RESUMO
To identify predictors of coverage continuity for United States children and assess how they have changed in the first 12 years since implementation of the Children's Health Insurance Program in 1997. Using data from the nationally-representative Medical Expenditure Panel Survey, we used logistic regression to identify predictors of discontinuity in 1998 and 2009 and compared differences between the 2 years. Having parents without continuous coverage was the greatest predictor of a child's coverage gap in both 1998 and 2009. Compared to children with at least one parent continuously covered, children whose parents did not have continuous coverage had a significantly higher relative risk (RR) of a coverage gap [RR 17.96, 95 % confidence interval (CI) 14.48-22.29 in 1998; RR 12.88, 95 % CI 10.41-15.93 in 2009]. In adjusted models, parental continuous coverage was the only significant predictor of discontinuous coverage for children (with one exception in 2009). The magnitude of the pattern was higher for privately-insured children [adjusted relative risk (aRR) 29.17, 95 % CI 20.99-40.53 in 1998; aRR 25.54, 95 % CI 19.41-33.61 in 2009] than publicly-insured children (aRR 5.72, 95 % CI 4.06-8.06 in 1998; aRR 4.53, 95 % CI 3.40-6.04 in 2009). Parental coverage continuity has a major influence on children's coverage continuity; this association remained even after public health insurance expansions for children. The Affordable Care Act will increase coverage for many adults; however, 'churning' on and off programs due to income fluctuations could result in coverage discontinuities for parents. If parental coverage instability persists, these discontinuities may continue to have a negative impact on children's coverage stability as well.
Assuntos
Children's Health Insurance Program/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Adolescente , Adulto , Fatores Etários , Criança , Pré-Escolar , Humanos , Renda/estatística & dados numéricos , Lactente , Recém-Nascido , Pais , Risco , Estados Unidos/epidemiologiaRESUMO
In the past decade, political and economic changes in the United States (US) have affected health insurance coverage for children and their parents. Most likely these policies have differentially affected coverage patterns for children (versus parents) and for low-income (versus high-income) families. We aimed to examine--qualitatively and quantitatively--the impact of changing health insurance coverage on US families. Primary data from interviews with Oregon families (2008-2010) were analyzed using an iterative process. Qualitative findings guided quantitative analyses of secondary data from the nationally-representative Medical Expenditure Panel Survey (MEPS) (1998-2009); we used Joinpoint Regression to assess average annual percent changes (AAPC) in health insurance trends, examining child and parent status and type of coverage stratified by income. Interviewees reported that although children gained coverage, parents lost coverage. MEPS analyses confirmed this trend; the percentage of children uninsured all year decreased from 9.6 % in 1998 to 6.1 % in 2009; AAPC = -3.1 % (95 % confidence interval [CI] from -5.1 to -1.0), while the percentage of parents uninsured all year rose from 13.6 % in 1998 to 17.1 % in 2009, AAPC = 2.7 % (95 % CI 1.8-3.7). Low-income families experienced the most significant changes in coverage. Between 1998 and 2009, as US children gained health insurance, their parents lost coverage. Children's health is adversely affected when parents are uninsured. Investigation beyond children's coverage rates is needed to understand how health insurance policies and changing health insurance coverage trends are impacting children's health.
Assuntos
Gastos em Saúde , Disparidades em Assistência à Saúde , Cobertura do Seguro/tendências , Seguro Saúde/tendências , Adulto , Criança , Serviços de Saúde da Criança/economia , Serviços de Saúde da Criança/estatística & dados numéricos , Pré-Escolar , Intervalos de Confiança , Estudos Transversais , Bases de Dados Factuais , Feminino , Reforma dos Serviços de Saúde , Humanos , Cobertura do Seguro/economia , Seguro Saúde/economia , Entrevistas como Assunto , Masculino , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Programas Nacionais de Saúde/organização & administração , Avaliação das Necessidades , Oregon , Relações Pais-Filho , Pais , Fatores Socioeconômicos , Estados UnidosRESUMO
Despite the promise of expanded health insurance coverage for children in the United States, a usual source of care (USC) may have a bigger impact on a child's receipt of preventive health counseling. We examined the effects of insurance versus USC on receipt of education and counseling regarding prevention of childhood injuries and disease. We conducted secondary analyses of 2002-2006 data from a nationally-representative sample of child participants (≤17 years) in the Medical Expenditure Panel Survey (n = 49,947). Children with both insurance and a USC had the lowest rates of missed counseling, and children with neither one had the highest rates. Children with only insurance were more likely than those with only a USC to have never received preventive health counseling from a health care provider regarding healthy eating (aRR 1.21, 95% CI 1.12-1.31); regular exercise (aRR 1.06, 95% CI 1.01-1.12), use of car safety devices (aRR 1.10, 95% CI 1.03-1.17), use of bicycle helmets (aRR 1.11, 95% CI 1.05-1.18), and risks of second hand smoke exposure (aRR 1.12, 95% CI 1.04-1.20). A USC may play an equally or more important role than insurance in improving access to health education and counseling for children. To better meet preventive counseling needs of children, a robust primary care workforce and improved delivery of care in medical homes must accompany expansions in insurance coverage.
