George E. Childs

A Cohort Study of Resource Use by Medicaid Children With Asthma

* Abbreviation: AFDC = : Aid to Families With Dependent Children Asthma is the most common chronic disease of childhood and accounts for 1% of all health care expenditures. A substantial portion of the cost is derived from care provided in both the inpatient setting and the emergency department.1 ,2Health care plans are using asthma disease management programs to address the rising cost of asthma care and to meet various accreditation requirements. Most asthma disease management programs enroll patients after either inpatient admissions or emergency department visits, and track their success by showing a decline in the use of hospital resources for asthma over a subsequent period of time. Asthma, especially pediatric asthma, is a relatively dynamic disease and there are scant data to support the assumption that 1 year of increased hospitalization or emergency department utilization is predictive of future utilization. We undertook this study 1) to determine the patterns of hospital utilization over a 2-year period among children with asthma, and 2) to describe factors associated with the persistence of high utilization of hospital resources. ### Study Group Selection and Demographics We elected to study a Medical Assistance population because the mortality and morbidity from pediatric asthma disproportionately affects children of lower socioeconomic status.3 ,4Using all of the Medical Assistance claims data for Allegheny County from the 1992–1993 fiscal year and the corresponding eligibility file, children between the ages of 0 and 16 years who were continuously enrolled in the traditional fee-for-service plan for both the 1992–1993 and 1993–1994 fiscal years were selected. Any child enrolled in one of the managed care plans during either fiscal year was eliminated from the study group. Children from the 1992–1993 fiscal year were identified as having asthma if one of the following combinations of claims was paid for by Medical Assistance during that year: a hospitalization with a diagnosis of asthma (ICD-9 code 493.00–493.99 …

In-Office Primary Care Management of Child Psychosocial Problems • 58

To examine the primary care management of child psychosocial problems and the patient, provider and insurance correlates of management. Questionnaires were completed by 401 clinicians from 44 states, Puerto Rico, and 4 Canadian provinces from two primary care research networks and by families of consecutive children aged 4-15 years presenting for non-emergent care. For children identified with a psychosocial problem, clinicians described interventions including drug prescriptions, counseling in the office and visit disposition. Treatment choices were modeled both independently and simultaneously. Complete data on 21,151 visits were analyzed. 19.0% (n=4,012) were identified by clinicians with a psychosocial problem. Among these, 24% received no medications, counseling or followup visits (41% of these were already in specialty mental health services). Of children with psychosocial problems, 10% were scheduled for an additional visit to address the problem, but received no other interventions. The remaining children with psychosocial problems received counseling only (22%), a psychotropic prescription only(29%), or both (15%). Children with commercial (vs public or no) insurance, younger females and those children seen for parental psychosocial concerns were more likely to receive counseling. Children were more likely to receive psychotropic medications if older, male, severe, or visited during the school year. Receipt of specialty services and visits for acute or chronic medical problems were associated with lower rates of drug prescriptions. When modeled simultaneously, clinician identification of attentional and hyperactivity problems was the best predictor of clinician intervention. Psychosocial problems are commonly managed in primary care. Counseling and/or psychotropic drugs are provided to 2/3 of all identified patients, but considerable variation exists in management. Development of guidelines or protocols for management for these common and high cost problems should be a priority.