Child Health Disparities in the 21st Century.

The topic of persistent child health disparities remains a priority for policymakers and a concern for pediatric clinicians. Health disparities are defined as differences in adverse health outcomes for specific health indicators that exist across sub-groups of the population, frequently between minority and majority populations. This review will highlight the gains that have been made since the 1990s as well as describe disparities that have persisted or have worsened into the 21st century. It will also examine the most potent social determinants and their impact on the major disparities in mortality, preventive care, chronic disease, mental health, educational outcomes, and exposure to selected environmental toxins. Each section concludes with a description of interventions and innovations that have been successful in reducing child health disparities.

Stridor is not always croup.

Respiratory distress and stridor are common presenting symptoms for children in the emergency department. Most of these children will have common illnesses such as bronchiolitis or croup. Clinicians, however, must maintain a broad differential diagnosis and a healthy skepticism in the approach to each child's case so as not to miss uncommon or atypical presentations. We describe the case of a child with stridor in whom an airway hemangioma was ultimately diagnosed.

Correlation of blood pressure readings from 6-hour intervals with the daytime period of 24-hour ambulatory blood pressure monitoring in pediatric patients.

Shorter-interval (6-hour) ambulatory blood pressure monitoring (ABPM) has been shown to correlate well with 24-hour ABPM in adults, but this has not been studied in children. The authors selected 131 patients aged 9 to 18 who underwent 24-ABPM from 2000-2008. Six-hour intervals beginning at different start times were compared with the daytime and 24-hour period, with subset analysis for normotensive and hypertensive patients. Concordance correlation coefficients (CCCs) were used to assess for agreement. Among normotensive patients, the mean difference between daytime and 6-hour intervals ranged from -0.1 mm Hg to 0.0 mm Hg for diastolic blood pressure (DBP) and -1.1 mm Hg to 0.6 mm Hg for systolic blood pressure (SBP) with CCCs of 0.88 to 0.93 for DBP and 0.93 to 0.96 for SBP. For hypertensive patients, mean difference ranged from -0.6 to 1.3 mm Hg for DBP and -0.8 to 1.1 mm Hg for SBP with CCCs of 0.89 to 0.98 for DBP and 0.86 to 0.95 for SBP. Shorter-interval monitoring correlates significantly with full daytime monitoring in children, allowing for assessment of blood pressure with improved convenience.

Patient identified needs for chronic obstructive pulmonary disease versus billed services for care received.

The American Lung Association of Minnesota (ALAMN) was granted access to a 2004 administrative claims data from an upper mid-Western, independent practice association model health plan. Claims information, including demographics, prevalence, medication and oxygen therapy, and health care utilization, was extracted for 7,782 patients with COPD who were 40 years of age and older. In addition, ALAMN conducted a survey of 1,911 patients from Minnesota diagnosed with COPD. The survey queried the patients about demographics, treatment, medications, limitations, wants, and needs. This article compares and contrasts the information gained through the health plan administrative claims database with the findings from the COPD patient survey in areas of age, gender, types of provider primarily responsible for COPD care, spirometry use, medication therapy, pulmonary rehabilitation, oxygen therapy, and health care utilization. Primary care practitioners provided a majority of the COPD-related care. The claims evidence of spirometry use was 16%-62% of COPD patients had claims evidence of COPD-related medications. 25% of patients reported, and 23% of patients had claims evidence of, a hospitalization during the observation year. 16% of patients reported using pulmonary rehabilitation programs. The results indicate there is an opportunity to improve COPD diagnosis and management.

Multi-method approach to evaluate inequities in prenatal care access in Haiti.

In this pilot study for evaluating equity in services at a hospital in rural Haiti, we investigated whether topography, walking time to dispensary, and presence of a mobile clinic were related to disparities in prenatal care utilization, using quantitative hospital record data on 100 women pregnant in 2002. We also assessed whether additional factors contributed to prenatal care disparities using qualitative key informant interviews with local health agents in Haiti. In logistic regression analyses, we found that walking time to the dispensary was associated with disparities in prenatal care utilization (p = .039). Health agent responses demonstrated lack of acknowledgment of disparities and attribution of underutilization to women undervaluing educational messages. Reducing disparities in prenatal care utilization will require attention to walking time to a point of care, though attitudes and experiential factors should not be overlooked. Similar multi-method approaches should be explored in future studies of health inequities in other communities.

Development of a hospital-based trauma registry in Haiti: an approach for improving injury surveillance in developing and resource-poor settings.

BACKGROUND: Trauma-related morbidity and mortality are a growing burden in the developing world. However, usable injury data in resource-poor and developing settings is lacking. Trauma registries can improve injury surveillance to enhance trauma care, outcomes, and prevention. This article provides, by example from Haiti, an approach to developing a hospital-based trauma registry in a resource-poor setting. METHODS: An assessment of trauma documentation was performed retrospectively with subsequent development and pilot testing of two injury surveillance systems. The system most promising for meeting the needs and capabilities of the institution was implemented. RESULTS: Retrospective medical record review from 1999 (n = 43) and 2002 (n = 43) revealed limitations in available data for trauma surveillance. Specific mechanism of injury was documented in 39.3% and 57.1% of 1999 and 2002 groups, respectively. Injury date and arrival vital signs were infrequently recorded. Two injury surveillance models were designed and pilot tested: provider-based (PTR) (pilot n = 19) and coordinator-based (CTR) (pilot n = 37) trauma registries. Analysis of the pilot testing resulted in revisions to operations and the trauma registry forms. Both registry models showed improved data collection compared with the retrospective study with CTR and PTR documenting specific mechanism of injury in 94.6% and 100% of patients, respectively. The PTR model was chosen for implementation at the hospital. CONCLUSIONS: Trauma registries in developing settings are plausible tools for injury surveillance. Successful trauma registries will be resource- and setting-specific in design and can potentially be the means by which trauma care and outcomes are improved, prevention programs are developed, and capacity-building goals realized.

Health equity issues at the local level: socio-geography, access, and health outcomes in the service area of the Hôpital Albert Schweitzer-Haiti.

BACKGROUND: Although health equity issues at regional, national and international levels are receiving increasing attention, health equity issues at the local level have been virtually overlooked. Here, we describe here a comprehensive equity assessment carried out by the Hôpital Albert Schweitzer-Haiti (HAS) in 2003. HAS has been operating health and development programs in the Artibonite Valley of Haiti for 50 years. METHODS: We reviewed all available information arising from a comprehensive evaluation of the programs of HAS carried out in 1999 and 2000. As part of this evaluation, two demographic and health surveys were carried out. We carried out exit interviews with clients receiving primary health care, observations within health facilities, interviews with households related to quality of care, and focus group discussions with community-based health workers. A special study was carried out in 2003 to assess factors determining the use of prenatal care services. Finally, selected findings were obtained from the HAS information system. RESULTS: We found markedly reduced access to health services in the peripheral mountainous areas compared to the central plains. The quality of services was more deficient and the coverage of key services was lower in the mountains. Finally, health status, as measured by under-five mortality rates and levels of childhood malnutrition, was also worse in the mountains. CONCLUSION: These findings indicate that local health programs need to give attention to monitoring the health status as well as the quality and coverage of basic services among marginalized groups within the program service area. Health inequities will not be overcome until such monitoring occurs and leaders of health programs ensure that inequities identified are addressed in the local programming of activities. It is quite likely that, within relatively small geographic areas in resource-poor settings around the world, similar, if not even greater, levels of health inequities exist. These inequities need to be measured and addressed in order for health programs to achieve equity and maximum improvement in health status within the population.