Assuntos
Serviços de Saúde da Criança/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Seguro Saúde , Serviços Preventivos de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Adolescente , Criança , Serviços de Saúde da Criança/economia , Pré-Escolar , Aconselhamento , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Lactente , Cobertura do Seguro , Masculino , Análise Multivariada , Pais , Serviços Preventivos de Saúde/economia , Atenção Primária à Saúde/economia , Fatores Socioeconômicos , Estados UnidosRESUMO
BACKGROUND: Many states have expanded public health insurance programs for children, and further expansions were proposed in recent national reform initiatives; yet the expansion of public insurance plans and the inclusion of a public option in state insurance exchange programs sparked controversies and raised new questions with regard to the quality and adequacy of various insurance types. OBJECTIVES: We aimed to examine the comparative effectiveness of public versus private coverage on parental-reported children's access to health care in low-income and middle-income families. METHODS/PARTICIPANTS/MEASURES: We conducted secondary data analyses of the nationally representative Medical Expenditure Panel Survey, pooling years 2002 to 2006. We assessed univariate and multivariate associations between child's full-year insurance type and parental-reported unmet health care and preventive counseling needs among children in low-income (n=28,338) and middle-income families (n=13,160). RESULTS: Among children in families earning <200% of the federal poverty level, those with public insurance were significantly less likely to have no usual source of care compared with privately insured children (adjusted relative risk, 0.79; 95% confidence interval, 0.63-0.99). This was the only significant difference in 50 logistic regression models comparing unmet health care and preventive counseling needs among low-income and middle-income children with public versus private coverage. CONCLUSIONS: The striking similarities in reported rates of unmet needs among children with public versus private coverage in both low-income and middle-income groups suggest that a public children's insurance option may be equivalent to a private option in guaranteeing access to necessary health care services for all children.
Assuntos
Acessibilidade aos Serviços de Saúde , Cobertura do Seguro , National Health Insurance, United States , Setor Privado , Qualidade da Assistência à Saúde , Adolescente , Criança , Pré-Escolar , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Análise Multivariada , Risco , Fatores Socioeconômicos , Estados UnidosRESUMO
BACKGROUND: In 2010, the United States (US) passed health insurance reforms aimed at expanding coverage to the uninsured. Yet, disparities persist in access to health care services, even among the insured. OBJECTIVE: To examine the separate and combined association between having health insurance and/or a usual source of care (USC) and self-reported receipt of health care services. DESIGN/SETTING: Two-tailed, chi-square analyses and logistic regression models were used to analyze nationally representative pooled 2002-2007 data from the Medical Expenditure Panel Survey (MEPS). PARTICIPANTS: US adults (≥18 years of age) in the MEPS population who had at least one health care visit and who needed any care, tests, or treatment in the past year (n = 62,067). MAIN OUTCOME MEASURES: We assessed the likelihood of an adult reporting unmet medical needs; unmet prescription needs; a problem getting care, tests, or treatment; and delayed care based on whether each individual had health insurance, a USC, both, or neither one. KEY RESULTS: Among adults who reported a doctor visit and a need for services in the past year, having both health insurance and a USC was associated with the lowest percentage of unmet medical needs, problems and delays in getting care while having neither one was associated with the highest unmet medical needs, problems and delays in care. After adjusting for potentially confounding covariates (age, race, ethnicity, employment, geographic residence, education, household income as a percent of federal poverty level, health status, and marital status), compared with insured adults who also had a USC, insured adults without a USC were more likely to have problems getting care, tests or treatment (adjusted relative risk [aRR] 1.27; 95% confidence interval [CI] 1.18-1.37); and also had a higher likelihood of experiencing a delay in urgent care (aRR 1.12; 95% CI 1.05-1.20). CONCLUSIONS: Amidst ongoing health care reform, these findings suggest the important role that both health insurance coverage and a usual source of care may play in facilitating individuals' access to care.
