Clinical care and health disparities.

Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, demographically, or geographically. This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.

[Parent-child agreement in the health related quality of life (HRQOL) of children with attention-deficit/hyperactivity disorder (ADHD): a longitudinal study]. / Concordancia entre padres e hijos en la calidad de vida relacionada con la salud en niños con trastorno por déficit de atención con hiperactividad: estudio longitudinal.

OBJECTIVES: To assess parent-child agreement on changes over a short-term period of time in the HRQOL of children treated for ADHD over a short period of time, and to compare child and parent ratings of children with ADHD with general population norms. METHODS: Prospective study in children 6-12 years old with ADHD. Children and parents completed the Spanish versions of the Child Health and Illness Profile-Child Edition (CHIP-CE) before and after 8 weeks of treatment. CHIP-PE scores at both visits were compared using paired t tests and effect sizes (ES), intra-class correlation coefficients (ICC), and scatter plots. Child and parent ratings were compared with CHIP-CE scores for a general population sample. RESULTS: Thirty-one children and parents were included in the analysis. The highest change between the first and the follow-up visit was on the Risk Avoidance domain both children and parents (effect size [ES]=0.24 and 0.40, respectively). The ICC ranged from 0.44 (Satisfaction) to 0.01 (Risk avoidance). Child self-ratings were close to general population values. All domains of the parent version presented standardized means below the reference values at the baseline visit and closer to the general population norm after treatment. CONCLUSIONS: This study found poor parent-child agreement and suggests that both ratings should be collected in future studies on the impact of ADHD and treatment effectiveness.

Primary care. Participants or gatekeepers?

Health systems that have a strong orientation toward primary care achieve lower overall costs, better satisfaction of their populations, and better health. The role of specialists in such systems is to provide consultative services on a short-term basis (secondary care) or long-term services for rare or complicated problems (tertiary care). Among both primary-care and specialist physicians, opinions vary considerably as to the specific tasks that are appropriate in primary and specialist care. Medical education has not proved an adequate basis for judging either the relative appropriateness of care by primary-care physicians and specialists or criteria for referral. Recent studies indicate that conventional wisdom concerning the nature and treatment of disease that is derived from research in tertiary medical centers is contradicted by collaborative practice-based studies in primary care. Better collaboration between primary-care physicians and specialists both in research and in the design of services will be the key to more informed decisions about improvement in the care of patients with diabetes and other important and common health-care problems.

Childhood morbidity: comparisons, clusters, and trends.

Standard mortality and morbidity data are important but incomplete descriptors of child health. Simple prevalences of individual conditions fail to capture fully the nature of ill health in childhood. More enlightening are comparative prevalences: cross-nationally, in different population subgroups, or as trends over time. A longitudinal perspective that provides information on high-risk states and that the nature of their impact on various aspects of health over time adds another dimension to an understanding of child health needs. A better understanding of the meaning of "health problems" in children and documentation of their distribution in the population will help to tailor better the organization and delivery of preventive, curative, and restorative child health services to child health needs.

Health care use by children receiving mental health services.

Reduction in medical care utilization is one criteria for assessing the impact of mental health treatment for children with psychosocial problems. This reduction has been termed the "offset" effect. Almost all published research concerning offset after mental health treatment concerns adults, and the few studies in pediatric populations are limited by methodologic problems. A study of health care utilization after mental health treatment for children was conducted. Mental health treatment for psychosocial problems was significantly associated with decreased use of medical care only for older children, after potentially confounding variables were controlled for. Furthermore, this decreased use was found only for nonmental health specialty care visits. No reduction in primary care visits occurred. Other factors such as previous patterns of use and the presence of other morbidity were stronger predictors of subsequent primary health care use than was mental health treatment. Mental health treatment does not have a major impact on the high utilization of most children with psychosocial problems in pediatric settings. Because the reasons for this may be particular morbidity patterns in these children, future studies should include some measure of case mix as a potentially important variable in assessment of mental health treatment effects.

