Preferences for physical activity: a conjoint analysis involving people with chronic knee pain.

OBJECTIVE: To investigate individual preferences for physical activity (PA) attributes in adults with chronic knee pain, to identify clusters of individuals with similar preferences, and to identify whether individuals in these clusters differ by their demographic and health characteristics. DESIGN: An adaptive conjoint analysis (ACA) was conducted using the Potentially All Pairwise RanKings of all possible Alternatives (PAPRIKA) method to determine preference weights representing the relative importance of six PA attributes. Cluster analysis was performed to identify clusters of participants with similar weights. Chi-square and ANOVA were used to assess differences in individual characteristics by cluster. Multinomial logistic regression was used to assess associations between individual characteristics and cluster assignment. RESULTS: The study sample included 146 participants; mean age 65, 72% female, 47% white, non-Hispanic. The six attributes (mean weights in parentheses) are: health benefit (0.26), enjoyment (0.24), convenience (0.16), financial cost (0.13), effort (0.11) and time cost (0.10). Three clusters were identified: Cluster 1 (n = 33): for whom enjoyment (0.35) is twice as important as health benefit; Cluster 2 (n = 63): for whom health benefit (0.38) is most important; and Cluster 3 (n = 50): for whom cost (0.18), effort (0.18), health benefit (0.17) and enjoyment (0.18) are equally important. Cluster 1 was healthiest, Cluster 2 most self-efficacious, and Cluster 3 was in poorest health. CONCLUSIONS: Patients with chronic knee pain have preferences for PA that can be distinguished effectively using ACA methods. Adults with chronic knee pain, clustered by PA preferences, share distinguishing characteristics. Understanding preferences may help clinicians and researchers to better tailor PA interventions.

Urinary tract infection after voiding cystourethrogram.

BACKGROUND: Reported rates of post-procedural urinary tract infection (ppUTI) after voiding cystourethrogram (VCUG) are highly variable (0-42%). OBJECTIVE: This study aimed to determine the risk of ppUTI after cystogram, and evaluate predictors of ppUTI. STUDY DESIGN: A retrospective cohort study of children undergoing VCUG or radionuclide cystogram (henceforth 'cystogram') was conducted. Children with neurogenic bladder who underwent cystogram in the operating room and without follow-up at the study institution were excluded. Incidence of symptomatic ppUTI within 7 days after cystogram was recorded. Predictors of ppUTI were evaluated using univariate statistics. RESULTS: A total of 1108 children (54% female, median age 1.1 years) underwent 1203 cystograms: 51% were on periprocedural antibiotics, 75% had a pre-existing urologic diagnosis (i.e., vesicoureteral reflux (VUR) or hydronephrosis; not UTI alone), and 18% had a clinical UTI within 30 days before cystogram. Of the cystograms, 41% had an abnormal cystogram and findings included VUR (82%), ureterocele (6%), and diverticula (6%). Twelve children had a ppUTI (1.0%; four girls, five uncircumcised boys, three circumcised boys; median age 0.9 years). Factors significantly associated with diagnosis of a ppUTI (Summary fig.) included: pre-existing urologic diagnosis prior to cystogram (12/12, 100% of patients with ppUTI), abnormal cystogram results (11/12, 92%), and use of periprocedural antibiotics (11/12, 92%). All 11 children with an abnormal cystogram had VUR ≥ Grade III. However, among all children with VUR ≥ Grade III, 4% (11/254) had a ppUTI. DISCUSSION: This is the largest study to date that has examined incidence and risk factors for ppUTI after cystogram. The retrospective nature of the study limited capture of some clinical details. This study demonstrated that the risk of ppUTI after a cystogram is very low (1.0% in this cohort). Having a pre-existing urologic diagnosis such as VUR or hydronephrosis was associated with ppUTI; therefore, children with moderate or high-grade VUR on cystogram may be at highest risk. Development of ppUTI after cystogram also highlighted the potential for a delay in diagnosis or oversight of a healthcare-associated infection due to several factors: 1) cystograms may be ordered, performed/interpreted, and followed up by multiple different providers; and 2) such infections are not captured by traditional healthcare-associated infection surveillance strategies. CONCLUSIONS: The risk of ppUTI after a cystogram is very low. Only children with pre-existing urologic diagnoses developed ppUTI in this study. This study's findings suggest that children undergoing a cystogram should not be given peri-procedural antibiotic prophylaxis for the sole purpose of ppUTI prevention.

