Missed Opportunities for Transcranial Doppler Screening Among Children With Sickle Cell Disease.

Transcranial Doppler (TCD) screening rates remain low among children with sickle cell disease (SCD). We assessed TCD screening rates and missed opportunities for TCD screening. Children 2 to 16 years old with SCD enrolled in Michigan Medicaid for ≥1 year (2007-2011) were identified through newborn screening. Receipt of TCD screening and presence of a missed opportunity (≥1 SCD-related outpatient visit, no TCD screening) were identified through administrative claims. Potential correlates of missed opportunities included SCD-related health services, comorbidities, and demographics. Logistic regression with generalized estimating equations modeled associations between a missed opportunity and correlates. Overall, 353 children contributed 1066 person-years. TCD screening was low yearly (10%-32%); missed opportunities occurred in 73% of the person-years. Increasing age (odds ratio [OR] = 1.11; confidence interval CI = 1.07, 1.15), previous TCD screening (OR = 0.26; CI = 0.16, 0.41), and 4 to 5 (OR = 0.48; CI = 0.26, 0.87) or ≥6 outpatient visits (OR = 0.26; CI = 0.14, 0.49) were associated with a missed opportunity. Reduction of missed opportunities is a potential strategy to increase TCD screening rates.

Prescription patterns for children with juvenile idiopathic arthritis in Michigan Medicaid: a comparison by prescriber type.

BACKGROUND: Due to a limited number and disparate distribution of pediatric rheumatologists in the US, a variety of physician types provide care to children with rheumatologic diseases. However, little is known about how that care may differ across prescribing physician groups. Our objective was to compare medication claims for children with juvenile idiopathic arthritis (JIA) by type of prescribing physician. METHODS: We performed a retrospective cohort study of children with JIA using Michigan Medicaid data for 7/1/2005-6/30/2007, employing descriptive and bivariate analyses by age, medication type, and prescriber type. RESULTS: Among 397 children, there was no difference in the frequency of medication claims for children with internist versus pediatric rheumatologist prescribers. Children with non-rheumatologist prescribers were less likely to have claims for disease modifying anti-rheumatic drugs (DMARDs) and biologic agents. CONCLUSION: Differential use of DMARDs and biologic agents by rheumatologists indicates the importance of referring children with JIA for specialty care.

Outpatient utilization by infants auto-assigned to Medicaid managed care plans.

To test the hypothesis that infants auto-assigned to a Medicaid managed care plan would have lower primary care and higher emergency department (ED) utilization compared to infants with a chosen plan. Retrospective cohort study. Medicaid administrative data were used to identify all children 0-3 months of age at enrollment in Michigan Medicaid managed care in 2005-2008 with 18-months of subsequent enrollment. Medicaid encounter and state immunization registry data were then acquired. Auto-assigned infants were compared versus chosen plan infants on: (1) well-child visits (WCVs); (2) immunizations; (3) acute office visits; and (4) ED visits. Chi squared and rank-sum tests and logistic and negative binomial regression were used in bivariate and multivariable analyses for dichotomous and count data, respectively. 18% of infants were auto-assigned. Auto-assigned infants were less likely to meet goal number of WCVs in 18-months of managed care enrollment (32 vs. 53%, p < 0.001) and to be up-to-date on immunizations at 12 months of age (75 vs. 85%, p < 0.001). Auto-assigned infants had fewer acute office visits (median: 4 vs. 5, p < 0.001) but were only slightly more likely to have 2 or more ED visits (51 vs. 46%, p < 0.001) in 18-months of enrollment. All results were significant in multivariable analyses. Auto-assigned infants were less likely to use preventive and acute primary care but only slightly more likely to use emergency care. Future work is needed to understand mechanisms of differences in utilization, but auto-assigned children may represent a target group for efforts to promote pediatric preventive care in Medicaid.

Follow-up analysis of adolescents partially vaccinated against human papillomavirus.