Rehospitalization in the first year of life for high-risk survivors.

The first year of life is an age when morbidity and medical care use is high, and this is particularly true for low birth weight infants. Whether certain factors characterize subgroups at especially increased risk was examined for a large random sample (N = 4,989) of 1-year-old infants by using rehospitalization as the dependent variable. Overall, 9.1% of the infants had been rehospitalized, and this increased with decreasing birth weight to 38.2% of those less than or equal to 1,500 gm at birth. Low birth weight infants accounted for 6.4% of 1-year-olds, but 13.6% of those hospitalized and 20.0% of all hospital days among these infants. Factors affecting the chances of rehospitalization for low birth weight and normal birth weight infants, with and without congenital anomalies/developmental delay, were similar. Maternal hospitalization during pregnancy, prolonged postnatal stay of the infant, variables indicative of low socioeconomic status, and certain types of medical care use were associated with increased risk of hospitalization. The risk of hospitalization associated with some variables was high, but it was not possible to identify with precision a group where reduction in hospitalization would result in major decrease in overall hospital use by infants.

Factors associated with maternal opinion of infant development--clues to the vulnerable child?

A mother's expectations about the development of her infant have been found to be a strong determinant of child development, but little is known about the factors that may affect maternal assessment of development. In this study, the relationship of the mother's opinion of the development of her infant with several sociodemographic, antenatal, intrapartum, and infant health variables was examined for a large sample of 1-year-old infants for whom gross motor observations were also obtained at the time of the interview. Among those observed to be developing at an appropriate rate, 4.0% were perceived by their mothers as developing more slowly than the mothers considered normal; among infants developing more slowly, 28.6% were considered to be developing slowly by their mothers. In both groups the major determinants of maternal opinion of slow development concerned the infant's health: low birth weight, congenital anomalies regardless of severity, hospitalization during the first year of life, and high ambulatory care use. These results indicate that maternal perception of infant development may not reflect the infant's level, but past or present illness, and raise questions about the influence of infant health on maternal-infant interactions and the effect of such interactions on subsequent development in the child.

Structured encounter form: the impact on provider performance and recording of well-child care.

The impact of record format on provider performance and recording of the process of care and their concordance were examined in this study. The process of care was defined by existing sets of explicit criteria developed for quality assessment. The study was conducted in an urban teaching hospital pediatric primary care clinic. Housestaff were encouraged, but not required, to use the clinic's structured, age-specific forms for recording well-child care. Performance and recording were compared during required well-child visits using the structured form and those using the basic clinic form. Study data from 1031 visits to 68 housestaff during a 14-month period were collected using medical record abstracting of all visits and direct observation of 243 of them. Twenty-three of the providers were assigned randomly to an unobserved control group to assess the effect of observation on recording. Use of the structured form was associated with significantly higher levels of both recorded and observed performance. When performance could be merely checked off to document performance, overdocumentation was found. Record-based estimates of performance were more accurate during visits when the structured form was used. Record format can improve provider performance and recording of the process of care.

Subspecialization within pediatric practice: a broader spectrum.

This study was undertaken to describe subspecialty characteristics and practices of the population of pediatricians given the ongoing controversy regarding a projected manpower oversupply of general pediatricians. A questionnaire was mailed to a national random sample of 1620 United States physicians listed in the American Medical Association's Physician Masterfile as being in office-based pediatric practice. The final response rate was 63%. Seventy percent of respondents designated their practices as "general pediatrics" versus 17% as "general pediatrics with a specific subspecialty interest" and 13% as "subspecialty practice." The general pediatricians with a specific subspecialty interest were intermediate in the proportion that had some training in a pediatric fellowship program (general pediatricians with a specific subspecialty interest, 63% versus general pediatricians, 14%, P < .0001, and pediatricians with a subspecialty practice, 92%, P < .0001) and that were certified in a pediatric subspecialty by the American Board of Pediatrics (general pediatricians with a specific subspecialty interest 16% versus general pediatricians, 2%, P < .0001, and pediatricians with a subspecialty practice, 62%, P < .0001). They were also intermediate in the proportion involved in various academic pursuits. Their practices, however, more closely resembled general pediatricians than pediatricians with a subspecialty practice in their location, setting, associates, and commitment to primary care. They were more likely than general pediatricians to utilize or provide specialized tests or procedures. A large percentage of pediatricians incorporate subspecialty elements into their general pediatric practices. Models of current and projected pediatric manpower supply need to be reassessed in light of this form of practice.

