Cross-linking of the ryanodine receptor/Ca2+ release channel from skeletal muscle.

The relationship between the tetrameric organization of the ryanodine receptor (RyR) and its activity in binding of ryanodine was approached through cross-linking studies using several bifunctional reagents, differing in their linear dimensions and flexibility, as well as in the reactivity of the active groups. Cross-linking with: 1,5-difluoro-2,4-dinitrobenzene (DFDNB); di(fluoro-3-nitrophenyl)sulfone (DFNPS), 1-ethyl-3-(3-dimethylamino)propyl)carbodiimide (EDC); dimethyl suberimidate (DMS); ethylene glycol bis(succinimidylsuccinate) (EGS); and glutaraldehyde resulted in the disappearance of the, 470 kDa, RyR monomer protein band with concomitant appearance of additional bands of molecular masses higher than the monomer. At the relatively low concentrations of the reagents and the conditions used, RyR is the only cross-linked protein of SR membranes. The 'new' protein bands cross-react with antibodies against the RyR and correspond to dimers and tetramers of the RyR subunits while trimers were not detectable. DFDNB and DFNPS produced also a 560 kDa protein band which probably represents an intramolecular cross-linked monomer. The SDS-electrophoretic patterns of the cross-linked purified RyR resemble those of the membrane-bound receptor. Ryanodine binding to the high-affinity site was inhibited by modification of SR membranes with DFDNB and DFNPS, but not with DMS, EDC, EGS and glutaraldehyde, although RyR was completely cross-linked. The inhibition by DFDNB and DFNPS is due to modification of a specific lysyl residue which is also involved in the control of Ca2+ release. On the other hand, cross linking of the RyR with glutaraldehyde or EGS resulted in inhibition of ryanodine binding to the low-affinity, but not to the high-affinity binding sites. Thus, the cross-linking of two or more sites in each monomer (which lead to fixation of dimers or tetramers) did not prevent the conformational changes involved in the binding and occlusion of ryanodine at the high-affinity site, but inhibited its binding to the low-affinity sites.

Health services for California's foster children: current practices and policy recommendations.

The organization and delivery of health services to children in foster care was investigated in 14 California counties in 1985. Foster care administrators, child welfare workers, foster parents, and health care providers responded to questionnaires and structured interviews performed by two pediatricians knowledgeable about the child welfare system. The organization of health services demonstrated a high degree of variability between counties. Although some counties initially evaluate all dependent children using specific protocols and examinations sites, more often services were poorly organized, fragmented, and had few safeguards to ensure delivery of appropriate health care. Use of recommended Early Periodic Screening Diagnosis and Treatment services was also variable, and counties could not provide documentation of use rates by foster children. Even less consistent was the performance of routine initial mental health assessments. Financial disincentives, fewer available providers, difficulties in obtaining and using Medicaid-reimbursed services, and fragmentation of services were frequently identified as barriers to access. To improve the organization and delivery of services, access barriers must be diminished, services must be better organized and integrated, and new financing mechanisms must be developed. Specific policy recommendations are presented.

Preventive care use by school-aged children: differences by socioeconomic status.

Use of ambulatory care services by children from low-income families has increased substantially since the early 1960s. However, in few studies have attempts been made to disaggregate physician visits according to type (eg, preventive upsilon diagnosis and treatment). In this study, receipt of preventive care (including physical, vision, and dental examinations), based on a sample of 16,838 children aged 5 to 16 years from the 1982 National Health Interview Survey, was examined. The results indicate that children in families with incomes below the poverty level, especially those without Medicaid insurance, are much less likely to receive routine preventive care on a timely basis. Poor school-aged children with Medicaid are much more likely to receive timely preventive care than their counterparts without Medicaid coverage. The effectiveness of preventive care for children is discussed and suggestions for improving access to routine preventive care are presented.

Children in foster care in California: an examination of Medicaid reimbursed health services utilization.