PURPOSE: To evaluate factors associated with human papillomavirus vaccination among a cohort of female adolescents previously identified as receiving only one or two doses of vaccine. METHODS: This was a 15-month follow-up analysis of a previously identified cohort of 9-18-year-old female adolescents seen in primary clinics within a university-based health system. Vaccine receipt and associated factors were identified by review of administrative records. RESULTS: Among the 1,714 partially vaccinated female adolescents, 53% eventually completed the vaccination series. There was a wide range of dosing intervals ranging from 31 to 840 days between first and second doses and from 85 to 666 days between second and third doses. Race and insurance type were associated with lower rates of series completion, but not with receiving second doses. CONCLUSIONS: Approximately half of the partially vaccinated girls in our cohort eventually completed the series, albeit often over a longer than recommended interval. There were important disparities in human papillomavirus vaccination.

Long-acting ß-agonist monotherapy among children and adults with asthma.

OBJECTIVES: To determine the prevalence of long-acting ß-agonist (LABA) monotherapy among a Medicaid-enrolled population with asthma and to describe continued LABA monotherapy use. STUDY DESIGN: Retrospective cohort. METHODS: Administrative Medicaid claims data for Michigan were used to identify children and adults with asthma, defined as having 4 or more asthma medication­dispensing events during a calendar year between 2006 and 2008. We determined the annual prevalence of LABA monotherapy, defined as having at least 1 dispensing event for a LABA medication in the absence of any other maintenance therapy. The cohort using LABA monotherapy was followed up for 12 months after the identification year to assess continued LABA monotherapy and the frequency of missed opportunities for changes in therapy. Analyses included prevalence proportions, median numbers of office visits, and χ(2) tests to test for significant differences between subgroups. RESULTS: LABA monotherapy among persons with asthma was uncommon (<1%) and decreased over time. LABA monotherapy was more prevalent among female subjects, persons of white race, and older age groups. The prevalence of continued LABA monotherapy during the followup year was 41.2% among the cohort of LABA monotherapy users. Most users of continued LABA monotherapy (92.9%) had at least 1 missed opportunity for therapy change or patient education during the follow-up period. CONCLUSION: Although our results indicate that LABA monotherapy was rare, this study provides further evidence supporting enhanced information sharing between points of service about medication utilization that is inconsistent with accepted guidelines.

Continuity of prescribers of short-acting beta agonists among children with asthma.

OBJECTIVE: To determine whether short-acting beta-agonist (SABA) prescriber continuity was associated with emergency department visits among children with asthma. STUDY DESIGN: An analysis of Michigan Medicaid administrative claims (2004-2005) for children ages 5 to 18 with asthma. Logistic regression models assessed the effect of SABA prescriber continuity (the number and site of prescribers) on emergency department visits, controlling for demographics, historical (2004) asthma use and SABA prescription frequency (2-5 low; > or = 6 high). RESULTS: Most children had one SABA prescriber (62%); 13% had multiple prescribers in the same practice as the primary care provider and 25% had multiple prescribers in different practices. Children with multiple prescribers in different practices had increased odds of an emergency department visit compared with those with 1 prescriber, among those with high SABA prescription frequency (AOR: 2.7, 95% CI: 1.9, 3.9), as well as those with low prescription frequency (AOR: 1.7, 95% CI: 1.3, 2.2). CONCLUSIONS: Children with discontinuity of SABA prescribers have an increased risk of asthma emergency department visits, irrespective of their SABA prescription frequency. Primary care providers may have difficulty identifying patients at high risk with asthma solely on the basis of SABAs prescribed within their own practices.

Interhospital transfer of critically ill and injured children: an evaluation of transfer patterns, resource utilization, and clinical outcomes.