Mortality Risk Factors Among Patients With Cirrhosis and a Low Model for End-Stage Liver Disease Sodium Score (≤15): An Analysis of Liver Transplant Allocation Policy Using Aggregated Electronic Health Record Data.

Although the Model for End-Stage Liver Disease sodium (MELD Na) score is now used for liver transplant allocation in the United States, mortality prediction may be underestimated by the score. Using aggregated electronic health record data from 7834 adult patients with cirrhosis, we determined whether the cause of cirrhosis or cirrhosis complications was associated with an increased risk of death among patients with a MELD Na score ≤15 and whether patients with the greatest risk of death could benefit from liver transplantation (LT). Over median follow-up of 2.3 years, 3715 patients had a maximum MELD Na score ≤15. Overall, 3.4% were waitlisted for LT. Severe hypoalbuminemia, hepatorenal syndrome, and hepatic hydrothorax conferred the greatest risk of death independent of MELD Na score with 1-year predicted mortality >14%. Approximately 10% possessed these risk factors. Of these high-risk patients, only 4% were waitlisted for LT, despite no difference in nonliver comorbidities between waitlisted patients and those not listed. In addition, risk factors for death among waitlisted patients were the same as those for patients not waitlisted, although the effect of malnutrition was significantly greater for waitlisted patients (hazard ratio 8.65 [95% CI 2.57-29.11] vs. 1.47 [95% CI 1.08-1.98]). Using the MELD Na score for allocation may continue to limit access to LT.

Applying the WHO conceptual framework for the International Classification for Patient Safety to a surgical population.

OBJECTIVE: Efforts to improve patient safety are challenged by the lack of universally agreed upon terms. The International Classification for Patient Safety (ICPS) was developed by the World Health Organization for this purpose. This study aimed to test the applicability of the ICPS to a surgical population. DESIGN: A web-based safety debriefing was sent to clinicians involved in surgical care of abdominal organ transplant patients. A multidisciplinary team of patient safety experts, surgeons and researchers used the data to develop a system of classification based on the ICPS. Disagreements were reconciled via consensus, and a codebook was developed for future use by researchers. RESULTS: A total of 320 debriefing responses were used for the initial review and codebook development. In total, the 320 debriefing responses contained 227 patient safety incidents (range: 0-7 per debriefing) and 156 contributing factors/hazards (0-5 per response). The most common severity classification was 'reportable circumstance,' followed by 'near miss.' The most common incident types were 'resources/organizational management,' followed by 'medical device/equipment.' Several aspects of surgical care were encompassed by more than one classification, including operating room scheduling, delays in care, trainee-related incidents, interruptions and handoffs. CONCLUSIONS: This study demonstrates that a framework for patient safety can be applied to facilitate the organization and analysis of surgical safety data. Several unique aspects of surgical care require consideration, and by using a standardized framework for describing concepts, research findings can be compared and disseminated across surgical specialties. The codebook is intended for use as a framework for other specialties and institutions.

Preventable errors in organ transplantation: an emerging patient safety issue?

Several widely publicized errors in transplantation including a death due to ABO incompatibility, two HIV transmissions and two hepatitis C virus (HCV) transmissions have raised concerns about medical errors in organ transplantation. The root cause analysis of each of these events revealed preventable failures in the systems and processes of care as the underlying causes. In each event, no standardized system or redundant process was in place to mitigate the failures that led to the error. Additional system and process vulnerabilities such as poor clinician communication, erroneous data transcription and transmission were also identified. Organ transplantation, because it is highly complex, often stresses the systems and processes of care and, therefore, offers a unique opportunity to proactively identify vulnerabilities and potential failures. Initial steps have been taken to understand such issues through the OPTN/UNOS Operations and Safety Committee, the OPTN/UNOS Disease Transmission Advisory Committee (DTAC) and the current A2ALL ancillary Safety Study. However, to effectively improve patient safety in organ transplantation, the development of a process for reporting of preventable errors that affords protection and the support of empiric research is critical. Further, the transplant community needs to embrace the implementation of evidence-based system and process improvements that will mitigate existing safety vulnerabilities.

