"Patients who can't get an appointment go to the ER": access to specialty care for publicly insured children.

STUDY OBJECTIVE: Emergency departments (EDs) frequently refer patients for needed outpatient specialty care, but little is known about the dynamics of these referrals when patients are publicly insured. Hence, we explored factors, including the role of ED referrals, associated with specialists' willingness to accept patients covered by Medicaid and the Children's Health Insurance Program (CHIP). METHODS: We conducted semistructured qualitative interviews with a purposive sample of 26 specialists and 14 primary care physicians in Cook County, Illinois, from April to September 2009, until theme saturation was reached. Transcripts and notes were entered into ATLAS.ti and analyzed using an iterative coding process to identify patterns of responses, ensure reliability, examine discrepancies, and achieve consensus through content analysis. RESULTS: Themes that emerged indicate that primary care physicians face considerable barriers getting publicly insured patients into outpatient specialty care and use the ED to facilitate this process. Specialty physicians reported that decisions to refuse or limit the number of patients with Medicaid/CHIP are due to economic strain or direct pressure from their institutions. Factors associated with specialist acceptance of patients with Medicaid/CHIP included high acuity or complexity, personal request from or an informal economic relationship with the primary care physician, geography, and patient hardship. Referral through the ED was a common and expected mechanism for publicly insured patients to access specialty care. CONCLUSION: These exploratory findings suggest that specialists are willing to see children with Medicaid/CHIP if they are referred from an ED. As health systems restructure, EDs have the potential to play a role in improving care coordination and access to outpatient specialty care.

Are your asset data as good as you think? Conducting a comprehensive census of built assets to improve urban population health.

Secondary data sources are widely used to measure the built asset environment, although their validity for this purpose is not well-established. Using community-engaged research methodology, this study conducted a census of public-facing, built assets via direct observation and then tested the performance of these data against widely used secondary datasets. After engaging community organizations, a community education campaign was implemented. Using web-enabled cell phones and a web-based application prepopulated with the secondary data, census workers verified, modified, and/or added assets using street-level observation, supplementing data with web searches and telephone calls. Data were uploaded to http://www.SouthSideHealth.org . Using direct observation as the criterion standard, the sensitivity of secondary datasets was calculated. Of 5,773 assets on the prepopulated list, direct observation of public-facing assets verified 1,612 as operating; another 653 operating assets were newly identified. Sensitivity of the commercial list for nonresidential, operating assets was 61 %. Using the asset census as the criterion standard, secondary datasets were incomplete and inaccurate. Comprehensive, accurate built asset data are needed to advance urban health research, inform policy, and improve individuals' access to assets.

Differential access to digital communication technology: association with health and health survey recruitment within an African-American underserviced urban population.

Digital communication technologies (DCT), such as cell phones and the internet, have begun to replace more traditional technologies even in technology-poor communities. We characterized access to DCT in an underserved urban population and whether access is associated with health and study participation. A general probability community sample and a purposive high-turnover housing sample were recruited and re-interviewed after 3 months. Selected characteristics were compared by sample type and retention. Associations between DCT access and self-reported health were examined using multivariable logistic regression. Of 363 eligible individuals, 184 (general community = 119; high-turnover housing = 65) completed the baseline survey. Eighty-four percent of respondents had a cell phone and 62% had ever texted. Ever use of the internet was high (69%) overall, but frequency and years of internet use were higher in the general community sample. Self-reported fair or poor health was more common for residents of cell phone-only households and those with less frequent internet use. Technology use was similar for those retained and not retained. Overall, access to DCT was high in this underserved urban population but varied by sample type. Health varied significantly by DCT use, but study retention did not. These data have implications for incorporating DCT into health-related research in urban populations.