Assuntos
Atenção à Saúde/métodos , Reforma dos Serviços de Saúde/tendências , Cobertura do Seguro/tendências , Seguro Saúde/tendências , Adolescente , Adulto , Idoso , Estudos Transversais/métodos , Atenção à Saúde/economia , Atenção à Saúde/tendências , Feminino , Reforma dos Serviços de Saúde/economia , Humanos , Cobertura do Seguro/economia , Seguro Saúde/economia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
PURPOSE In the United States, children who have a usual source of care (USC) have better access to health care than those who do not, but little is known about how parental USC affects children's access. We examined the association between child and parent USC patterns and children's access to health care services. METHODS We undertook a secondary analysis of nationally representative, cross-sectional data from children participating in the 2002-2007 Medical Expenditure Panel Survey (n = 56,302). We assessed 10 outcome measures: insurance coverage gaps, no doctor visits in the past year, less than yearly dental visits, unmet medical and prescription needs, delayed care, problems getting care, and unmet preventive counseling needs regarding healthy eating, regular exercise, car safety devices, and bicycle helmets. RESULTS Among children, 78.6% had a USC and at least 1 parent with a USC, whereas 12.4% had a USC but no parent USC. Children with a USC but no parent USC had a higher likelihood of several unmet needs, including an insurance coverage gap (adjusted risk ratio [aRR] 1.33; 95% confidence interval [CI], 1.21-1.47), an unmet medical or prescription need (aRR 1.70; 95% CI 1.09-2.65), and no yearly dental visits (aRR 1.12; 95% CI 1.06-1.18), compared with children with a USC whose parent(s) had a USC. CONCLUSIONS Among children with a USC, having no parent USC was associated with a higher likelihood of reporting unmet needs when compared with children whose parent(s) had a USC. Policy reforms should ensure access to a USC for all family members.
Assuntos
Serviços de Saúde da Criança/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Cobertura do Seguro , Pais , Atenção Primária à Saúde/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Estudos Transversais , Serviços de Saúde Bucal/estatística & dados numéricos , Pesquisa sobre Serviços de Saúde , Humanos , Lactente , Seguro Saúde/estatística & dados numéricos , Prescrições/estatística & dados numéricos , Estados UnidosRESUMO
This study of 632 drug injectors enrolled in eight residential detoxification centers within the National Drug Abuse Treatment Clinical Trials Network tested three interventions to reduce drug and sex risk behaviors. Participants were randomized to: (a) a two-session, HIV/HCV counseling and education (C&E) model added to treatment as usual (TAU), (b) a one-session, therapeutic alliance (TA) intervention conducted by outpatient counselors to facilitate treatment entry plus TAU, or (c) TAU. Significant reductions in drug and sex risk behaviors occurred for all three conditions over a 6-month follow-up period. C&E participants reported significantly greater rates of attending an HIV testing appointment, but this was not associated with better risk reduction outcomes. Reporting treatment participation within 2 months after detoxification and self-efficacy to practice safer injection behavior predicted reductions in injection risk behaviors. Findings indicate that participation in detoxification was followed by significant decreases in drug injection and risk behaviors for up to 6-months; interventions added to standard treatment offered no improvement in risk behavior outcomes.
Assuntos
Aconselhamento , Usuários de Drogas , Infecções por HIV/prevenção & controle , Comportamento de Redução do Risco , Comportamento Sexual , Abuso de Substâncias por Via Intravenosa/reabilitação , Adulto , Usuários de Drogas/educação , Usuários de Drogas/psicologia , Feminino , Infecções por HIV/complicações , Infecções por HIV/psicologia , Humanos , Inativação Metabólica , Tempo de Internação , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Assunção de Riscos , Distribuição por Sexo , Centros de Tratamento de Abuso de Substâncias/estatística & dados numéricos , Abuso de Substâncias por Via Intravenosa/complicações , Abuso de Substâncias por Via Intravenosa/psicologia , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
Millions of US children have unstable health insurance coverage. Some of these uninsured children have parents with stable coverage. We examined whether household income was associated with longer coverage gaps among US children with at least one insured parent. A secondary data analysis of the nationally-representative 2004 Medical Expenditure Panel Survey, this study uses logistic regression models to examine the association between income and children's insurance gaps. We focused on children with at least one parent insured all year (n = 6,151; estimated weighted N = 53.5 million). In multivariate models, children from families earning between 125 and 400% of the federal poverty level (FPL) had twice the odds of experiencing coverage gaps >6 months, as compared to those from high income families. Children in the poorest income groups (<125% FPL) did not have significantly greater odds of a gap >6 months. However, the odds of a gap ≤6 months were significantly greater for all income groups below 400% FPL, when compared to the highest income group. Among children with continuously insured parents, those from lower middle income families were most vulnerable to experiencing coverage gaps >6 months, as compared to those from the lowest and highest income families. These findings are likely due to middle class earnings being too high to qualify for public insurance but not high enough to afford private coverage. This study highlights the need for new US health care financing models that give everyone in the family the best chance to obtain stable coverage. It also provides valuable information to other countries with employer-sponsored insurance models or those considering privatization of insurance payment systems and how this might disproportionately impact the middle class.