OBJECTIVE: To describe patterns of transfer, resource utilization, and clinical outcomes associated with interhospital transfer of critically ill and injured children. DESIGN: Secondary analysis of administrative claims data. PARTICIPANTS: Children 0 to 18 years in the Michigan Medicaid program who underwent interhospital transfer for intensive care from January 1, 2002 to December 31, 2004. The 3 sources of transfer from referring hospitals were: emergency department (ED), ward, or intensive care unit (ICU). MEASUREMENTS: Mortality and duration of hospital stay at the receiving hospitals. RESULTS: Of 1643 interhospital transfer admissions to intensive care at receiving hospitals, 62%, 31%, and 7% were from the ED, ward, and ICU of referring hospitals, respectively. Nineteen percent had comorbid illness, while 11% had organ dysfunction at the referring hospital. After controlling for comorbid illness, patient age, and pretransfer organ dysfunction; compared with ED transfers, mortality in the receiving hospital was higher for ward transfers (odds ratio [OR], 1.76; 95% confidence interval [CI], 1.02-3.03) but not for ICU transfers. Also, compared with ED transfers, hospital stay was longer by 1.5 days for ward transfers and by 13.5 days for ICU transfers. CONCLUSION: In this multiyear, statewide sample, mortality and resource utilization were higher among children who underwent interhospital transfer to intensive care after initial hospitalization, compared with those transferred directly from emergency to intensive care. Decision-making underlying initial triage and subsequent interhospital transfer of critically ill children warrants further study.

Effect of missed opportunities on influenza vaccination rates among children with asthma.

OBJECTIVES: To assess rates of influenza vaccination among children with asthma; document the frequency, timing, and patterns of missed opportunities to vaccinate during successive influenza seasons; and project potential influenza vaccination rates that could be achieved by reducing or eliminating missed opportunities. SETTING: Michigan Medicaid program during the 2001-2002 and 2002-2003 influenza seasons. DESIGN: Retrospective cohort analysis of administrative claims. PARTICIPANTS: We evaluated the claims of 4358 children aged 5 to 18 years with persistent asthma who were continuously enrolled in Medicaid. MAIN OUTCOME MEASURES: Influenza vaccinations and missed opportunities assessed using procedure and diagnosis codes. RESULTS: During the 2001-2002 season, 16.7% of children with asthma received an influenza vaccination; during 2002-2003, 21.8% received the vaccine (9.5% vaccinated in both seasons). However, 76.5% of children had at least 1 office visit during the 2001-2002 influenza season (75.3% during 2002-2003). Among children without influenza vaccination, 72.9% had at least 1 missed opportunity for vaccination during the 2001-2002 season and 69.3% during 2002-2003. The most common outcome was having at least 1 missed opportunity (39.6%) in each of 2 successive influenza seasons. Eliminating missed opportunities prior to the historical peak of influenza season would have increased the influenza vaccination rate among this population of children to 76%. CONCLUSIONS: Missed opportunities for influenza vaccination among children with asthma are common and are often repeated from one influenza season to the next. Future studies should assess how interventions could be aimed at patients and health care professionals to improve awareness of the need for annual influenza vaccination.

Geographic variation of asthma quality measures within and between health plans.

OBJECTIVE: To contrast health plan performance in treating pediatric asthma within and between different geographic regions. STUDY DESIGN: Retrospective analysis of administrative claims data for 18 health plans serving Medicaid enrollees. METHODS: The study population was 3970 children 5-18 years old with persistent asthma who were continuously enrolled in the same Michigan Medicaid health plan for 2002 and 2003, with no other source of health insurance. Outcome measures were assessed based on national guidelines for asthma management: at least 1 asthma controller medication prescription, at least 1 outpatient visit, 1 or more asthma emergency department visits, and an annual influenza vaccination. RESULTS: Adherence to national guidelines varied significantly (P

Blood lead testing among Medicaid-enrolled children in Michigan.