The number of children in foster care in California doubled from 27,534 in 1980 to more than 62,419 in 1988, representing approximately 1% of the child population in the state. Past studies have demonstrated that children in foster care have high rates of medical and mental health problems. An examination of all Medi-Cal-paid claims was undertaken to describe the utilization of health services by children in foster care. Although children in foster care represent 4% of Medi-Cal-eligible children younger than 18 years of age, they account for approximately 5% of children using Medi-Cal services and 6.7% of expenditures, representing a 23% greater utilization rate and 41% greater expenditure rate than all children covered by Medi-Cal. Using the entire Medi-Cal population younger than 18 years of age as comparison group, examination of inpatient and outpatient service utilization for specific condition categories showed few differences between children in foster care and the comparison group except for mental health service utilization, where children in foster care were much higher users of services.

Mental health service utilization by children in foster care in California.

An examination of Medi-Cal-paid claims was undertaken to assess the utilization of mental health services by children in California's foster care system. Using unduplicate counts of service use and diagnoses, it was determined that children in foster care account for 41% of all users of mental health services even though they represent less than 4% of Medi-Cal-eligible children. When partitioned into specific service categories, children in foster care account for 53% of all psychologist visits, 47% of psychiatry visits, 43% of Short Doyle/Medi-Cal inpatient hospitalization in public hospitals, and 27% of inpatient psychiatric hospitals. Expenditure for services paralleled utilization frequency. When compared to the non-foster care Medi-Cal-eligible child population, children in foster care have 10 to 20 times the rate of utilization per eligible child for selected services. For children in foster care, 75% of all diagnoses for billed service were accounted for by four diagnoses: adjustment disorders (28.6%), conduct disorders (20.5%), anxiety disorders (13.8%), and emotional disorders (11.9%), with clear age-related differences in the distribution of diagnoses.

Access to ambulatory care services for economically disadvantaged children.

Using data from the 1981 Child Health Supplement to the National Health Interview Survey, we examined differences in access to ambulatory services for children of different family incomes. The results indicate that much progress has been made in equalizing access since the War on Poverty was initiated in the mid-1960s. Poor children with superior health status now generally see physicians at the same rates as children in similar health but from higher income families. However, children with substantial health problems from low-income families continue to lag behind their higher income counterparts in similar health. Medicaid was shown to substantially improve access to ambulatory services for economically disadvantaged children in poor health, but less than half of these children are covered by Medicaid. Recent changes in federal and state policies concerning Medicaid are discussed as well as policy options for addressing the needs of children afflicted by both poverty and ill health.

Geographic distribution of pediatricians in the United States: an analysis of the fifty states and Washington, DC.

OBJECTIVES: To determine current geographic distribution of pediatricians in the United States, to assess the changes in the geographic distribution of pediatricians between 1982 and 1992, and to identify factors associated with the distribution of pediatricians among the 50 states. METHODS: A data set was constructed using several published data sources including the American Medical Association Physician Masterfile as the principal source for physician information. The pediatrician-to-child population ratio (PCPR, the number of pediatricians per 100 000 people under 18 years of age) was calculated to compare the distribution of pediatricians among states and the distributional changes between 1982 and 1992. Lorenz curves and Gini indices were used to describe distributions and to compare distributions across time periods. Linear regression analysis was performed to assess the relationship between PCPR (dependent variable) with 9 predictor variables. RESULTS: Between 1982 and 1992, there was a 5.4% increase in the United States (US) child population and a 46.1% increase in the number of pediatricians in patient care. During that time period, the PCPR increased by 38.6% from 35.1 per 100 000 to 48.6 per 100 000. There was a more than 4-fold difference in the PCPRs of the highest state (Maryland, 84.3) and the lowest state (Idaho, 18.5) in 1992. The PCPR increased in all 50 states, but varied from a 4.1% increase in Wyoming to a 63.4% increase in Massachusetts. The Lorenz curve showed that pediatricians were less evenly distributed than all physicians, but more evenly distributed than pediatric cardiologists. Between 1982 to 1992 the Gini index decreased 9.8% for all physicians and 10.2% for pediatric cardiologists, but only 1. 9% for pediatricians. Since a decrease in the Gini index signifies better overall distribution, these changes are relatively modest for pediatricians as a whole, especially when compared to other physicians. Regression analysis showed that a higher PCPR was associated with a greater number of residency positions per 100 000 children and with the per capita income of the state (R = .93). CONCLUSIONS: The distribution of pediatricians does not parallel the distribution of the child population in the US, nor has this distribution changed substantially in spite of a 38.6% increase in the PCPR. Pediatricians tend to concentrate in states with high per capita income and in states with a larger number of residency training positions. The failure of market forces to improve the geographic distribution may require manpower policy changes designed to improve distribution in underrepresented states. The uncertain impact of market changes due to increased use of managed care could affect distributional requirements of pediatricians in the future.