Assuntos
Serviços de Saúde da Criança/estatística & dados numéricos , Política de Saúde , Disparidades em Assistência à Saúde/estatística & dados numéricos , Renda , Seguro Saúde/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Adolescente , Criança , Serviços de Saúde da Criança/economia , Pré-Escolar , Definição da Elegibilidade , Características da Família , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Análise Multivariada , Pais , Pobreza , Estados UnidosRESUMO
The National Drug Abuse Treatment Clinical Trials Network (CTN) is an alliance of drug abuse treatment programs and research centers testing new interventions and implementation factors for treating alcohol and drug use disorders. A workforce survey distributed to those providing direct services in 295 treatment units in the CTN obtained responses from 1750 individuals with a job title of counselor (n = 1395) or counselor supervisor (n = 355). A secondary analysis compares and describes both groups. Supervisors were more likely to be licensed or certified. Master's degrees were more common among counselors in outpatient and methadone programs. Counselors in residential settings tended to be on the job fewer years. Finally, higher education was associated with greater familiarity with and acceptance of evidence-based practices.
Assuntos
Atitude do Pessoal de Saúde , Certificação/estatística & dados numéricos , Aconselhamento/estatística & dados numéricos , Escolaridade , Licenciamento/estatística & dados numéricos , Centros de Tratamento de Abuso de Substâncias/estatística & dados numéricos , Centros de Tratamento de Abuso de Substâncias/normas , Coleta de Dados/estatística & dados numéricos , Prática Clínica Baseada em Evidências , Feminino , Humanos , Masculino , Estados UnidosRESUMO
INTRODUCTION: Patients with multiple chronic conditions (multimorbidity) are seen commonly in primary care practices and often have suboptimal uptake of preventive care owing to competing treatment demands. The complexity of multimorbidity patterns and their impact on receiving preventive services is not fully understood. This study identifies multimorbidity combinations associated with low receipt of preventive services. METHODS: This was a retrospective cohort study of U.S. community health center patients aged ≥19 years. Electronic health record data from 209 community health centers for the January 1, 2014-December 31, 2017 study period were analyzed in 2018-2019. Multimorbidity patterns included physical only, mental health only, and physical and mental health multimorbidity patterns, with no multimorbidity as a reference category. Electronic health record-based preventive ratios (number of months services were up-to-date/total months the patient was eligible for services) were calculated for the 14 preventive services. Negative binomial regression models assessed the relationship between multimorbidity physical and/or mental health patterns and the preventive ratio for each service. RESULTS: There was a variation in receipt of preventive care between multimorbidity groups: individuals with mental health only multimorbidity were less likely to be up-to-date with cardiometabolic and cancer screenings than the no multimorbidity group or groups with physical health conditions, and the physical only multimorbidity group had low rates of depression screening. CONCLUSIONS: This study provided critical insights into receipt of preventive service among adults with multimorbidity using a more precise method for measuring up-to-date preventive care delivery. Findings would be useful to identify target populations for future intervention programs to improve preventive care.
Assuntos
Multimorbidade , Serviços Preventivos de Saúde , Adulto , Doença Crônica , Serviços de Saúde , Humanos , Atenção Primária à Saúde , Estudos RetrospectivosRESUMO
Folate deficiency has been implicated in the carcinogenesis of several tumor types. The role of folate in prostate cancer remains indeterminate. We investigated folate as a risk factor for prostate cancer among 140 biopsy-confirmed prostate cancer patients, 230 age-matched clinic controls, and 250 negative prostate biopsy controls. Dietary folate intake was inversely associated with overall risk of prostate cancer as compared to clinic controls (P for a linear trend = 0.003). When stratified by disease severity, dietary folate and folate from natural sources were associated with reduced risk of high-grade cancer as compared to both clinic controls (P for a linear trend = 0.0009 and 0.02, respectively) and biopsy negative controls (P for a linear trend = 0.03 and 0.05, respectively). There was no interaction between alcohol consumption and folate intake. These analyses support an inverse association between dietary folate intake and prostate cancer risk and primarily risk of high-grade prostate cancer.