Anatomy of a patient safety event: a pediatric patient safety taxonomy.

BACKGROUND: Idiosyncratic terminology and frameworks in the study of patient safety have been tolerated but are increasingly problematic. Agreement on standard language and frameworks is needed for optimal improvement and dissemination of knowledge about patient safety. METHODS: Patient safety events were assessed using critical incident analysis, a method used to classify risks that has been more recently applied to medicine. Clinician interviews and clinician reports to a web based reporting system were used for analysis of hospital based and ambulatory care events, respectively. Events were classified independently by three investigators. RESULTS: A pediatric patient safety taxonomy, relevant to both hospital based and ambulatory pediatric care, was developed from the analysis of 122 hospital based and 144 ambulatory care events. It is composed of four main categories: (1) problem type; (2) domain of medicine; (3) contributing factors in the patient (child-specific), environment (latent conditions) and care providers (human factors); and (4) outcome or result of the event and level of harm. A classification of preventive mechanisms was also developed. Inter-rater reliability of classifications ranged from 72% to 86% for sub-categories of the taxonomy. CONCLUSIONS: This patient safety taxonomy reflects the nature of events that occur in both pediatric hospital based and ambulatory care settings. It is flexible in its construction, permits analysis to begin at any point, and depicts the relationships and interactions of elements of an event.

Evaluation of children's health insurance: from New York State's CHild Health Plus to SCHIP.

BACKGROUND: The legislation and funding of the State Children's Health Insurance Program (SCHIP) in 1997 resulted in the largest public investment in child health care in 30 years. The program was designed to provide health insurance for the estimated 11 million uninsured children in the United States. In 1991 New York State implemented a state-funded program-Child Health Plus (CHPlus)-intended to provide health insurance for uninsured children who were ineligible for Medicaid. The program became one of the prototypes for SCHIP: This study was designed to measure the association between CHPlus and access to care, utilization of care, quality of care, and health care costs to understand the potential impact of one type of prototype SCHIP program. METHODS: The study took place in the 6-county region of upstate New York around and including the city of Rochester. A before-and-during design was used to compare children's health care for the year before they enrolled in CHPlus versus the first year during enrollment in CHPlus. The study included 1828 children (ages 0-6.99 years at enrollment) who enrolled between November 1, 1991 and August 1, 1993. A substudy involved 187 children 2 to 12.99 years old who had asthma. Data collection involved: 1) interviews of parents to obtain information about demographics, sources of health care, experience and satisfaction with CHPlus, and perceived impact of CHPlus; 2) medical chart reviews at all primary care offices, emergency departments, and health department clinics in the 6-county region to measure utilization of health services; 3) claims analysis to assess costs of care during CHPlus and to impute costs before CHPlus; and 4) analyses of existing datasets including the Current Population Survey, National Health Interview Survey, and statewide hospitalization datasets to anchor the study in relation to the statewide CHPlus population and to assess secular trends in child health care. Logistic regression and Poisson regression were used to compare the means of dependent measures with and without CHPlus coverage, while controlling for age, prior insurance type, and gap in insurance coverage before CHPlus. ENROLLMENT: Only one third of CHPlus-eligible children throughout New York State had enrolled in the program by 1993. Lower enrollment rates occurred among Hispanic and black children than among white children, and among children from lowest income levels. PROFILE OF CHPlus ENROLLEES: Most enrollees were either previously uninsured, had Medicaid but were no longer eligible, or had parents who either lost a job and related private insurance coverage or could no longer afford commercial or private insurance. Most families heard about CHPlus from a friend, physician, or insurer. Television, radio, and newspaper advertisements were not major sources of information. Nearly all families had at least 1 employed parent. Two thirds of the children resided in 2-parent households. Parents reported that most children were in excellent or good health and only a few were in poor health. The enrolled population was thus a relatively low-risk, generally healthy group of children in low-income, working families. ACCESS AND UTILIZATION OF HEALTH CARE: Utilization of primary care increased dramatically after enrollment in CHPlus, compared with before CHPlus. Visits to primary care medical homes for preventive, acute, and chronic care increased markedly. Visits to medical homes also increased for children with asthma. There was, however, no significant association between enrollment in CHPlus and changes in utilization of emergency departments, specialty services, or inpatient care. QUALITY OF CARE: CHPlus was associated with improvements in many measures involving quality of primary care, including preventive visits, immunization rates, use of the medical home for health care, compliance with preventive guidelines, and parent-reported health status of the child. (ABSTRACT TRUNCATED)

Evolution of a children's health insurance program: lessons from New York State's Child Health Plus.

