The extent and patterns of multiple chronic conditions in low-income children.

BACKGROUND AND OBJECTIVES: Little is known about the magnitude of multiple chronic conditions (MCC) in children. This study describes the prevalence of and patterns of comorbidities in children receiving Medicaid assistance. METHODS: Diagnoses from 5 years of Medicaid claims data were reviewed and identified 128,044 children with chronic conditions. The relationship between comorbidities and significant urgent health care events was analyzed using logistic regression modeling. RESULTS: More than 15,000 children (12%) had claims for more than 1 condition. The most frequent combination was asthma and allergic rhinitis. Significant health care events ranged from 18% to 51% in children, and the odds of having a significant event increased with each additional condition. Those with ≥4 conditions had 4.5 times the odds of a significant event compared with those with 1 condition (P < .0001). CONCLUSION: MCC are prevalent in low-income children and are associated with greater risk for urgent health care use.

Asthma coalition effects on vulnerable sub groups of children: the most frequent users of health care and the youngest.

OBJECTIVE: To examine the impact of Allies Against Asthma, community-based coalitions working to improve asthma outcomes, on vulnerable children: those with the most urgent health care use and those of youngest age. METHODS: Allies zip codes were matched with comparison communities on demographic factors. Five years of Medicaid data (n = 26,836) for significant health care events: hospitalizations, ED and urgent care facility visits, were analyzed. Longitudinal analyses using generalized estimating equations and proportional hazards models compared Allies and comparison group children. RESULTS: In the two start-up years of Allies, odds of having a significant event were greater for Allies children than for comparison children (p < 0.05). During the third and fourth years when Allies activities were fully implemented, for frequent health care users at baseline, odds of an asthma event were the same for both Allies and comparison children, yet in the less frequent users, odds of an event were lower in Allies children (p < 0.0001). In the initial year of Allies efforts, among the youngest, the Allies children had greater odds than comparison children of an event (p < 0.01), but by the fourth year the Allies group had lower odds (p = 0.02) of an event. Hazard ratios over all years of the study for the youngest Allies children and most frequent baseline users of urgent care were lower than for comparison children (p = 0.01 and p = 0.0004). CONCLUSION: Mobilizing a coalition of diverse stakeholders focused on policy and system change generated community-wide reductions over the long-term in health care use for vulnerable children.

Improvements in health care use associated with community coalitions: long-term results of the allies against asthma initiative.

OBJECTIVES: We assessed changes in asthma-related health care use by low-income children in communities across the country where 6 Allies Against Asthma coalitions (Hampton Roads, VA; Washington, DC; Milwaukee, WI; King County/Seattle, WA; Long Beach, CA; and Philadelphia, PA) mobilized stakeholders to bring about policy changes conducive to asthma control. METHODS: Allies intervention zip codes were matched with comparison communities by median household income, asthma prevalence, total population size, and race/ethnicity. Five years of data provided by the Center for Medicare and Medicaid Services on hospitalizations, emergency department (ED) use, and physician urgent care visits for children were analyzed. Intervention and comparison sites were compared with a stratified recurrent event analysis using a Cox proportional hazard model. RESULTS: In most of the assessment years, children in Allies communities were significantly less likely (P < .04) to have an asthma-related hospitalization, ED visit, or urgent care visit than children in comparison communities. During the entire period, children in Allies communities were significantly less likely (P < .02) to have such health care use. CONCLUSIONS: Mobilizing a diverse group of stakeholders, and focusing on policy and system changes generated significant reductions in health care use for asthma in vulnerable communities.

A peek at the revised Nursing Professional Development: Scope and Standards of Practice.

The American Nurses Association will publish the revised Nursing Professional Development: Scope and Standards of Practice this summer. The new document focuses on outcomes, successes, change, and a global audience. This column highlights key changes within the context of nursing professional development, especially continuing nursing education.

Health service use and outcomes among disabled Medicaid pregnant women.

PURPOSE: We investigated differences in health service use and pregnancy outcomes among women enrolled in Medicaid under eligibility categories for the blind and disabled and those enrolled under other eligibility categories. METHODS: We used Medicaid enrollment and claims data to create episodes of pregnancy- and delivery-related care for women with and without disabilities who had Medicaid-covered deliveries in Florida, Georgia, and New Jersey during 1995 and Texas during 1997. We linked birth certificate information on prenatal care and birth outcomes to the files for Georgia and Texas. We then computed the unadjusted and adjusted odds ratios for the receipt of selected routine prenatal and illness-related services and the occurrence of selected pregnancy outcomes among women with disabilities relative to women without disabilities. FINDINGS: In all states, women with disabilities were more likely than women without disabilities to have had continuous Medicaid coverage from preconception through the postnatal period. Women with disabilities were equally or less likely to have received adequate prenatal care compared to women without disabilities in the two study states with these data. They were also more likely to have had emergency room visits, hospital admissions during pregnancy, cesarean deliveries, and readmissions within 3 months of delivery in all study states. We also found women with disabilities to have been more likely to deliver preterm and low birthweight infants. CONCLUSION: Our results suggest that opportunities exist to improve access to prenatal care among women with disabilities enrolled in Medicaid under blind and disabled eligibility categories who become pregnant.