Childhood asthma and poverty: differential impacts and utilization of health services.

Data from the 1988 National Health Interview Survey on Child Health showed that 4.3% of all children younger than 17 years of age had asthma, with poor children demonstrating a slightly greater prevalence than nonpoor (4.8 poor vs 4.2 nonpoor). This poor/nonpoor differential was even greater for children younger than 6 years old (4.2 vs 3.1). Poor children were also more likely to have had more than 7 bed days in the past year because of their asthma. Measures of health service utilization showed that poor children had 40% fewer doctor visits (3.2 vs 5.4) and had 40% more hospitalizations in the previous year (10.6% vs 7.4%). Although more than 90% of all children had a usual source of routine and/or sick care, poor children were more likely to receive routine care in a neighborhood health center (15.1% vs 1.6%) or hospital-based clinic (11.1% vs 2.8%) than in a doctor's office (67.2% vs 91.1%) and, when sick, then were more than four times more likely to report an emergency department as a usual source of care (8.1% vs 1.7%). Diminished accessibility to appropriate outpatient health services for poor children with asthma was associated with increased morbidity, measured by hospitalization, and bed days. These findings have significant implications for the development of comprehensive models of care and the potential role that community clinics could play with increased funding as a result of Medicaid changes that were instituted as part of the 1989 Omnibus Budget Reconciliation Act.

Routine emergency department use for sick care by children in the United States.

BACKGROUND: The use of the emergency departments as a regular source of sick care has been increasing, despite the fact that it is costly and is often an inappropriate source of care. This study examines factors associated with routine use of emergency departments by using a national sample of US children. METHODS: Data from the 1988 National Health Interview Survey on Child Health, a nationally representative sample of 17710 children younger than 18 years, was linked to country-level health resource data from the Area Resource File. Bivariate and multivariate analyses were used to assess the association between children's use of emergency departments as their usual sources of sick care and predisposing need and enabling characteristics of the families, as well as availability of health resources in their communities. RESULTS: In 1988 3.4% or approximately 2 million US children younger than 18 years were reported to use emergency departments as their usual sources of sick care. Significant demographic risk factors for reporting an emergency department as a usual source of sick care included black versus white race (odds ratio [OR], 2.08), single-parent versus two-parent families (OR, 1.53), mothers with less than a high school education versus those with high school or more (OR, 1.76), poor versus nonpoor families (OR, 1.76), and living in an urban versus suburban setting (OR, 1.38). Specific indicators of need, such as recurrent health conditions (asthma, tonsillitis, headaches, and febrile seizures), were not associated with routine use of emergency departments for sick care. Furthermore, health insurance status and specifically Medicaid coverage had no association with use of the emergency department as a usual source of sick care. Compared with children who receive well child care in private physicians' offices or health maintenance organizations, children whose sources of well child care were neighborhood health centers were more likely to report emergency departments for sick care (OR, 2.01). Children residing in counties where the supply of primary care physicians was in the top quintile had half the odds (OR, 0.50) of reporting emergency departments as usual sources of sick care. CONCLUSIONS: Reliance on hospital emergency departments for routine sick care is strongly associated with demographic and social characteristics of the child and family, the type and source of available well child care, and the supply of primary care physicians. Because health insurance status was not a significant predictor of use, public policies aimed at reducing the use of emergency departments by children will need to address other factors. These include the organizational characteristics and responsiveness of the health care system and the motivation of families for routine use of hospital emergency departments.

Access to health care for children with special health care needs.