The State Children's Health Insurance Program (SCHIP) was passed by Congress in 1997. It provides almost $40 billion in federal block grant funding through the year 2007 for states to expand health insurance for children. States have the option of expanding their Medicaid programs, creating separate insurance programs, or developing combination plans using both Medicaid and the private insurance option. New York State's child health insurance plan, known by its marketing name Child Health Plus, was created by the New York Legislature in 1990. New York's program, along with similar ones from several other states, served as models for the federal legislation, especially for state health insurance plans offered through private insurers. New York's program provides useful data for successful implementation of SCHIP.

Evaluation of New York State's Child Health Plus: methods.

BACKGROUND: The State Children's Health Insurance Program (SCHIP) is the largest public investment in child health care in 30 years, targeting 11 million uninsured children, yet little is known about the impact of health insurance on uninsured children. In 1991 New York State implemented Child Health Plus (CHPlus), a health insurance program that was a prototype for SCHIP. A study was designed to measure the association between CHPlus and access to care, utilization of services, and quality of care. METHODS: The setting was a 6-county region in upstate New York (population 1 million) around and including the city of Rochester. A before-and-during design was used to compare children's health care for the year before they enrolled in CHPlus versus the first year during CHPlus, for 1828 children (ages 0-6.99 years at enrollment) who enrolled between November 1, 1991 and August 1, 1993. An additional study involved 187 children 2 to 12.99 years old who had asthma. Parents were interviewed to assess demographic characteristics, sources of health care, experience with CHPlus, and impact of CHPlus on their children's quality of care and health status. Medical charts were reviewed to measure utilization and quality of care, for 1730 children 0 to 6.99 years and 169 children who had asthma. Charts were reviewed at all primary care offices and at the 12 emergency departments and 6 public health department clinics in the region. CHPlus claims files were analyzed to determine costs during CHPlus and to impute costs before CHPlus from utilization data. ANALYSES: Logistic regression and Poisson regression were used to compare the means of dependent measures with and without CHPlus coverage, while controlling for age, prior insurance type, and gap in insurance coverage before CHPlus. CONCLUSIONS: This study developed and implemented methods to evaluate the association between enrollment in a health insurance program and children's health care. These methods may also be useful for evaluations of SCHIP.

A profile of the population enrolled in New York State's Child Health Plus.

BACKGROUND: The recently enacted State Children's Health Insurance Program (SCHIP), designed to provide affordable health insurance for uninsured children, was modeled in part on New York State's Child Health Plus (CHPlus), which was implemented in 1991. All SCHIP programs involve voluntary enrollment of eligible children. Little is known about characteristics of children who enroll in these programs. OBJECTIVES: To provide a profile of children enrolled in CHPlus between 1993 and 1994 in the 6-county upstate New York study area, and to estimate the participation rate in CHPlus. Methods. A parent interview was conducted to obtain information about children, 0 to 6.9 years old, who enrolled in CHPlus in the study area. Two school-based surveys and the Current Population Survey were used to estimate health insurance coverage. Enrollment data from New York State's Department of Health, together with estimates of the uninsured, were used to estimate participation rates in CHPlus. RESULTS: Most children enrolled in CHPlus in the study area were white. Although 17% of all children in the study area who were <13 years old and living in families with incomes below 160% of the federal poverty level were black, only 9% of CHPlus-enrolled children were black. Twenty-one percent of enrolled children were uninsured during the entire year before enrollment and 61% of children had a gap in coverage lasting >1 month. Children were generally healthy; only 4% had fair or poor health. Eighty-eight percent of parents of enrolled children had completed high school or a higher level of education. Parents reported that loss of a job was the main reason for loss of prior health insurance for their child. Most families learned about CHPlus from a friend (30%) or from their doctor (26%). The uninsured rate among children in the study area was approximately 4.1%. By 1993, the participation rate in CHPlus was about 36%. CONCLUSION: Blacks were underrepresented in CHPlus. Because the underlying uninsured rate was relatively low and parental education and family income were relatively high, the effects of CHPlus observed in this evaluation may be conservative in comparison to the potential effects of CHPlus for other populations of children. Participation rates during the early years of the program were modest.

