Embry M. Howell

Deregionalization of Neonatal Intensive Care in Urban Areas

OBJECTIVES This report describes the extent of deregionalization of neonatal intensive care in urban areas of the United States in the 1980s and 1990s and the factors associated with it. METHODS We conducted a 15-year retrospective analysis of secondary data from US metropolitan statistical areas. Primary outcome measures are number of neonatal intensive care unit (NICU) beds, number of NICU hospitals, and number of small NICUs. RESULTS Growth in the supply of NICU care has outpaced the need. During the study period (1980-1995), the number of hospitals grew by 99%, the number of NICU beds by 138%, and the number of neonatologists by 268%. In contrast, the growth in needed bed days was only 84%. Of greater concern, the number of beds in small NICU facilities continues to grow. Local regulatory and practice characteristics are important in explaining this growth. CONCLUSIONS Local policymakers should examine the factors that facilitate the proliferation of services, especially the development of small NICUs. Policies that encourage cooperative efforts by hospitals should be developed. Eliminating small NICUs would not restrict the NICU bed supply in most metropolitan statistical areas.

Children's Mental Health Care: Differences by Race/Ethnicity in Urban/Rural Areas

This study examines racial/ethnic disparities in children’s mental health and the receipt of mental health services, and whether those disparities differ between urban and rural areas. We find no significant difference between racial/ethnic groups in the prevalence of child mental health problems in either urban or rural areas. However, there are disparities in the use of mental health services. Hispanic children and Black children in urban areas receive less mental health care than their White counterparts, and the disparity persists for Hispanic children in rural areas, even after controlling for other relevant factors. Initiatives to improve access to mental health care for racial/ethnic minorities should recognize these disparities, and address the lack of culturally appropriate services in both urban and rural areas. In addition, outreach should raise awareness among parents, teachers, and other community members concerning the need for mental health services for minority children.

Back to the Future: Community Involvement in the Healthy Start Program

This article discusses how community involvement is incorporated into Healthy Start, a major initiative to reduce infant mortality in selected communities with disproportionately high levels of infant mortality. Based on site visits to each of the fifteen original Healthy Start project areas, we discovered that two main community involvement strategies were used: a service consortium model and a community empowerment model. In the service consortium model, the community is involved primarily through a consortium of local providers, other professionals, and some governmental representatives who help to plan services. The community empowerment model involves the community by engaging neighborhood-based groups, contracting with community-based organizations, employing community residents as lay workers in the Healthy Start program, and creating other economic development initiatives. Important lessons drawn from this study are that the purpose and commitment to community involvement is not always clear; that it is difficult to involve community residents; that efforts to involve the community are extremely labor intensive; that given monetary incentives, it is easier to involve community providers than residents; that community involvement may conflict with efficient program operations; that increased community involvement may create program goals that differ from the programs original goals; and that community involvement may slow program development.

The Health Status of HOPE VI Public Housing Residents

The purpose of this study is to provide new data on the relationship between housing quality and health status for people in five HOPE VI public housing developments around the country. HOPE VI is a federal program to replace or redevelop some of the poorest quality public housing in the country. A special survey of residents of these developments was conducted while they lived in HOPE VI housing before its redevelopment. Data for these individuals provides a profile of the quality of housing and the health status of people in HOPE VI housing before its renovation, of residents of publicly assisted housing across the nation, of other people living below the federal poverty level, and of non-poor people. Previously, the lack of data sets that included both housing quality and health status measures has prevented such an analysis. We examined two indicators of health status—perceived overall health status and medically diagnosed asthma. The health status of HOPE VI residents is decidedly worse than that of others in assisted housing and other poor people, despite their similarity in terms of economic deprivation. The difference in the level of asthma prevalence, a condition that has been tied to various measures of housing quality, is especially pronounced. Our analysis indicates that one major benefit of improving housing quality may be improved health status.

An Assessment of Evaluation Designs Case Studies of 12 Large Federal Evaluations

This article provides a critical review of the quality of 12 recent large federal program evaluations. The review focused on elements of the evaluation design, inclusion of evaluation expertise among those who have oversight of the evaluation, and evaluation dissemination. Overall, the process analyses from these evaluations provide good models for how to assess implementation and provide feedback to grantees. However, other features of these evaluations require improvement. For example, program monitoring often did not include adequate outcome data and few evaluations had solid impact analyses. Efforts to disseminate findings to grantees, government stakeholders, and academic audiences were also weak. The authors provide recommendations to improve the evaluations of large federal programs.