OBJECTIVE: To assess the role health insurance plays in influencing access to care and use of services by children with special health care needs. METHODS: We analyzed data on 57 553 children younger than 18 years old included in the 1994-1995 National Health Interview Survey on Disability. The survey obtained information on special health care needs, insurance status, and access to and use of health services. Bivariate and multivariate analyses were used to assess the association of insurance with several measures of access and utilization, including usual source of care, site of usual care, missed or delayed care, and use of ambulatory physician services. RESULTS: Using the federal Maternal and Child Health Bureau definition of children with special health care needs, we estimate that 18% of US children under 18 years old had an existing special health care need in 1994-1995. An estimated 89% of these children had some form of health insurance coverage, most often private health insurance. Insured children were more likely than uninsured children to have a usual source of care (96.9% vs 79.2%). Among those with a usual source of care, insured children were more likely than uninsured children to have an identified regular clinician (87. 6% vs 80.7%). Insured children were less likely to report unmet health needs, including medical care (2.2% vs 10.5%), dental care (6. 1% vs 23.9%), prescriptions, and/or eyeglasses (3.1% vs 12.3%), and mental health care (.9% vs 3.4%). Insured children were also more likely to have a physician contact in the past year (89.3% vs 73.6%) and have more physician contacts on an annual basis (8.5 vs 4.1 contacts). Unexpectedly, no differences were found between insured and uninsured children in availability of after hours medical care (evenings and weekends) or satisfaction with care. We also found some modest differences in access between publicly and privately insured children. Privately insured children were more likely to have a usual source of care (97.6% vs 95.3%) and a regular clinician (91.0% vs 81.1%). Privately insured children were also less likely to report dissatisfaction with care at their usual site of care (14. 9% vs 21.0%) and have access to care on evenings and weekends (6.8% vs 13.4%). No substantial differences were found between privately and publicly insured children in prevalence of unmet health needs or delays in obtaining care due to cost. CONCLUSIONS: This study illustrates the importance of health insurance for children with special health care needs. Continued efforts are needed to ensure that all children with special health care needs have insurance and that remaining access and utilization barriers for currently insured children with special health care needs are also addressed.

Factors related to immunization status among inner-city Latino and African-American preschoolers.

OBJECTIVE: To identify factors associated with undervaccination at 3 months and 24 months among low-income, inner-city Latino and African-American preschool children. DESIGN: Interviews with a representative sample of inner-city families using a cross-sectional, multi-stage, cluster-sample design combined with a replicated quota sampling approach. SETTING: South Central and East Los Angeles areas in inner-city Los Angeles. POPULATION: Eight hundred seventeen Latino and 387 African-American families with children between 12 and 36 months of age. MAIN OUTCOME VARIABLES: Being fully immunized or up-to-date (UTD) at 3 months (1 diphtheria-tetanus-pertussis vaccine and 1 oral polio vaccine) and 24 months of age (4 diphtheria-tetanus-pertussis vaccines, 3 oral polio vaccines, and 1 measles-mumps-rubella vaccine). METHODS: Logistic regressions of UTD immunization status at 3 and 24 months by population and health care system factors. RESULTS: Seventy percent of Latino children and 53% of African-American children were UTD at 3 months of age. At 24 months of age, 42% of Latino children and 26% of African-American children were UTD on their immunizations. Receipt of the first immunizations by 3 months was associated with smaller family size, and evidence of connection to prenatal care. Latino children were less likely to be UTD at 24 months if they obtained well child care from private providers versus public clinics (odds ratio [OR] = 0.45, 95% confidence interval [CI] = 0.26, 0.79). There was also a trend for Latino children to be less well immunized if they were in health maintenance organizations versus public clinics (0.31, 0.05 < P < .1). African-American children were more likely to be UTD at 24 months if they were UTD at 3 months (OR = 5.56, 95% CI = 1.43, 21.6), had more health visits (OR = 1.13, 95% CI = 1.01, 1.27), and were less likely to be UTD at 24 months if they were on Medicaid versus private insurance (OR = 0.26, 95% CI = 0.08, 0.90). IMPLICATIONS: Both African-American and Latino children in inner-city Los Angeles have low immunization rates at 3 and 24 months. Prenatal care and family size are strongly associated with being UTD by 3 months; however, family and child characteristics are relatively unimportant predictors of being UTD at 24 months of age. Important risk factors for underimmunization at 2 years of age in the inner-city, low-income communities studied include type of health insurance and source of well child care, with the public sector having higher rates than private doctors' offices or health maintenance organization/managed care plans.

Knowledge of the childhood immunization schedule and of contraindications to vaccinate by private and public providers in Los Angeles.