Assuntos
Dieta , Ácido Fólico/administração & dosagem , Neoplasias da Próstata/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Consumo de Bebidas Alcoólicas , Biópsia , Índice de Massa Corporal , Estudos de Casos e Controles , Intervalos de Confiança , Inquéritos sobre Dietas , Ácido Fólico/classificação , Humanos , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Razão de Chances , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/patologia , Fatores de Risco , Estados Unidos/epidemiologia , Veteranos/estatística & dados numéricosRESUMO
PURPOSE: Insured children in the United States have better access to health care services; less is known about how parental coverage affects children's access to care. We examined the association between parent-child health insurance coverage patterns and children's access to health care and preventive counseling services. METHODS: We conducted secondary analyses of nationally representative, cross-sectional, pooled 2002-2006 data from children (n = 43,509), aged 2 to 17 years, in households responding to the Medical Expenditure Panel Survey (MEPS). We assessed 9 outcome measures pertaining to children's unmet health care and preventive counseling needs. RESULTS: Cross-sectionally, among US children (aged 2 to 17 years) living with at least 1 parent, 73.6% were insured with insured parents, 8.0% were uninsured with uninsured parents, and the remaining 18.4% had discordant family insurance coverage patterns. In multivariable analyses, insured children with uninsured parents had higher odds of an insurance coverage gap (odds ratio [OR] = 2.45; 95% confidence interval [CI], 2.02-2.97), no usual source of care (OR = 1.31; 95% CI, 1.10-1.56), unmet health care needs (OR = 1.11; 95% CI, 1.01-1.22), and having never received at least 1 preventive counseling service (OR = 1.20; 95% CI, 1.04-1.39) when compared with insured children with insured parents. Insured children with mixed parental insurance coverage had similar vulnerabilities. CONCLUSIONS: Uninsured children had the highest rates of unmet needs overall, with fewer differences based on parental insurance status. For insured children, having uninsured parents was associated with higher odds of going without necessary services when compared with having insured parents.
Assuntos
Família , Acessibilidade aos Serviços de Saúde/economia , Cobertura do Seguro , Seguro Saúde , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Aconselhamento/estatística & dados numéricos , Estudos Transversais , Pesquisas sobre Atenção à Saúde , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/economia , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , Estados UnidosRESUMO
INTRODUCTION: There is an increasing need for the development of new methods to understand factors affecting delivery of preventive care. This study applies a new measurement approach and assesses clinic-level factors associated with preventive care delivery. METHODS: This retrospective longitudinal cohort study of 94 community health centers used electronic health record data from the OCHIN community health information network, 2014-2015. Clinic-level preventive ratios (time covered by a preventive service/time eligible for a preventive service) were calculated in 2017 for 12 preventive services with A or B recommendations from the U.S. Preventive Services Task Force along with an aggregate preventive index for all services combined. For each service, multivariable negative binomial regression modeling and calculated rate ratios assessed the association between clinic-level variables and delivery of care. RESULTS: Of ambulatory community health center visits, 59.8% were Medicaid-insured and 10.4% were uninsured. Ambulatory community health centers served 16.9% patients who were Hispanic, 13.1% who were nonwhite, and 68.7% who had household incomes <138% of the federal poverty line. Clinic-level preventive ratios ranged from 3% (hepatitis C screening) to 93% (blood pressure screening). The aggregate preventive index including all screening measures was 47% (IQR, 42%-50%). At the clinic level, having a higher percentage of uninsured visits was associated with lower preventive ratios for most (7 of 12) preventive services. CONCLUSIONS: Approaches that use individual preventive ratios and aggregate prevention indices are promising for understanding and improving preventive service delivery over time. Health insurance remains strongly associated with access to needed preventive care, even for safety net clinic populations.