Changes in infant morbidity associated with decreases in neonatal mortality.

Neonatal mortality and morbidity among infants surviving to 1 year of age in eight geographic areas have been compared to determine whether recent decreases in mortality have affected the risk of infants having congenital anomalies or developmental delay. Mortality was obtained from birth and death records in 1976 and either 1978 or 1979; morbidity through home interviews with mothers of random samples of infants and developmental observations on the children. It is concluded that the decrease in mortality was not offset by increases in children with defects. Neonatal mortality decreased by 18% in this 2- to 3-year period; risk of congenital anomalies or developmental delay (all types combined) declined by 16% among the surviving infants. The reduction in risk was concentrated in the minor congenital anomalies or developmental delay category; the proportion of children with severe or moderate congenital anomalies or developmental delay did not change. Decreases occurred at every birth weight including the very low birth weights of 1,500 g or less, a subgroup with especially high mortality and morbidity resulting from perinatal events.

Social environment and vulnerability of low birth weight children: a social-epidemiological perspective.

This study examined the impact of low birth weight on children's health and assessed the influence of the social environment on various aspects of health in low birth weight and normal birth weight children. Data on 8661 children aged 2 through 11 from the 1981 Child Health Supplement of the National Health Interview Survey provided strong evidence for two major conclusions: (1) Low birth weight children in high-risk social environments are at increased for poor health outcomes compared with comparable normal birth weight children. This vulnerability was found across all age groups, suggesting that the effects of low birth weight are long-lasting. The poor health outcomes for low birth weight children in high-risk social environments were found for all seven aspects of child health status studied: excessive bed days, restricted-activity days, and school-loss days; school failure, low school-ranking, behavior problems, and maternal perception of child health status as fair/poor. (2) The mechanism of risk was complex and differed by birth weight group. Whereas certain combinations of individual risk factors protected normal birth weight children from several adverse outcomes, none for low birth weight children were identified. However, low birth weight children in low- or moderate-risk social environments were not at greater risk for poor outcomes compared with comparable normal birth weight children. This study underscores the importance of a healthy social environment for children who are already at high risk for poor health outcomes by virtue of being low birth weight.

Validating the content of pediatric outpatient medical records by means of tape-recording doctor-patient encounters.

Information in 51 tape-recorded physician-patient encounters was compared with information written in the patients' medical records. Diagnoses, chief complaints, scheduled appointments, non-drug therapy, and diagnostic studies were uniformly well-recorded. Medication names were well-recorded but dosages were not. Characteristics of care such as levels of function, probable cause of illness, reason for follow-up, and compliance were recorded poorly. Patients were more likely to known about and understand their diagnosis, and names, dosage, and intended function of their medications when this information was written in the record than when it was not. These findings indicate a relationship between the quality of medical records and the effectiveness of care.

Who provides health care to children and adolescents in the United States?

Face-to-face visits by children and adolescents in office-based practice in the mid-1970s were studied. Pediatricians, family physicians, and general practitioners accounted for 35%, 6%, and 30%, respectively, of all child visits. Although 40% to 45% of preventive and medical encounters were with pediatricians, only 12% of visits for minor surgery, 20% of visits for psychosocial problems, and 9% of visits for combined medical-surgical reasons were to pediatricians. Only in very young children did pediatricians provide a substantial proportion of care for each of the types of visits. For some common diagnoses (acne, refractive error) most care was provided by specialists other than primary care specialists, but less than 16% of all preventive care visits (including routine eye examinations) was provided by specialists other than primary care physicians. A substantial proportion of the prenatal care and management of minor trauma was provided by family physicians and general practitioners. Although the limitations of the study (including an average response rate of 55%, exclusion of certain specialties and institutional physicians, sampling at different times of the year, lack of control for area of location of practice, and lack of information about response rates of different types of physicians within each specialty) preclude definitive conclusions, the findings raise important questions for future study.

