Provision of pneumococcal prophylaxis for publicly insured children with sickle cell disease.

CONTEXT: It is recommended that children younger than 5 years with sickle cell disease (SCD) take daily prophylactic antibiotics to prevent pneumococcal infections; however, how much prophylactic medication they actually are dispensed is unclear. OBJECTIVES: To measure the amount of prophylactic antibiotics dispensed to young children with SCD and to investigate factors associated with increased delivery of medication. DESIGN, SETTING, AND PATIENTS: Retrospective longitudinal study conducted January 1995 through December 1999 using Tennessee and Washington State Medicaid administrative claims and encounter data. Children (N = 261) who had 1 inpatient or 2 outpatient claims or encounters listing an International Classification of Diseases, Ninth Revision, Clinical Modification code for SCD, were younger than 4 years at study entry (mean age, 1.4 years), and were continuously enrolled in Medicaid for a 1-year period. MAIN OUTCOME MEASURE: Number of days during a 365-day period covered by prescription fills for a penicillin or macrolide antibiotic, or for trimethoprim-sulfamethoxazole. RESULTS: In a 365-day period, patients were dispensed a mean of 148.4 (SD, 121.3; median, 114; interquartile range [IQR], 39-247) days of prophylactic medication. The total amount of medication dispensed varied widely: 10.3% of patients received none and 21.5% received more than 270 days of medication. In a 365-day period, a mean of 12.7 (SD, 10.5; range, 0-40) prophylactic prescriptions were filled per patient. The median prescription duration was 10 days. In a multivariate linear regression model adjusting for state, sex, age at study entry, inclusion year, residence in urban community, outpatient inclusion encounter, required prescription co-payment, and number of outpatient visits for nonpreventive care, each preventive visit was associated with 12.0 (95% confidence interval [CI], 2.3-21.7) additional days of prophylactic antibiotics, and each emergency department visit was associated with 10.0 (95% CI, 1.2-18.8) additional days. CONCLUSIONS: Publicly insured children with SCD may receive inadequate antibiotic prophylaxis against pneumococcal infections, placing them at increased risk of morbidity and mortality; however, increased numbers of outpatient visits for preventive care are associated with improved provision of prophylactic antibiotics.

Antiemetic use for acute gastroenteritis in children.

OBJECTIVES: To describe patterns of and factors associated with antiemetic use among a population-based sample of children with acute gastroenteritis; to determine if filling a prescription for an antiemetic is associated with a significant risk of adverse events; and to determine if filling a prescription for an antiemetic is associated with an increased risk of subsequent health care use. METHOD AND DESIGN: Retrospective cohort study of 20,222 children aged 1 month to 18 years, receiving Medicaid, who had a first diagnosis of gastroenteritis, diarrhea, or vomiting between January 1, 1998, and December 31, 1998. MAIN OUTCOME MEASURES: Presence of a claim for an antiemetic in the 3 days after the initial diagnosis of acute gastroenteritis, subsequent health care usage, and an adverse event within 14 days of the initial diagnosis. RESULTS: Parents of 1802 children (8.9%) with acute gastroenteritis had a prescription for an antiemetic filled within 3 days of the index visit. Factors associated with antiemetic prescription filling for children include older age, provider type (emergency physician, family physician, or general practitioner vs pediatrician), Spanish as the primary language, and rural residency. There was no difference in adverse events between children for whom an antiemetic prescription was filled and for those who did not have an antiemetic prescription filled (odds ratio, 0.68; 95% confidence interval, 0.31-1.46). No difference in risk of subsequent health care use was seen in children who had an antiemetic prescription filled and those who did not (incidence rate ratio, 1.04; 95% confidence interval, 0.94-1.16). CONCLUSION: Antiemetic use among children with acute gastroenteritis is common and adverse effects seem to be rare.

Continuity of care for children in foster care.

OBJECTIVE: To compare the continuity of care experienced by children who are in foster care with that of children who are not in foster care and are covered under Medicaid managed care and Medicaid fee-for-service (FFS). METHODS: This retrospective cohort study used Medicaid claims/encounter data from Washington state. A total of 903 children who were in foster care and continuously enrolled in Medicaid for 24 months (1998-1999) were matched by age, gender, and rural/urban residence to 903 Medicaid managed care enrollees and 903 FFS beneficiaries who were not in foster care. Indices of the continuity of primary care experienced were calculated for each patient, and differences in continuity among the cohorts were assessed by running 3 multiple linear regression models for all possible pairings of cohorts, controlling for age, gender, rural/urban residence, and total number of primary care visits. RESULTS: Foster care status was associated with decreased continuity of care relative to nonfoster managed care status (beta = -0.12; 95% confidence interval [CI]: -0.15 to -0.09). Nonfoster FFS status was associated with lower continuity than managed care (beta = -0.09; 95% CI: -0.12 to -0.06) and slightly higher continuity than foster care status (beta = 0.03; 95% CI: 0.01-0.06). CONCLUSION: Although not dramatically different, continuity seems somewhat lacking for children in foster care. It is unclear to what degree the observed difference is confounded by the managed care/FFS distinction. As the enrollment of children in foster care into managed care plans has been controversial, efforts to promote the consistency of contact with providers while maintaining the flexibility afforded by FFS coverage seem warranted.

The relationship of post-acute home care use to Medicaid utilization and expenditures.

RESEARCH OBJECTIVES: To describe the use of post-acute home care (PAHC) and total Medicaid expenditures among hospitalized nonelderly adult Medicaid eligibles and to test whether health services utilization rates or total Medicaid expenditures were lower among Medicaid eligibles who used PAHC compared to those who did not. STUDY POPULATION: 5,299 Medicaid patients aged 18-64 discharged in 1992-1996 from 29 hospitals in the Cleveland Health Quality Choice (CHQC) project. DATA SOURCES: Linked Ohio Medicaid claims and CHQC medical record abstract data. DATA EXTRACTION: One stay per patient was randomly selected. DESIGN: Observational study. To control for treatment selection bias, we developed a model predicting the probability (propensity) a patient would be referred to PAHC, as a proxy for the patient's need for PAHC. We matched 430 patients who used Medicaid-covered PAHC ("USE") to patients who did not ("NO USE") by their propensity scores. Study outcomes were inpatient re-admission rates and days of stay (DOS), nursing home admission rates and DOS, and mean total Medicaid expenditures 90 and 180 days after discharge. PRINCIPAL FINDINGS: Of 3,788 medical patients, 12.1 percent were referred to PAHC; 64 percent of those referred used PAHC. Of 1,511 surgical patients, 10.9 percent were referred; 99 percent of those referred used PAHC. In 430 pairs of patients matched by propensity score, mean total Medicaid expenditures within 90 days after discharge were $7,649 in the USE group and $5,761 in the NO USE group. Total Medicaid expenditures were significantly higher in the USE group compared to the NO USE group for medical patients after 180 days (p < .05) and surgical patients after 90 and 180 days (p < .001). There were no significant differences for any other outcome. Sensitivity analysis indicates the results may be influenced by unmeasured variables, most likely functional status and/or care-giver support. CONCLUSIONS: Thirty-six percent of the medical patients referred to PAHC did not receive Medicaid-covered services. This suggests potential underuse among medical patients. The high post-discharge expenditures suggest opportunities for reducing costs through coordinating utilization or diverting it to lower-cost settings. Controlling for patients' need for services, PAHC utilization was not associated with lower utilization rates or lower total Medicaid expenditures. Medicaid programs are advised to proceed cautiously before expanding PAHC utilization and to monitor its use carefully. Further study, incorporating non-economic outcomes and additional factors influencing PAHC use, is warranted.