Assuntos
Centros Comunitários de Saúde/estatística & dados numéricos , Atenção à Saúde/estatística & dados numéricos , Pobreza , Serviços Preventivos de Saúde/estatística & dados numéricos , Adulto , Registros Eletrônicos de Saúde/estatística & dados numéricos , Feminino , Humanos , Estudos Longitudinais , Masculino , Medicaid/estatística & dados numéricos , Pessoas sem Cobertura de Seguro de Saúde/estatística & dados numéricos , Modelos Estatísticos , Estudos Retrospectivos , Estados UnidosRESUMO
PURPOSE: Implausible anthropometric measures are typically identified using population outlier definitions, conflating implausible and extreme measures. We determined the impact of a longitudinal outlier approach on prevalence of body mass index (BMI) categories and mean change in anthropometric measures in pediatric electronic health record data. METHODS: We examined 996,131 observations from 147,375 children (10-18 years) in the ADVANCE Clinical Data Research Network, a national network of community health centers. Sex-stratified, mixed effects, linear spline regression modeled weight, height, and BMI as a function of age. Longitudinal outliers were defined as observations with studentized residual greater than |6|; population outliers were defined by Centers for Disease Control-defined z-score thresholds. RESULTS: At least 99.7% of anthropometric measures were not extreme by longitudinal or population definitions (agreement ≥ 0.995). BMI category prevalence after excluding longitudinal or population outliers differed by less than 0.1%. Among children greater than 85th percentile at baseline, annual mean changes in anthropometric measures were larger in data that excluded longitudinal (girls: 1.24 inches, 12.39 pounds, 1.53 kg/m2; boys: 2.34, 14.08, 1.07) versus population outliers (girls: 0.61 inches, 8.22 pounds, 0.75 kg/m2; boys: 1.53, 11.61, 0.48). CONCLUSIONS: Longitudinal outlier methods may reduce underestimation of anthropometric change in children with elevated baseline values.
Assuntos
Obesidade Infantil/epidemiologia , Adolescente , Estatura , Índice de Massa Corporal , Peso Corporal , Criança , Feminino , Humanos , Masculino , Obesidade Infantil/diagnóstico , Prevalência , Valores de Referência , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: To examine trends in health insurance type among US children and their parents. METHODS: Using the Medical Expenditure Panel Survey (1998-2011), we linked each child (n = 120,521; weighted n ≈ 70 million) with his or her parent or parents and assessed patterns of full-year health insurance type, stratified by income. We examined longitudinal insurance trends using joinpoint regression and further explored these trends with adjusted regression models. RESULTS: When comparing 1998 to 2011, the percentage of low-income families with both child and parent or parents privately insured decreased from 29.2% to 19.1%, with an estimated decline of -0.86 (95% confidence interval, -1.10, -0.63) unadjusted percentage points per year; middle-income families experienced a drop from 74.5% to 66.3%, a yearly unadjusted percentage point decrease of -0.73 (95% confidence interval, -0.98, -0.48). The discordant pattern of publicly insured children with uninsured parents increased from 10.4% to 27.2% among low-income families and from 1.4% to 6.7% among middle-income families. Results from adjusted models were similar to joinpoint regression findings. CONCLUSIONS: During the past decade, low- and middle-income US families experienced a decrease in the percentage of child-parent pairs with private health insurance and pairs without insurance. Concurrently, there was a rise in discordant coverage patterns-mainly publicly insured children with uninsured parents.
Assuntos
Acessibilidade aos Serviços de Saúde/tendências , Cobertura do Seguro/tendências , Seguro Saúde/tendências , Pessoas sem Cobertura de Seguro de Saúde , Pais , Adolescente , Adulto , Criança , Pré-Escolar , Children's Health Insurance Program/tendências , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Pobreza , Estados Unidos , Adulto JovemRESUMO
IMPORTANCE: In the United States, health insurance is not universal. Observational studies show an association between uninsured parents and children. This association persisted even after expansions in child-only public health insurance. Oregon's randomized Medicaid expansion for adults, known as the Oregon Experiment, created a rare opportunity to assess causality between parent and child coverage. OBJECTIVE: To estimate the effect on a child's health insurance coverage status when (1) a parent randomly gains access to health insurance and (2) a parent obtains coverage. DESIGN, SETTING, AND PARTICIPANTS: Oregon Experiment randomized natural experiment assessing the results of Oregon's 2008 Medicaid expansion. We used generalized estimating equation models to examine the longitudinal effect of a parent randomly selected to apply for Medicaid on their child's Medicaid or Children's Health Insurance Program (CHIP) coverage (intent-to-treat analyses). We used per-protocol analyses to understand the impact on children's coverage when a parent was randomly selected to apply for and obtained Medicaid. Participants included 14409 children aged 2 to 18 years whose parents participated in the Oregon Experiment. EXPOSURES: For intent-to-treat analyses, the date a parent was selected to apply for Medicaid was considered the date the child was exposed to the intervention. In per-protocol analyses, exposure was defined as whether a selected parent obtained Medicaid. MAIN OUTCOMES AND MEASURES: Children's Medicaid or CHIP coverage, assessed monthly and in 6-month intervals relative to their parent's selection date. RESULTS: In the immediate period after selection, children whose parents were selected to apply significantly increased from 3830 (61.4%) to 4152 (66.6%) compared with a nonsignificant change from 5049 (61.8%) to 5044 (61.7%) for children whose parents were not selected to apply. Children whose parents were randomly selected to apply for Medicaid had 18% higher odds of being covered in the first 6 months after parent's selection compared with children whose parents were not selected (adjusted odds ratio [AOR]=1.18; 95% CI, 1.10-1.27). The effect remained significant during months 7 to 12 (AOR=1.11; 95% CI, 1.03-1.19); months 13 to 18 showed a positive but not significant effect (AOR=1.07; 95% CI, 0.99-1.14). Children whose parents were selected and obtained coverage had more than double the odds of having coverage compared with children whose parents were not selected and did not gain coverage (AOR=2.37; 95% CI, 2.14-2.64). CONCLUSIONS AND RELEVANCE: Children's odds of having Medicaid or CHIP coverage increased when their parents were randomly selected to apply for Medicaid. Children whose parents were selected and subsequently obtained coverage benefited most. This study demonstrates a causal link between parents' access to Medicaid coverage and their children's coverage.