Variations in utilization of health services by children.

In this longitudinal study in two prepaid group practices, many more children stayed at the same level of use of services over a six- to ten-year period than would be expected if use of services had distributed randomly. Overall, about 13% remained consistently in the highest third of the distribution of use, and another 13% remained consistently in the middle or lowest third. If use of services had distributed randomly, 4% and 7%, respectively, would have been in these groups. Conversely, many fewer children (25%) showed fluctuating patterns of use over time than would be expected by chance alone (37%). Although the reasons for this phenomenon are unknown (and may be multiple), the findings have implications both for clinical care and for development of policy regarding the organization and financing of health services for children.

Utilization and morbidity: random or tandem?

Earlier studies have shown that one in eight children persist in being high users of health care services over long periods of time and, conversely, about the same proportion of children are consistently low users. As these studies failed to discover reasons for these persistent deviations from average, this study explored three possible explanations: persistent morbidity, mental health problem, and familial patterns of use. Although all three phenomena were associated with both persistence of high utilization of services as well as an overall large number of visits, the number of types of morbidity was the most significant correlate of high use. Children who were constantly low users of services were much more likely to have only a few types of morbidity whereas children who were constantly high users were much more likely to experience a wide variety of types of problems. These findings suggest that an understanding of the demand for health services requires an understanding of the interrelationships of illnesses within individuals rather than a focus on particular illnesses or particular types of illnesses.

Gatekeeping and referral of children and adolescents to specialty care.

OBJECTIVE: In this study we examined how gatekeeping arrangements influence referrals to specialty care for children and adolescents in private and Medicaid insurance plans. DESIGN/PARTICIPANTS: We conducted a prospective study of office visits (n = 27 104) made to 142 pediatricians in 94 practices distributed throughout 36 states in a national primary care practice-based research network. During 10 practice-days, physicians and patients completed questionnaires on referred patients, while office staff kept logs of all visits. Physicians used medical records to complete questionnaires for a subset of patients 3 months after their referral was made. RESULTS: Gatekeeping arrangements were common among children and adolescents with private (57.8%) and Medicaid (43.3%) insurance. Patients in gatekeeping plans were more likely to be referred with private (3. 16% vs 1.85% visits referred) and Medicaid (5.39% vs 3.73%) financing. Increased parental requests for specialty care among gatekeeping patients did not explain the increased referral rate. Physicians' reasons for making the referral were similar between the two groups. Physicians were less likely to schedule an appointment or communicate with the specialist for referred patients in gatekeeping plans. However, rates of physician awareness that a specialist visit occurred and specialist communication back to pediatricians did not differ between the two groups 3 months after the referrals were made. CONCLUSIONS: Gatekeeping arrangements are common among insured children and adolescents in the United States. Our study suggests that gatekeeping arrangements increase referrals from pediatricians' offices to specialty care and compromise some aspects of coordination.

The health profile of incarcerated male youths.