Evaluation of New York State's Child Health Plus: access, utilization, quality of health care, and health status.

BACKGROUND: The recently enacted State Children's Health Insurance Program (SCHIP) is modeled after New York State's Child Health Plus (CHPlus) program. Since 1991, CHPlus has provided health insurance to children 0 to 13 years old whose annual family income was below 222% of the federal poverty level and who were ineligible for Medicaid or did not have equivalent health insurance coverage. CHPlus covered the costs for ambulatory, emergency, and specialty care, and prescriptions, but not inpatient services. OBJECTIVES: To assess the change associated with CHPlus regarding 1) access to health care; 2) utilization of ambulatory, inpatient, and emergency services; 3) quality of health care; and 4) health status. SETTING: Six western New York State counties (including the city of Rochester). SUBJECTS: Children (0-6.99 years old) enrolled for at least 9 consecutive months in CHPlus. METHODS: The design was a before-and-after study, comparing individual-level outcomes for the 12 months immediately before CHPlus enrollment and the 12 months immediately after enrollment in CHPlus. Parent telephone interviews and medical chart reviews conducted 12 months after enrollment to gather information. Subjects' primary care charts were located by using interview information; emergency department (ED) charts were identified by searching patient records at all 12 EDs serving children in the study; and health department charts were identified by searching patient records at the 6 county health department clinics. Logistic regression and Poisson regression were used to compare the means of dependent measures with and without CHPlus coverage, while controlling for age, prior insurance type, and gap in insurance coverage before CHPlus. RESULTS: Complete data were obtained for 1730 children. Coverage by CHPlus was associated with a significant improvement in access to care as measured by the proportion of children reported as having a usual source of care (preventive care: +1.9% improvement during CHPlus and sick care: +2. 7%). CHPlus was associated, among children 1 to 5 years old, with a significant increase in utilization of preventive care (+.23 visits/child/year) and sick care (+.91 visits/child/year) but no measurable change in utilization of specialty, emergency, or inpatient care. CHPlus was also associated, among children 1 to 5 years old, with significantly higher immunization rates (up-to-date for immunizations: 76% vs 71%), and screening rates for anemia (+11% increased proportion screened/year), lead (+9%), vision (+11%), and hearing (+7%). For 25% of the children, a parent reported that their child's health was improved as a result of having CHPlus. CONCLUSION: After enrollment in CHPlus, access to and utilization of primary care increased, continuity of care improved, and many quality of care measures were improved while utilization of emergency and specialty care did not change. Many parents reported improved health status of their child as a result of enrollment in CHPlus. Implication. This evaluation suggests that SCHIP programs are likely to improve access to, quality of, and participation in primary care significantly and may not be associated with significant changes in specialty or emergency care.

Evaluating Child Health Plus in upstate New York: how much does providing health insurance to uninsured children increase health care costs?

