Andrew D. Racine

Social-Emotional Screening for Infants and Toddlers in Primary Care

BACKGROUND AND OBJECTIVES: Recommendations in pediatrics call for general developmental screening of young children; however, research suggests social-emotional development, in particular, is important as an initial indicator of general well-being versus risk. We aim to describe a program designed to identify the social-emotional status of young children in the pediatric setting by using the Ages and Stages Questionnaires: Social-Emotional (ASQ:SE) as a universal screening tool, and to assess the effect of interventions by a colocated psychologist on changes in ASQ:SE scores over time. METHODS: In a prospective cohort design we analyzed scores on ASQ:SE surveys completed on children 6 to 36 months of age, to determine if children were at risk for problems in social-emotional development. The probability of remaining at risk over time was then compared between subjects receiving intervention by the psychologist, and those who declined intervention. Logit specifications were used in multivariate comparisons to control for a set of covariates. RESULTS: Three thousand one hundred and sixty-nine children were screened; 711 (22.4%) scored at or above the risk cutoff. Among the 711 at-risk children, 170 were rescreened. At the time of rescreening, those children who received intervention from the psychologist showed significant improvement on ASQ:SE scores compared with those who declined intervention (P = .01). CONCLUSIONS: Universal social-emotional screening in a busy pediatric practice is challenging. Significant percentages of children can be identified as being at risk for social-emotional problems, and colocation of a psychologist promotes the ability to effectively address young children’s social-emotional development within their medical home.

Food Insecurity and Obesogenic Maternal Infant Feeding Styles and Practices in Low-Income Families

OBJECTIVES: We explored the relationship between household food insecurity and maternal feeding styles, infant feeding practices, and perceptions and attitudes about infant weight in low-income mothers. METHODS: Mothers participating in the Special Supplemental Food Program for Women, Infants, and Children with infants aged between 2 weeks and 6 months were interviewed. By using regression analyses, the following relationships were examined between food insecurity and: (1) controlling feeding styles (restrictive and pressuring); (2) infant feeding practices, including breastfeeding, juice consumption, and adding cereal to the bottle; and (3) perceptions and attitudes about infant weight. Path analysis was used to determine if perceptions and attitudes about infant weight mediated the relationships between food insecurity and controlling feeding styles. RESULTS: The sample included 201 mother–infant pairs, with 35% reporting household food insecurity. Food-insecure mothers were more likely to exhibit restrictive (B [SE]: 0.18 [0.08]; 95% confidence interval [CI]: 0.02–0.34) and pressuring (B [SE]: 0.11 [0.06]; 95% CI: 0.001–0.22) feeding styles compared with food-secure mothers. No associations were found with feeding practices. Concern for their infant becoming overweight in the future was associated with food insecurity (adjusted odds ratio: 2.11 [95% CI: 1.02–4.38]). This concern mediated the relationship between food insecurity and both restrictive (P = .009) and pressuring (P = .01) feeding styles. CONCLUSIONS: Increased concern about future overweight and controlling feeding styles represent potential mechanisms by which food insecurity could be related to obesity. Obesity prevention should aim to decrease food insecurity and to reduce controlling feeding styles in families who remain food insecure.

Children’s Health Insurance Program (CHIP): Accomplishments, Challenges, and Policy Recommendations

Sixteen years ago, the 105th Congress, responding to the needs of 10 million children in the United States who lacked health insurance, created the State Children’s Health Insurance Program (SCHIP) as part of the Balanced Budget Act of 1997. Enacted as Title XXI of the Social Security Act, the Children’s Health Insurance Program (CHIP; or SCHIP as it has been known at some points) provided states with federal assistance to create programs specifically designed for children from families with incomes that exceeded Medicaid thresholds but that were insufficient to enable them to afford private health insurance. Congress provided

Obesity and symptomatic cholelithiasis in childhood: epidemiologic and case-control evidence for a strong relation.