OBJECTIVE: To identify the health needs of adolescent males incarcerated in a juvenile justice facility and to compare their health profiles with those of male adolescents in the community. METHODS: Cross-sectional surveys were conducted of incarcerated (N = 202) and school (N = 379) samples of male youths. Questionnaires were self-administered and completed before admission health screens (incarcerated youth) or in classrooms (school sample). Health status was assessed by the Child Health and Illness Profile, Adolescent Edition, using scale and item means and by categorizing each youth's pattern of health into 1 of 13 mutually exclusive health profile types. RESULTS: Compared with school counterparts, incarcerated male youths had significantly worse health status as demonstrated by poorer health and functioning scores in perceived well being, self-esteem, physical discomfort, acute, chronic, and psychosocial disorders, family involvement, physical activity, interpersonal problem-solving, risk behaviors, and academic performance. Three profile types-High Risks, High Risks/Low Resilience, and Worst Health-accounted for patterns of health for 69.8% of incarcerated youth versus 37.3% of an age-matched school sample. Just 6.4% of incarcerated males were in the Excellent/Good Health profile types, which contrasted with 34.2% of the age-matched school sample. CONCLUSIONS: The health profiles of incarcerated male youths were worse than those of male youths in school. Our results indicate that rehabilitation programs will need to address incarcerated youth's basic health needs as well as modifying their risk and antisocial behaviors.

Psychosocial and psychosomatic diagnoses in primary care of children.

In this study in seven primary care facilities the proportion of children recognized as having behavioral, educational, or social problems was much higher than generally assumed. Although there was great variability among the facilities, at least 5% and as many as 15% of children seen in one year were diagnosed as having these problems in all but the hospital teaching facilities. The prevalence was even higher among children from poor families. The variability among facilities was much less for psychosomatic problems, which were diagnosed in 8% to 10% of the children. For both psychosocial and psychosomatic types of problems, but especially for psychosocial ones, the proportion of visits with the diagnoses was much lower than the proportion of children with them, so that these problems engendered fewer visits for their management than might have been expected from their frequency in the population. However, available evidence suggests that individuals with unresolved psychosocial problems make more than their share of visits for other diagnoses. The findings of this study have implications for the content of educational programs for primary care practitioners, for the organization of primary care practice, and for the current debate over policy concerning reimbursement and benefit packages.

Measuring consumer experiences with primary care.

OBJECTIVE: To assess the adequacy of the Primary Care Assessment Tool-Child Edition (PCAT-CE) for evaluating the attainment of the key characteristics of primary care services for children and youth. DESIGN: Community-based telephone survey. SETTING: Specific political subdivision in Washington, DC. PARTICIPANTS: Four hundred fifty parents/guardians of offspring 18 years of age or less. MEASURES: Reliability, validity and principal component analysis of 5 scales representing key aspects of the 4 cardinal domains of primary care included in the PCAT-CE. In addition, 2 subdomains (first contact use and extent of affiliation with a primary care source) were included as indices to describe overall patterns of use and affiliation with the particular source of care. RESULTS: Most scales had adequate internal consistency, test-retest reliability, and construct validity. The principal components factor analysis yielded 5 separate factors. These corresponded to the subdomains of first contact accessibility; coordination of care; characteristics of the professional-patient relationship over-time; and comprehensiveness (both services available and indicated services received). CONCLUSIONS: Psychometric assessment supported the integrity and general adequacy of the PCAT-CE for assessing the characteristics and quality of primary care for children and youth. Testing of revised versions in a variety of different settings is underway. A major component of this testing is to explore the possibility of reducing the number of items while retaining sufficient detail about each component of primary care to make judgements about people's experiences with that care.

Adolescent health status measurement: development of the Child Health and Illness Profile.

This report describes the early stages in the development and testing of an instrument, known as the CHIP (Child Health and Illness Profile), for assessing the health of individuals aged 11 through 17. The purpose of the instrument is to assess health in epidemiologic surveys, to determine the existence of systematic differences in health in subpopulations (including the socioeconomically disadvantaged), and to provide a basis for assessing the impact of changes in health services or health policies. An instrument consisting of six domains with 25 subdomains was developed based on the literature, the involvement of focus groups and expert panels, and pretesting in four groups of teenagers known to differ in their health. The results of work with panels of experts suggest that the instrument has content validity. Most domains and subdomains had acceptable reliability as measured by alpha coefficients. Differences in the scores of individuals in the four groups were in the predicted directions, suggesting that the instrument also has construct validity. Additional research is under way to establish other aspects of validity as well as reliability in school populations of adolescents as well as specific clinical settings.