BACKGROUND: In response to the increase in the number of American children without health insurance, new federal and state programs have been established to expand health insurance coverage for children. However, the presence of insurance reduces the price of care for families participating in these programs and stimulates the use of medical services, which leads to an increase in health care costs. In this article, we identified the additional expenditures associated with the provision of health insurance to previously uninsured children. METHODS: We estimated the expenditures on additional services using data from a study of children living in the Rochester, New York, area who were enrolled in the New York State Child Health Plus (CHPlus) program. CHPlus was designed specifically for low-income children without health insurance who were not eligible for Medicaid. The study sample consisted of 1910 children under the age of 6 who were initially enrolled in CHPlus between November 1, 1991 and August 1, 1993 and who had been enrolled for at least 9 continuous months. We used medical chart reviews to determine the level of primary care utilization, parent interviews for demographic information, as well as specialty care utilization, and we used claims data submitted to CHPlus for the year after enrollment to calculate health care expenditures. Using this information, we estimated a multivariate regression model to compute the average change in expenditures associated with a unit of utilization for a cross-section of service types while controlling for other factors that independently influenced total outpatient expenditures. RESULTS: Expenditures for outpatient services were closely related to primary care utilization-more utilization tended to increase expenditures. Age and the presence of a chronic condition both affected expenditures. Children with chronic conditions and infants tended to have more visits, but these visits were, on average, less expensive. Applying the average change in expenditures to the change in utilization that resulted from the presence of insurance, we estimated that the total increase in expenditures associated with CHPlus was $71.85 per child in the year after enrollment, or a 23% increase in expenditures. The cost increase was almost entirely associated with the provision of primary care. Almost three-quarters of the increase in outpatient expenditures was associated with increased acute and well-child care visits. CONCLUSIONS: CHPlus was associated with a modest increase in expenditures, mostly from additional outpatient utilization. Because the additional primary care provided to young children often has substantial long-term benefits, the relatively modest expenditure increases associated with the provision of insurance may be viewed as an investment in the future.

Evaluation of New York State's Child Health Plus: children who have asthma.

BACKGROUND: Little is known about the impact of providing health insurance to uninsured children who have asthma or other chronic diseases. OBJECTIVES: To evaluate the association between health insurance and the utilization of health care and the quality of care among children who have asthma. DESIGN: Before-and-during study of children for a 1-year period before and a 1-year period immediately after enrollment in a state-funded health insurance plan. INTERVENTION: In 1991 New York State implemented Child Health Plus (CHPlus), a health insurance program providing ambulatory and ED (ED), but not hospitalization coverage for children 0 to 12.99 years old whose family incomes were below 222% of the federal poverty level and who were not enrolled in Medicaid. SUBJECTS: A total of 187 children (2-12.99 years old) who had asthma and enrolled in CHPlus between November 1, 1991 and August 1, 1993. MAIN OUTCOME MEASURES: Rates of primary care visits (preventive, acute, asthma-specific), ED visits, hospitalizations, number of specialists seen, and quality of care measures (parent reports of the effect of CHPlus on quality of asthma care, and rates of recommended asthma therapies). The effect of CHPlus was assessed by comparing outcome measures for each child for the year before versus the year after CHPlus enrollment, controlling for age, insurance coverage before CHPlus, and asthma severity. DATA ASCERTAINMENT: Parent telephone interviews and medical chart reviews at primary care offices, EDs, and public health clinics. MAIN RESULTS: Visit rates to primary care providers were significantly higher during CHPlus compared with before CHPlus for chronic illness care (.995 visits before CHPlus vs 1.34 visits per year during CHPlus), follow-up visits (.86 visits vs 1.32 visits per year), total visits (5.69 visits vs 7.11 visits per year), and for acute asthma exacerbations (.61 visits vs 0.84 visits per year). There were no significant associations between CHPlus coverage and ED visits or hospitalizations, although specialty utilization increased (30% vs 40%; P =.02). According to parents, CHPlus reduced asthma severity for 55% of children (no change in severity for 44% and worsening severity for 1%). Similarly, CHPlus was reported to have improved overall health status for 45% of children (no change in 53% and worse in 1%), primarily attributable to coverage for office visits and asthma medications. CHPlus was associated with more asthma tune-up visits (48% before CHPlus vs 63% during CHPlus). There was no statistically significant effect of CHPlus on several other quality of care measures such as follow-up after acute exacerbations, receipt of influenza vaccination, or use of bronchodilators or antiinflammatory medications. CONCLUSIONS: Health insurance for uninsured children who have asthma helped overcome financial barriers that prevented children from receiving care for acute asthma exacerbations and for chronic asthma care. Health insurance was associated with increased utilization of primary care for asthma and improved parent perception of quality of care and asthma severity, but not with some quality indicators. Although more intensive interventions beyond health insurance are needed to optimize quality of asthma care, health insurance coverage substantially improves the health care for children who have asthma.

Evaluation of a state health insurance program for low-income children: implications for state child health insurance programs.

