associated with children's poor psychosocial adjustment and mental health care use.
Citation: Whitney P. Witt (AHRQ grant HS11254). Family Influences on Children's Health and Health Care (Final Report, NTIS Accession No. PB2002-100381).
Available from: The National Technical Information Service.
Youths with dual diagnoses need a specialized approach.
Description:
An analysis of data on 564 youths in residential treatment and State custody examined clinical characteristics and placement outcomes. Researchers recommend screening youths entering residential treatment for type and severity of substance use problems and tailored services to ensure close supervision and monitoring of high-risk behaviors.
Citation: Weiner, Abraham, and Lyons. Psychiatr Serv 52(6):793-9, 2001 (NRSA training grant T32 HS00078).
Monographs cover children's mental health issues.
Description:
Two monographs, produced by the Children's Mental Health Alliance, focus on children's mental health issues. The first covers best practices, approaches, outcomes, and professional responsibilities across systems of care. The second monograph examines children's access to and use of mental health services.
Citations: Steinberg, Children's Mental Health: The Changing Interface Between Primary and Specialty Care (AHRQ grant HS09813). (AHRQ Publication No. 00-R040); and Leonard Davis Institute of Health Economics Issue Brief—Children's Mental Health: Recommendations for Research, Practice, and Policy 7(5), 2000 (AHRQ grant HS09813) (AHRQ Publication No. 00-R042).
Available from: AHRQ Publications Clearinghouse.
Children who suffer traffic injuries may develop posttraumatic stress disorder (PTSD).
Description: Data show that even with minor injuries following a traffic accident, children and their parents are at risk for developing PTSD. Researchers interviewed parents from 102 families in which children had suffered traffic-related injuries; 25 percent of the children and 15 percent of parents suffered PTSD.
Citation: De Vries, Kassam-Adams, Cnaan, et al. Pediatrics 104(6):1293-9, 1999 (AHRQ grant HS09058).