Assuntos
Seguro Saúde/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Pais , Adolescente , Adulto , Criança , Proteção da Criança/economia , Pré-Escolar , Feminino , Acessibilidade aos Serviços de Saúde/economia , Humanos , Cobertura do Seguro/estatística & dados numéricos , Masculino , Oregon , Distribuição Aleatória , Fatores Socioeconômicos , Estados UnidosRESUMO
OBJECTIVE: To evaluate selected Children's Health Insurance Program Reauthorization Act claims-based quality measures using claims data alone, electronic health record (EHR) data alone, and both data sources combined. METHODS: Our population included pediatric patients from 46 clinics in the OCHIN network of community health centers, who were continuously enrolled in Oregon's public health insurance program during 2010. Within this population, we calculated selected pediatric care quality measures according to the Children's Health Insurance Program Reauthorization Act technical specifications within administrative claims. We then calculated these measures in the same cohort, by using EHR data, by using the technical specifications plus clinical data previously shown to enhance capture of a given measure. We used the k statistic to determine agreement in measurement when using claims versus EHR data. Finally, we measured quality of care delivered to the study population, when using a combined dataset of linked, patient-level administrative claims and EHR data. RESULTS: When using administrative claims data, 1.0% of children (aged 3-17) had a BMI percentile recorded, compared with 71.9% based on the EHR data (k agreement [k] # 0.01), and 72.0% in the combined dataset. Among children turning 2 in 2010, 20.2% received all recommended immunizations according to the administrative claims data, 17.2% according to the EHR data (k = 0.82), and 21.4% according to the combined dataset. CONCLUSIONS: Children's care quality measures may not be accurate when assessed using only administrative claims. Adding EHR data to administrative claims data may yield more complete measurement.
Assuntos
Registros Eletrônicos de Saúde/estatística & dados numéricos , Registros Eletrônicos de Saúde/normas , Revisão da Utilização de Seguros/estatística & dados numéricos , Revisão da Utilização de Seguros/normas , Seguro Saúde/estatística & dados numéricos , Seguro Saúde/normas , Pediatria/estatística & dados numéricos , Pediatria/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Qualidade da Assistência à Saúde/estatística & dados numéricos , Qualidade da Assistência à Saúde/normas , Projetos de Pesquisa/estatística & dados numéricos , Projetos de Pesquisa/normas , Planos Governamentais de Saúde/estatística & dados numéricos , Planos Governamentais de Saúde/normas , Adolescente , Índice de Massa Corporal , Criança , Estudos de Coortes , Interpretação Estatística de Dados , Feminino , Humanos , Masculino , Medicaid/normas , Medicaid/estatística & dados numéricos , Oregon , Avaliação de Resultados em Cuidados de Saúde/normas , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Reprodutibilidade dos Testes , Estados Unidos , Vacinação/normas , Vacinação/estatística & dados numéricosRESUMO
STUDY DESIGN: Cross-sectional analysis of electronic medical and pharmacy records. OBJECTIVE: To examine associations between use of medication for erectile dysfunction or testosterone replacement and use of opioid therapy, patient age, depression, and smoking status. SUMMARY OF BACKGROUND DATA: Males with chronic pain may experience erectile dysfunction related to depression, smoking, age, or opioid-related hypogonadism. The prevalence of this problem in back pain populations and the relative importance of several risk factors are unknown. METHODS: We examined electronic pharmacy and medical records for males with back pain in a large group model health maintenance organization during 2004. Relevant prescriptions were considered for 6 months before and after the index visit. RESULTS: There were 11,327 males with a diagnosis of back pain. Males who received medications for erectile dysfunction or testosterone replacement (n = 909) were significantly older than those who did not and had greater comorbidity, depression, smoking, and use of sedative-hypnotics. In logistic regressions, the long-term use of opioids was associated with greater use of medications for erectile dysfunction or testosterone replacement compared with no opioid use (odds ratio, 1.45; 95% confidence interval, 1.12-1.87, P < 0.01). Age, comorbidity, depression, and use of sedative-hypnotics were also independently associated with the use of medications for erectile dysfunction or testosterone replacement. Patients prescribed daily opioid doses of 120 mg of morphine-equivalents or more had greater use of medication for erectile dysfunction or testosterone replacement than patients without opioid use (odds ratio, 1.58; 95% confidence interval, 1.03-2.43), even with adjustment for the duration of opioid therapy. CONCLUSION: Dose and duration of opioid use, as well as age, comorbidity, depression, and use of sedative-hypnotics, were associated with evidence of erectile dysfunction. These findings may be important in the process of decision making for the long-term use of opioids. LEVEL OF EVIDENCE: 4.