BACKGROUND: The State Child Health Insurance Program (SCHIP) is the largest public investment in child health care in 30 years, targeting 11 million uninsured children, yet little is known about the impact of health insurance on uninsured children. In 1991, New York State implemented Child Health Plus (CHPlus), a health insurance program that became a model for SCHIP: OBJECTIVE: To examine changes in access to care, utilization of services, and quality of care among children enrolled in CHPlus. DESIGN: A pre-post design was used to evaluate the health care experiences of children in the year before enrollment in CHPlus and during the year after CHPlus enrollment. SETTING: New York State, stratified into 4 regions: New York City, urban counties around New York City, upstate urban counties, and upstate rural counties. PARTICIPANTS: A total of 2126 children (0-12.99 years of age) who enrolled in CHPlus in 1992-1993. DATA COLLECTION: Parents were interviewed by telephone, and primary care medical charts were reviewed for 694 children (0-3. 99 years of age). ANALYSIS: Access, utilization, and quality of care measures for each child were compared for the year before and the year after CHPlus enrollment, controlling for age, geographic region, previous insurance coverage, and CHPlus plan type (indemnity or managed care). RESULTS: Enrollment in CHPlus was associated with fewer children lacking a medical home (5% before CHPlus vs 1% during CHPlus), with the greatest change occurring in New York City (11% vs 1%), where access before CHPlus was lowest. CHPlus was also associated with increased primary care visits: by 25% for preventive visits, by 52% for acute visits, and by 42% for total visits. The number of specialists seen during CHPlus was more than twice as high than before CHPlus. CHPlus was not associated with changes in emergency department utilization, although hospitalizations, which were not covered by CHPlus, were 36% lower during CHPlus coverage. Use of public health departments for immunizations declined by 64%, with more immunizations delivered in the medical home during CHPlus coverage. One third of parents reported improved quality of health care for their child as a result of CHPlus, and virtually none noted worse quality of care. CONCLUSIONS: This statewide health insurance program for low-income children was associated with improved access, utilization, and quality of care, suggesting that SCHIP has the potential to improve health care for low-income American children.

Profile of uninsured children in the United States.

OBJECTIVES: To describe the demographic characteristics, utilization of medical services, and health status of uninsured children compared with insured children in the United States and to assess the factors associated with lack of health insurance among children. An estimated 8 million children in the United States are uninsured. Medicaid expansions and tax credits have had little impact on the overall problem. An understanding of the characteristics of uninsured children is essential for the design of appropriate outreach and enrollment strategies, benefit packages, and health care provision arrangements for uninsured children. METHODS: Analysis of the 1988 Child Health Supplement of the National Health Interview Survey. RESULTS: Diverse groups of children in the United States lack health insurance. Residence in the South (odds ratio [OR], 2.3) and West (OR, 1.9. [corrected]) and being poor (OR, 2.2) or nearly poor (OR, 2.1) are independently associated with being uninsured. Substantial differences in both sources of care and utilization of medical services exist between uninsured and insured children. Uninsured children lack usual sources of routine care (OR, 3.1) and sick care (OR, 3.8) and also lack appropriate well-child care (OR, 1.5) compared with insured children. Neither being in fair or poor health nor emergency department use are significant independent predictors of being uninsured among children. Children who have a chronic disease, such as asthma, face difficulties of access to care and utilize substantially fewer outpatient and inpatient services. CONCLUSIONS: Universal health insurance, rather than efforts directed at specific groups, appears to be the only way to provide health insurance for all US children. Uninsured and insured children reveal marked discrepancies in access to and utilization of medical services, including preventive services, but have similar rates of chronic health conditions and limitations of activity. Uninsured children do not appear to form a population that will incur higher mean annual expenditures for medical care compared with insured children.

Violence among children and adolescents and the role of the pediatrician.

Violence has reached epidemic proportions in the United States and has become the single most important public health problem affecting adolescent males. It is believed that violence and its subsequent morbidity and mortality have a multifactorial origin, including developmental factors, gang involvement, access to firearms, drugs, the media, poverty, and family violence. Pediatricians have a critical role in reducing violence through early identification of family violence, education and counseling to decrease well-known risk factors, and provision of nonviolent problem-solving and coping strategies to children, youth, and their families. It is essential that we initiate preventive measures now rather than be paralyzed by the weight of the crisis.