BACKGROUND: Missed opportunities to vaccinate occur commonly and contribute to the underimmunization of young children. They are related to provider knowledge of the immunization schedule and contraindications to vaccination. METHODS: We surveyed private physicians (n = 50) and public health department physicians and nurses (n = 47). The questionnaire presented two sets of clinical scenarios in which they had to assess what immunizations were due and assess whether there were any contraindications to vaccination. RESULTS: The mean percent correct responses on the immunization schedule questions was 64% (sd = 3.6%) for the private physicians, 71% (SD = 4.7%) for the public physicians and 78% (SD = 2.8%) for the public nurses (P = 0.04). The mean percent correct responses on the contraindications to vaccinate questions was 73% (SD = 5.4%) for public physicians, 58% (SD = 3.3%) for private physicians, and 55% (SD = 4.7%) for public health nurses (P = 0.02). CONCLUSIONS: Our survey shows that providers in the public and private sectors have important deficits in their knowledge of the immunization schedule and the appropriate contraindications to vaccinate which might lead to missed opportunities to vaccinate and low immunization coverage.

Primary care services promoting optimal child development from birth to age 3 years: review of the literature.

OBJECTIVE: To examine the evidence base for primary health care services promoting the optimal development of typically developing children aged birth to 3 years. DATA SOURCES: Peer-reviewed publications addressing clinical evaluations of primary care services from the MEDLINE and PsychINFO databases. STUDY SELECTION: Criteria for selection were as follows: (1) publication between 1979 and 1999; (2) evaluation of efficacy or effectiveness of education, intervention, and care coordination services or validation of assessment approaches; (3) services applicable to an office practice setting; (4) target population including children aged birth to 3 years; and (5) publication in English. DATA EXTRACTION: A total of 312 publications were abstracted and reviewed by both of us; 47 were selected for inclusion. DATA SYNTHESIS: Assessments of parental concerns and psychosocial risk factors using validated approaches seem to be more accurate in identifying developmental problems than clinicians' appraisals. In general, study results support the efficacy of (1) primary care educational efforts toward promoting optimal parent-child interaction, parents' understanding of child temperament, book-sharing activities, and approaches to healthy sleep habits and (2) office interventions such as counseling for the management of excessive infant crying and sleep problems. CONCLUSIONS: The literature suggests that many primary care activities promoting the optimal development of children are efficacious. Evaluations of developmental assessment and services in primary care should be expanded in depth and breadth. The implications for clinical practice, training, and health care policy are discussed.

Health status of children in foster care. The experience of the Center for the Vulnerable Child.

OBJECTIVES: To describe the health status and to illustrate the usefulness of an enhanced primary care model for children in foster care. DESIGN: Cross-sectional analysis of a clinical cohort via chart review. SETTING: Foster Care Program of the Center for the Vulnerable Child at the Children's Hospital, Oakland, Calif. SUBJECTS: Two hundred thirteen children in foster care assessed between August 1988 and June 1991. INTERVENTIONS: None. METHODS: A multidisciplinary assessment protocol was used to collect health and social histories and to conduct developmental, emotional, and behavioral assessments and medical examinations. Cross-tabulations were used to compare distributions of conditions and characteristics of the population, including the reasons for, timing of, and number of placements. RESULTS: The population was largely African-American (83.4%), with a mean age of approximately 3 years. At least 78% of children came from homes where drug use was a primary reason for placement. A history of maternal drug use was present in 94% of infants. The number of placements ranged from one to eight (mean, 2.0). Placement changes were common. Over 20% of children had growth abnormalities, 30% had neurologic abnormalities, and 16% had asthma. Fewer than 20% of children had no medical conditions, while 28.8% had three or more conditions. Over 80% of children had developmental, emotional, or behavioral problems. Emotional, relational, and behavioral problems were more common in children first placed after 2 years of age and in those with a greater number of placements (chi 2 = 12.6, P < .05). CONCLUSION: This comprehensive assessment of children in foster care revealed higher rates of chronic multiple medical and mental health problems than previously reported.

The impact of the vaccine for children's program on child immunization delivery. A policy analysis.