40 billion in block grants over 10 years for states to expand their existing Medicaid programs to cover the intended populations, to erect new stand-alone SCHIP programs for these children, or to effect some combination of both options. Congress reauthorized CHIP once in 2009 under the Children’s Health Insurance Program Reauthorization Act and extended its life further within provisions of the Patient Protection and Affordable Care Act of 2010. The purpose of this statement is to review the features of CHIP as it has evolved over the 16 years of its existence; to summarize what is known about the effects that the program has had on coverage, access, health status, and disparities among participants; to identify challenges that remain with respect to insuring this group of vulnerable children, including the impact that provisions of the new Affordable Care Act will have on the issue of health insurance coverage for near-poor children after 2015; and to offer recommendations on how to expand and strengthen the national commitment to provide health insurance to all children regardless of means.

Scope of Health Care Benefits for Children From Birth Through Age 26

Objectives: The aims of this study were to correlate the temporal trends in obesity prevalence with hospitalization rates for symptomatic cholelithiasis and to estimate the strength of the association between obesity and symptomatic cholelithiasis in patients hospitalized at an urban childrens hospital in New York serving a multiethnic population. Methods: Using obesity prevalence data from the National Health and Nutrition Examination Survey and the rates of hospitalization for cholelithiasis derived from the Kids’ Inpatient Database for 1997–2007, we estimated a correlation and a linear regression. We conducted a retrospective, case-control study in which each case ages 4 to 20 years with symptomatic cholelithiasis was individually matched to a control admitted with appendicitis based on age, sex, ethnicity, and race. Results: The prevalence of obesity and the cholelithiasis hospitalization rate increased over time (R = 0.87, P = 0.0025). For every 1% increase in the obesity rate among children, the rate of hospitalization for gallstones increased by 0.65/100,000 children (R2 = 0.75, P = 0.0025, 95% confidence interval [CI] 0.32–0.99). The odds ratio for obesity in cases versus controls was 5.78 (n = 518, P < 0.0001, 95% CI 3.50–9.53). We found a significant dose-response effect, which showed that for every 1 z score increase in body mass index, the risk of cholelithiasis was increased by 79% (P < 0.0001, 95% CI 1.5–2.13). Conclusions: The national trend in the prevalence of obesity from 1997 to 2009 was significantly correlated with increasing rates of hospitalization for pediatric cholelithiasis. Our case-control study suggests that obesity is a significant risk factor for hospital admission because of cholelithiasis.

Did recent expansions in Medicaid narrow socioeconomic differences in hospitalization rates of infants

The optimal health of all children is best achieved with access to appropriate and comprehensive health care benefits. This policy statement outlines and defines the recommended set of health insurance benefits for children through age 26. The American Academy of Pediatrics developed a set of recommendations concerning preventive care services for children, adolescents, and young adults. These recommendations are compiled in the publication Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, third edition. The Bright Futures recommendations were referenced as a standard for access and design of age-appropriate health insurance benefits for infants, children, adolescents, and young adults in the Patient Protection and Affordable Care Act of 2010 (Pub L No. 114–148).

Upstairs downstairs : Vertical integration of a pediatric service

OBJECTIVE To test whether socioeconomic differences in the ratio of infant hospitalizations to births, a proxy for infant hospitalization rates, and hospital lengths of stay for infants narrowed between 1988 and 1992: a period of large increases in the numbers of low-income infants enrolled in Medicaid. RESEARCH DESIGN Before and after comparison of socioeconomic differences in the ratio of infant hospitalizations to births (ie, infant hospitalization rates) and lengths of stay between 1988 and 1992. By use of ICD-9 codes, hospitalizations were categorized as mandatory or discretionary. The difference between the 2 is that discretionary hospitalizations are potentially avoidable with appropriate primary care. Difference-in-differences techniques were used to assess the differential change in the rates of hospitalizations and lengths of stay for infants from low-income, compared with high-income, zip codes. SETTING AND PARTICIPANTS Discharges of infants <2 years of age at 326 nonfederal, short-term, general, and other specialty hospitals in 8 states. OUTCOME MEASURES Ratios of discretionary and mandatory hospitalizations to births (ie, hospitalization rates) and hospital lengths of stay of infants <2 years of age. RESULTS Infants from the poorest zip codes had ratios of discretionary hospitalizations to births (discretionary hospitalization rate) that were 3.1% points higher than infants from the wealthiest zip codes and ratios of mandatory hospitalizations to births (mandatory hospitalization rates) that were 0.2% points higher. Poor versus nonpoor differences in lengths of stay were 0.3 and 1.9 days for discretionary and mandatory hospitalizations, respectively. No narrowing in the socioeconomic gradients about ratios of hospitalizations to births (ie, rates of hospitalization) or lengths of stay was observed. CONCLUSIONS Expansions in the Medicaid program from 1988 to 1992 did not result in a decrease in ratios of discretionary hospitalizations to births (ie, discretionary hospitalization rate) or hospital length of stay for infants from low-income areas.