Assuntos
Analgésicos Opioides/uso terapêutico , Dor nas Costas/tratamento farmacológico , Disfunção Erétil/tratamento farmacológico , Testosterona/uso terapêutico , Adulto , Fatores Etários , Idoso , Analgésicos Opioides/efeitos adversos , Androgênios/uso terapêutico , Dor nas Costas/epidemiologia , Carbolinas/uso terapêutico , Comorbidade , Estudos Transversais , Depressão/epidemiologia , Prescrições de Medicamentos/estatística & dados numéricos , Disfunção Erétil/induzido quimicamente , Disfunção Erétil/epidemiologia , Terapia de Reposição Hormonal , Humanos , Imidazóis/uso terapêutico , Seguro Saúde/organização & administração , Seguro Saúde/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Piperazinas/uso terapêutico , Prevalência , Purinas/uso terapêutico , Citrato de Sildenafila , Fumar/epidemiologia , Sulfonas/uso terapêutico , Tadalafila , Triazinas/uso terapêutico , Estados Unidos/epidemiologia , Agentes Urológicos/uso terapêutico , Dicloridrato de VardenafilaRESUMO
INTRODUCTION: Although recent health care reforms will expand insurance coverage for U.S. children, disparities regarding access to pediatric care persist, even among the insured. We investigated the separate and combined effects of having health insurance and a usual source of care (USC) on children's receipt of health care services. METHODS: We conducted secondary analysis of the nationally representative 2002-2007 Medical Expenditure Panel Survey data from children (≤ 18 years of age) who had at least one health care visit and needed any additional care, tests, or treatment in the preceding year (n = 20,817). RESULTS: Approximately 88.1% of the study population had both a USC and insurance; 1.1% had neither one; 7.6% had a USC only, and 3.2% had insurance only. Children with both insurance and a USC had the fewest unmet needs. Among insured children, those with no USC had higher rates of unmet needs than did those with a USC. DISCUSSION: Expansions in health insurance are essential; however, it is also important for every child to have a USC. New models of practice could help to concurrently achieve these goals.
Assuntos
Serviços de Saúde da Criança , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Adolescente , Criança , Serviços de Saúde da Criança/economia , Serviços de Saúde da Criança/estatística & dados numéricos , Pré-Escolar , Estudos Transversais , Feminino , Reforma dos Serviços de Saúde , Acessibilidade aos Serviços de Saúde/economia , Humanos , Lactente , Recém-Nascido , Cobertura do Seguro/economia , Seguro Saúde/economia , Masculino , Pais , Atenção Primária à Saúde/economia , Fatores Socioeconômicos , Estados Unidos/epidemiologiaRESUMO
Adoption of contingency management (CM) by the addiction treatment community is limited to date despite much evidence for its efficacy. This study examined systemic and idiographic staff predictors of CM adoption attitudes via archival data collected from treatment organizations affiliated with the National Drug Abuse Treatment Clinical Trials Network. Multilevel modeling analyses evaluated potential predictors from organizational, treatment unit, and workforce surveys. Among these were individual and shared perceptions of staff concerning aspects of their clinic culture and climate. Modeling analyses identified three systemic predictors (clinic provision of opiate agonist services, national accreditation, and lesser shared perception of workplace stress) and five idiographic predictors (staff with a graduate degree, longer service tenure, managerial position, e-communication facility, and openness to change in clinical procedures). Findings are discussed as they relate to extant literature on CM attitudes and established implementation science constructs, and their practical implications are discussed.