BACKGROUND: Federal regulations mandate that Medicaid-enrolled children be tested for lead poisoning at the age of 1 and 2 years or 3 through 5 years if not previously tested. OBJECTIVES: To measure the rate of blood lead testing among Medicaid-enrolled children in Michigan and the subsequent proportion of children with elevated lead levels and to determine factors associated with testing and elevated lead levels. METHODS: We performed a retrospective analysis of children aged 5 years or younger continuously enrolled in Michigan Medicaid during 2002. RESULTS: There were 216,578 children included in the analysis. The overall rate of blood lead testing was 19.6% (95% confidence interval [CI], 19.4-19.8) of which 8.3% (95% CI, 8.0-8.5) had a level of 10 microg/dL [0.48 micromol/L] or higher. Hispanic or nonwhite children or those living in high-risk areas for lead exposure were more likely to be tested and more likely to have an elevated blood lead level. However, 1.2% of tested children without these additional risk factors had a level of 10 microg/dL or higher. Enrollment in Medicaid managed care was associated with an increased likelihood of blood lead testing. After adjusting for other factors, those in managed care for 75% or more of their enrollment in 2002 had 1.98 (95% CI, 1.46-2.68) greater odds of being tested than those in fee-for-service for 75% or more of their enrollment. CONCLUSIONS: The rate of blood lead testing was low. Patterns suggest testing was targeted to those at highest risk, potentially leading some children with elevated blood lead levels to be missed.

Follow-up testing among children with elevated screening blood lead levels.

CONTEXT: Follow-up testing after an abnormal screening blood lead level is a key component of lead poisoning prevention. OBJECTIVES: To measure the proportion of children with elevated screening lead levels who have follow-up testing and to determine factors associated with such care. DESIGN, SETTING, AND PARTICIPANTS: Retrospective, observational cohort study of 3682 Michigan Medicaid-enrolled children aged 6 years or younger who had a screening blood lead level of at least 10 microg/dL (0.48 micromol/L) between January 1, 2002, and June 30, 2003. MAIN OUTCOME MEASURE: Testing within 180 days of an elevated screening lead level. RESULTS: Follow-up testing was received by 53.9% (95% confidence interval [CI], 52.2%-55.5%) of the children. In multivariate analysis adjusting for age, screening blood lead level results, and local health department catchment area, the relative risk of follow-up testing was lower for Hispanic or nonwhite children than for white children (0.91; 95% CI, 0.87-0.94), for children living in urban compared with rural areas (0.92; 95% CI, 0.89-0.96), and for children living in high- compared with low-risk lead areas (0.94; 95% CI, 0.92-0.96). Among children who did not have follow-up testing, 58.6% (95% CI, 56.3%-61.0%) had at least 1 medical encounter in the 6-month period after the elevated screening blood lead level, including encounters for evaluation and management (39.3%; 95% CI, 36.9%-41.6%) or preventive care (13.2%; 95% CI, 11.6%-14.8%). CONCLUSIONS: The rate of follow-up testing after an abnormal screening blood lead level was low, and children with increased likelihood of lead poisoning were less likely to receive follow-up testing. At least half of the children had a missed opportunity for follow-up testing. The observed disparities of care may increase the burden of cognitive impairment among at-risk children.

Patterns of vision care among Medicaid-enrolled children.

OBJECTIVE: To describe patterns of vision care among Medicaid-enrolled children. METHODS: We evaluated claims data over a 1-year period among children who were 18 years and younger, living in Michigan, and continuously enrolled in Medicaid but did not have a complex medical condition or were disabled. For this study, vision care comprised eye care services provided by optometrists or ophthalmologists and lens services, including dispensing and fitting of corrective lenses. RESULTS: Children in rural counties had increased odds of receiving eye care (odds ratio [OR]: 1.24) or lens services (OR: 1.22) compared with those in urban counties. In urban counties, non-Hispanic white children had greater odds than Hispanic or nonwhite children to have eye care (OR: 1.37) and lens services (OR: 1.37). An increasing supply of eye care professionals per population within a county was associated with decreased vision care in urban counties and slightly increased eye care and no changes in lens services in rural counties. Urban children who received mostly fee-for-service Medicaid had greater odds of receiving vision care than those with longer periods of managed care. Rural children who received mostly fee-for-service Medicaid had greater odds of eye care but similar odds of lens services. Regardless of urban/rural status, girls had increased odds of receiving eye care (OR: 1.24 for urban, 1.20 for rural) and lens services (OR: 1.36 for urban, 1.24 for rural). CONCLUSIONS: Patterns emerged that suggest underutilization or overutilization of vision care services. Such differences may have an impact on the development of children or waste limited health care resources.