Variations in Medicaid Mental Health Service Use and Cost for Children

Mental health care is a critical component of Medicaid for children. This study used summary tables drawn from the 1999 Medicaid Analytic Extract (MAX) files, the first available Medicaid data for the entire US, to examine fee-for-service Medicaid in 23 selected states. Data show that 9% of children and youth (ages 0–21) had a mental health-related diagnosis on a claim, varying from 5% to 17% across the states. The proportion increased with age, and was higher for boys. Over half of those diagnosed received psychotropic medication, and approximately 7% had an inpatient psychiatric admission during the year. Mental health costs accounted for 26.5% of total fee-for-service Medicaid expenditures, varying from 14% to 61% depending on the state.

Improving Coverage And Access For Immigrant Latino Children: The Los Angeles Healthy Kids Program

A large number of California counties have recently taken bold steps to extend health insurance to all poor and near-poor children through county-based Childrens Health Initiatives. One initiative, the Los Angeles Healthy Kids program, extends coverage to uninsured children in families with incomes below 300 percent of the federal poverty level who are ineligible for Medi-Cal (California Medicaid) and Healthy Families (its State Childrens Health Insurance Program). A four-year evaluation of Healthy Kids finds that the program has improved access for more than 40,000, most of whom are immigrant Latino children, who have almost no access to employer coverage. However, sustaining this effective program has proved to be challenging.

Trends in maternal and infant health in poor urban neighborhoods: good news from the 1990s, but challenges remain.

Objectives. During the 1990s, numerous public policy changes occurred that may have affected the health of mothers and infants in low-income neighborhoods. This article examines trends in key maternal and child health indicators to determine whether disparities between high-poverty neighborhoods and other neighborhoods have declined. Methods. Using neighborhood-level vital statistics and U.S. Census data, we categorized “neighborhoods” (Census tracts) as being high poverty (greater than 30% of population below the federal poverty level in 1990) or not. We compared trends in four key indicators—births to teenagers, late prenatal care, low birthweight; and infant mortality—over the 1990s among high-poverty and other neighborhoods in Cuyahoga County, Ohio; Denver, Colorado; Marion County, Indiana; and Oakland, California. Results. In all four metropolitan areas, trends in high-poverty neighborhoods were more favorable than in other neighborhoods. The most consistently positive trend was the reduction in the rate of teen births. The metropolitan areas with the most intensive programs to improve maternal and child health—Cuyahoga County and Oakland—saw the most consistent improvement across all indicators. Still, great disparities between high-poverty and other neighborhoods remain, and only Oakland shows promise of achieving some of the Healthy People 2010 maternal and child health goals in its high-poverty neighborhoods. Conclusions. While there has been a reduction in maternal and infant health disparities between high-poverty and other neighborhoods, much work remains to eliminate disparities and achieve the 2010 goals. Small area data are useful in isolating the neighborhoods that should be targeted. Experience from the 1990s suggests that a combination of several intensive interventions can be effective at reducing disparities.

Midwifery Care at a Freestanding Birth Center: A Safe and Effective Alternative to Conventional Maternity Care

OBJECTIVE To estimate the effect of a midwifery model of care delivered in a freestanding birth center on maternal and infant outcomes when compared with conventional care. DATA SOURCES/STUDY SETTING Birth certificate data for women who gave birth in Washington D.C. and D.C. residents who gave birth in other jurisdictions. STUDY DESIGN Using propensity score modeling and instrumental variable analysis, we compare maternal and infant outcomes among women who receive prenatal care from birth center midwives and women who receive usual care. We match on observable characteristics available on the birth certificate, and we use distance to the birth center as an instrument. DATA COLLECTION/EXTRACTION METHODS Birth certificate data from 2005 to 2008. PRINCIPAL FINDINGS Women who receive birth center care are less likely to have a C-section, more likely to carry to term, and are more likely to deliver on a weekend, suggesting less intervention overall. While less consistent, findings also suggest improved infant outcomes. CONCLUSIONS For women without medical complications who are able to be served in either setting, our findings suggest that midwife-directed prenatal and labor care results in equal or improved maternal and infant outcomes.

The Impact of New Health Insurance Coverage on Undocumented and Other Low-Income Children: Lessons from Three California Counties

Three California counties (Los Angeles, San Mateo, and Santa Clara) expanded health insurance coverage for undocumented children and some higher income children not covered by Medi-Cal (Medicaid) or Healthy Families (SCHIP). This paper presents findings from evaluations of all three programs. Results consistently showed that health insurance enrollment increased access to and use of medical and dental care, and reduced unmet need for those services. After one year of enrollment the programs also improved the health status of children, including reducing the percentage of children who missed school due to health.