The Vaccine for Children (VFC) program was proposed as part of President Clinton's 1993 Childhood Immunization Initiative. It is a federal vaccine-financing program that pays for and distributes free vaccine to providers serving 4 classes of children: (1) Medicaid insured, (2) uninsured, (3) children with private insurance that does not cover immunizations, and (4) American Indian and Alaskan Native children. Despite support from major professional organizations, the VFC program has come under intense criticism, with critics arguing that the cost of vaccines is not a major barrier to immunization receipt. In this article, we analyze how the VFC program will influence the receipt of immunizations by children under different child health care delivery and financing systems. We conclude that the impact of VFC on access to immunizations will be uneven; however, VFC could significantly improve access to immunizations for the over one third of US children who are either uninsured or covered under Medicaid fee for service. With further augmentations and refinements, VFC could be fashioned to overcome significant and persistent barriers to the timely delivery of immunizations in our disjointed child health financing and delivery systems.

Prevalence, impact, and trends in childhood disability due to asthma.

BACKGROUND: Although not widely recognized as such, asthma is the single most prevalent cause of childhood disability and has contributed to a substantial rise in the overall prevalence of disability among children during the past 25 years. OBJECTIVE: To provide a national profile of the prevalence, impact, and trends in childhood disability due to asthma. (Disability is a long-term reduction in the ability to participate in children's usual activities, such as attending school or engaging in play, due to a chronic condition.) METHODS: We derived our primary findings from a cross-sectional, descriptive analysis of 62171 children younger than 18 years who were included in the 1994-1995 National Health Interview Survey. MAIN OUTCOME MEASURES: Outcome measures include the presence of disability, degree of disability, restricted activity days, school absence days, and use of hospital and physician services. We also used data from the 1969-1970, 1979-1981, and 1994-1995 National Health Interview Surveys to assess trends in the prevalence of disability due to asthma. RESULTS: A small, but significant, proportion of children, estimated at 1.4% of all US children, experienced some degree of disability due to asthma in 1994-1995. Prevalence of disability due to asthma was higher for adolescents (odds ratio [OR], 1.64), black children (OR, 1.66), males (OR, 1.23), and children from low income (OR, 1.46) and single-parent families (OR, 1.37). Disabling asthma resulted in an annual average of 20 restricted activity days, including 10 days lost from school-almost twice the level of illness burden as experienced by children with disabilities due to other types of chronic conditions. Finally, prevalence of disabling asthma, as reported in the National Health Interview Survey, has increased 232% since 1969, the first year that electronic data are available from the survey. In contrast, prevalence of disability due to all other childhood chronic conditions increased by 113% over the same period. CONCLUSIONS: Disabling asthma has profound effects on children. The social costs of asthma are likely to rise in the future if current trends in the prevalence of disabling asthma continue.

African American mothers in south central Los Angeles. Their fears for their newborn's future.

OBJECTIVE: To determine what African American mothers in a low-income community fear for their newborn's future. DESIGN: An interview survey was conducted with mothers of recently born infants randomly sampled from birth certificate records in the spring of 1994 in 10 postal codes in the Compton Health District in south central Los Angeles, Calif, with high concentrations of low-income African American children. Among 522 eligible mothers, 419 (80%) were interviewed. Children were an average of 17.7 days old at the time of the interview. MAIN OUTCOME MEASURE: The open-ended survey item, "What is your biggest fear for [child's name] growing up?" Mothers were prompted to give more than 1 answer. Responses were classified into 16 categories. RESULTS: Thirty-nine percent of the mothers reported a fear of gangs, violence, or both. The largest other response categories included disease, illness, and health problems (17%); drugs and alcohol (15%); growing up in the local environment (10%); and society and the world in general (6%). Fifty percent of the mothers of boys reported a fear of gangs, violence, or both compared with 28% of the mothers of girls (P < .001). CONCLUSIONS: More than half the fears are in the medical and public health domains. Some involve traditional health concerns (e.g., disease), while others are problems that the health professions have been addressing more recently (e.g., violence). The American Academy of Pediatrics has recommended counseling families about violence prevention and the prevention of firearm injuries. While this study shows that many mothers are concerned about these subjects, we need a greater understanding of what role physicians can play in helping their patients (and their patients' families) address violence in their lives.

Assessing the quality of care for children. Prospects under health reform.