Comparative effectiveness of health centers as regular source of care: application of sentinel ACSC events as performance measures.

A 4-state (Alabama, California, Georgia, Pennsylvania) retrospective analysis of claims data from 1.6 million Medicaid beneficiaries to assess the performance of community health centers compared with other Medicaid providers (office-based and hospital-based practices) served as a regular source of care to Medicaid beneficiaries, each with at least one diagnosed ambulatory care-sensitive condition (ACSC). The health centers compared with the other Medicaid providers experienced one third fewer sentinel ACS events: 5.7 and 8.2 ACS admissions and 26.1 and 37.7 ACS emergency visits, respectively, per 100 persons. Controlling for case mix and other factors, the logistic regression results for sentinel events indicated that Medicaid beneficiaries who relied on health centers for primary care were significantly less likely to experience an ACS admission (OR = 0.89, P < .0001) or an ACS emergency visit (OR = 0.81, P < .0001) than the Medicaid beneficiaries who relied on other Medicaid providers. Sentinel ACS events can serve as efficient measures for assessing provider performance and comparing effectiveness of regular sources for primary care.

Access for pregnant women on Medicaid: variation by race and ethnicity.

Disparities in early and adequate prenatal care and infant/maternal outcomes still exist between white and nonwhite populations. Although Medicaid expansions were intended to improve outcomes, eligible women often delay enrollment and access barriers remain. This study examines racial disparities among pregnant women in Florida, Georgia, New Jersey, and Texas. The disproportionate location of minorities enrolled in Medicaid in urban areas with greater physician supply was not found to increase office-based prenatal care among blacks. More local physicians, especially foreign medical graduates, sometimes increased access, largely for Hispanics. The presence and use of safety net providers did increase prenatal care use among minorities. This evidence lends support to policies to maintain safety net providers, which are perhaps better equipped than others to serve low-income populations. However, policies should encourage participation extending to all racial/ethnic groups by office-based physicians. The role of foreign medical graduates, who are more likely to participate in Medicaid, should be considered.

Racial and ethnic disparities in the use of pregnancy-related health care among Medicaid pregnant women.

OBJECTIVE: To assess the extent to which racial and ethnic disparities exist in the use of prenatal services among Medicaid pregnant women. METHODS: Medicaid claims data for Florida, Georgia, New Jersey, and Texas, with linked birth certificate data for Georgia and Texas, were used to investigate the use of selected prenatal services, including the initiation and adequacy of prenatal care visits; prescriptions for multiple vitamins and iron supplements; and claims for complete blood cell counts, blood type and RH status, hepatitis B surface antigen, ultrasound, maternal serum alphafetoprotein, drug screening, and HIV tests. We computed raw and adjusted odds ratios of having the health service of interest during pregnancy for women in three minority groups: black non-Hispanics, Hispanics, and Asian/Pacific Islanders. RESULTS: We found racial and ethnic disparities in the use of every health service investigated. Compared with white non-Hispanics, minority women were less likely to receive services that the woman initiates, discretionary services, and services potentially requiring specialized follow-up care, whereas they were more likely to receive screening tests for diseases related to high-risk behaviors. Disparities were generally larger, more consistent across states, and less likely to be explained by other factors among black non-Hispanics than among either Hispanics or Asian/Pacific Islanders. CONCLUSIONS: Even among women who are provided equal financial access to health care services, unexplained racial and ethnic disparities persist in the initiation and use of both routine and specialized prenatal care services.

Quality of care for women undergoing a hysterectomy: effects of insurance and race/ethnicity.

OBJECTIVE: We assessed the quality of hospital care for women who underwent a hysterectomy to compare Medicaid-covered women with privately insured women and minority women with White women. METHODS: We evaluated medical decisions, inpatient care, quality of inpatient care, and outcomes. RESULTS: Quality of hospital care was equivalent for Medicaid-covered women compared with privately insured women and for non-Hispanic Black women compared with White women. Medicaid-covered women (40%) and Black women (68%) were more likely to have a complication compared with privately insured women and White women, respectively. CONCLUSIONS: Increased complications after hysterectomy may result in increased economic burdens to Medicaid. Further studies of the racial/ethnic and sociodemographic issues are needed so that disparities may be adequately addressed.