Medicaid Policy Statement

Background. The combined effects of recent changes in health care financing and training priorities have compelled academic medical centers to develop innovative structures to maintain service commitments yet conform to health care marketplace demands. In 1992, a municipal hospital in the Bronx, New York, affiliated with a major academic medical center reorganized its pediatric service into a vertically integrated system of four interdependent practice teams that provided comprehensive care in the ambulatory as well as inpatient settings. One of the goals of the new system was to conserve inpatient resources. Objective. To describe the development of a new vertically integrated pediatric service at an inner-city municipal hospital and to test whether its adoption was associated with the use of fewer inpatient resources. Design. A descriptive analysis of the rationale, goals, implementation strategies, and structure of the vertically integrated pediatric service combined with a before-and-after comparison of in-hospital resource consumption. Methods. A before-and-after comparison was conducted for two periods: the period before vertical integration, from January 1989 to December 1991, and the period after the adoption of vertical integration, from July 1992 to December 1994. Four measures of inpatient resource use were compared after adjustment for case mix index: mean certified length of stay per case, mean number of radiologic tests per case, mean number of ancillary tests per case, and mean number of laboratory tests per case. Difference-in-differences-in-differences estimators were used to control for institution-wide trends throughout the time period and regional trends in inpatient pediatric practice occurring across institutions. Results. In 1992, the Department of Pediatrics at the Albert Einstein College of Medicine reorganized the pediatric service at Jacobi Medical Center, one of its principal municipal hospital affiliates, into a vertically integrated pediatric service that combines ambulatory and inpatient activities into four interdependent practice teams composed of attending pediatricians, allied health professionals, house officers, and social workers. The new vertically integrated service was designed to improve continuity of care for patients, provide a model of practice for professional trainees, conserve scarce resources, and create a clinical research infrastructure. The vertically integrated pediatric service augmented the role of attending pediatricians, extended the use of allied health professionals from the ambulatory to the inpatient sites, established interdisciplinary practice teams that unified the care of pediatric patients and their families, and used less inpatient resources. Controlling for trends within the study institution and trends in the practice of pediatrics across institutions throughout the time period, the vertical integration was associated with a decline in 0.6 days per case, the use of 0.62 fewer radiologic tests per case, 0.21 fewer ancillary tests per case, and 2.68 fewer laboratory tests per case. Conclusions. We conclude that vertical integration of a pediatric service at an inner-city municipal hospital is achievable; conveys advantages of improved continuity of care, enhanced opportunities for primary care training, and increased participation of senior clinicians; and has the potential to conserve significant amounts of inpatient resources.

Essential Contractual Language for Medical Necessity in Children

Medicaid insures 39% of the children in the United States. This revision of the 2005 Medicaid Policy Statement of the American Academy of Pediatrics reflects opportunities for changes in state Medicaid programs resulting from the 2010 Patient Protection and Affordable Care Act as upheld in 2012 by the Supreme Court. Policy recommendations focus on the areas of benefit coverage, financing and payment, eligibility, outreach and enrollment, managed care, and quality improvement.

Evaluating serial strategies for preventing wrong-patient orders in the NICU

The previous policy statement from the American Academy of Pediatrics, “Model Language for Medical Necessity in Children,” was published in July 2005. Since that time, there have been new and emerging delivery and payment models. The relationship established between health care providers and health plans should promote arrangements that are beneficial to all who are affected by these contractual arrangements. Pediatricians play an important role in ensuring that the needs of children are addressed in these emerging systems. It is important to recognize that health care plans designed for adults may not meet the needs of children. Language in health care contracts should reflect the health care needs of children and families. Informed pediatricians can make a difference in the care of children and influence the role of primary care physicians in the new paradigms. This policy highlights many of the important elements pediatricians should assess as providers develop a role in emerging care models.