The failure to pass federal health reform legislation this year does not mean that the health care crisis has been solved. As we look forward to predictably more incremental efforts to reduce costs, increase access, and improve quality, key issues from the most recent round of deliberations will undoubtedly reemerge. In the last session of Congress, private and public policymakers sent a clear signal that the era of accountability had arrived. In the health reform bills that Congress considered last year, a range of "measurement" strategies were put forth as essential elements for achieving accountability in a reformed health care system. For example, routine monitoring of the quality of care delivered by health plans and health providers was viewed as necessary to balance the impact of policies to control the cost of health care. Each of the major bills that were introduced this past year--Gephardt/Mitchell (S 1757/HR 3600), Cooper/Grandy (HR 3222), Breaux/Durenburger (S 1579), Nickles (S 1743), Chafee/Thomas (S 1770/HR 3704), and Wellstone/McDermott (S 491/HR 1200)--and the mark-up bills that have emerged from Senate and House committees have placed considerable emphasis on evaluating changes in access to health care and quality of care. Although the bills addressed issues related to financing, coverage, and the structure of the delivery system quite differently, they demonstrated much more consensus with regard to quality monitoring.

Prevalence of behavior problems in US children with asthma.

OBJECTIVES: To present national population-based estimates of the prevalence of parent-reported emotional and/or behavioral problems in children with asthma and the relationship of medical comorbidity and asthma severity with behavior problems. DESIGN: Cross-sectional study of the 1988 National Health Interview on Child Health. MAIN OUTCOME MEASURES: Parent responses to a checklist of child health conditions were used to assign school-age children (5 to 17 years old) into one of four groups: children without reported chronic conditions; children with asthma alone; children with asthma and additional reported chronic conditions; and children with the same chronic conditions, but without asthma. Parental responses to the Behavior Problem Index (BPI) were used for construction of an overall BPI score, as well as subscale scores. Cross-tabulation and linear and logistic regression were used to determine the relation of the different condition categories to emotional and/or behavioral problems expressed by relative values of the BPI. RESULTS: Children with asthma and comorbid conditions had a mean BPI score of 7.3, compared with 5.4 for children without chronic conditions, and all subscale scores, except those for antisocial conduct and immature behavior, were significantly elevated. Using logistic regression to control for confounding variables, children with severe asthma alone had nearly three times the odds (odds ratio, 2.96; 95% confidence interval, 1.22 to 7.17) and children with asthma plus comorbid conditions nearly twice the odds (odds ratio, 1.86; 95% confidence interval, 1.20 to 2.90) of children without chronic conditions to have severe behavior problems. CONCLUSIONS: Severe asthma and asthma with medical comorbidity represent significant risk factors for emotional and/or behavioral problems. Clinicians caring for children with asthma and their families should be aware of the relationship between asthma and emotional and/or behavioral problems and anticipate that a substantial number of their patients may have mental health services needs.

Reducing missed opportunities to vaccinate during child health visits. How effective are parent education and case management?

BACKGROUND: At child health visits, immunizations that are due are frequently not given. Increased parent understanding of and demand for immunizations may influence providers to not miss these opportunities. OBJECTIVE: To assess, as part of a larger study of effectiveness of parent education and case management (CM) in raising immunization rates, the intervention's effectiveness at reducing missed opportunities to vaccinate during child health visits. METHODS: A representative sample of African American newborns and their families from south central Los Angeles, Calif, were randomly assigned to a control or a CM group and observed during the first year of life. Case managers visited and telephoned parents, educating them on the benefits and safety of immunizations, and encouraging them to request immunizations from providers. When the children were at least 1 year of age, parents were interviewed and provider records were abstracted. RESULTS: Complete records were abstracted for 126 controls and 129 CM group children. For these children, 1092 visits were documented where immunizations were due. Missed opportunities to vaccinate occurred at more than 50% of visits. Case management was associated with a modest reduction in the percentage of visits with missed opportunities in the bivariate analysis but not after adjustment for other covariates. In a logistic regression model, missed opportunities were more frequent at visits with private than public physicians and at acute illness than well-child visits. Missed opportunities were less frequent among children with a history of at least 1 cancelled appointment, and for visits of children with mothers who smoked. CONCLUSIONS: Missed opportunities were minimally influenced by a home visitation and parent education program. They are primarily determined by issues under the control of the provider. Family- and child-related characteristics, however, do influence the likelihood of a missed opportunity occurring independent of provider factors.