Jeffrey J. Stoddard

Health Insurance and Access to Primary Care for Children

BACKGROUND Numerous studies have demonstrated that insurance status influences the amount of ambulatory care received by children, but few have assessed the role of insurance as a determinant of childrens access to primary care. We studied the effect of health insurance on childrens access to primary care. METHODS We analyzed a sample of 49,367 children under 18 years of age from the 1993-1994 National Health Interview Survey, a nationwide household survey. The overall rate of response was 86.5 percent. The survey included questions on insurance coverage and access to primary care. RESULTS An estimated 13 percent of U.S. children did not have health insurance in 1993-1994. Uninsured children were less likely than insured children to have a usual source of care (75.9 percent vs. 96.2 percent, P<0.001). Among those with a usual source of care, uninsured children were more likely than insured children to have no regular physician (24.3 percent vs. 13.8 percent, P<0.001), to be without access to medical care after normal business hours (11.8 percent vs. 7.1 percent, P<0.001), and to have families that were dissatisfied with at least one aspect of their care (19.6 percent vs. 14.0 percent, P=0.01). Uninsured children were more likely than insured children to have gone without needed medical, dental, or other health care (22.2 percent vs. 6.1 percent, P<0.001). Uninsured children were also less likely than insured children to have had contact with a physician during the previous year (67.4 percent vs. 83.8 percent, P<0.001). All differences remained significant after we controlled for potential confounders using linear and logistic regression. CONCLUSIONS Among children, having health insurance is strongly associated with access to primary care. The new childrens health insurance program enacted as part of the Balanced Budget Act of 1997 may substantially improve access to and use of primary care by children.

Health Insurance Status and Ambulatory Care for Children

BACKGROUND Many children in the United States lack health insurance. We tested the hypothesis that these children are less likely than children with insurance to visit a physician when they have specific conditions for which care is considered to be indicated. METHODS We examined the association between whether children were covered by health insurance and whether they received medical attention from a physician for pharyngitis, acute earache, recurrent ear infections, or asthma. Data were obtained on the subsample of 7578 children and adolescents 1 through 17 years of age who were included in the 1987 National Medical Expenditures Survey, a national probability sample of the civilian, noninstitutionalized population. RESULTS Uninsured children were more likely than children with health insurance to receive no care from a physician for all four conditions (unadjusted odds ratios, 2.38 for pharyngitis; 2.04 for acute earache; 2.84 for recurrent ear infections; and 1.87 for asthma). Multiple logistic-regression analysis was subsequently used to control for age, sex, family size, race or ethnic group, region of the country, place of residence (rural vs. urban), and household income. After adjustment for these factors, uninsured children remained significantly more likely than insured children to go without a visit to a physician for pharyngitis (adjusted odds ratio, 1.72; 95 percent confidence interval, 1.11 to 2.68), acute earache (1.85; 95 percent confidence interval, 1.15 to 2.99), recurrent ear infections (2.12; 95 percent confidence interval, 1.28 to 3.51), and asthma (1.72; 95 percent confidence interval, 1.05 to 2.83). CONCLUSIONS As compared with children with health insurance, children who lack health insurance are less likely to receive medical care from a physician when it seems reasonably indicated and are therefore at risk for substantial avoidable morbidity.

Safety, immunogenicity and efficacy of intranasal, live attenuated influenza vaccine

Data supporting the use of the live attenuated influenza vaccine (LAIV) in children and adults is reviewed, and the development and characteristics of the vaccine are summarized. The vaccine is highly effective and well tolerated in children and adults from 5 to 49 years of age. Correlates of immune protection include serum hemagglutination-inhibition antibody and secretory immunoglobulin A. Efficacy against antigenically well-matched epidemic influenza strains was high at 92%. In 1 year, despite a significant antigenic change in the epidemic influenza virus that did not match the vaccine, LAIV conferred 86% protection against culture-confirmed illness in children. In the future it is expected that additional studies will support a broadening of the age range for use with the LAIV to prevent influenza in children and adults.

A Pilot Study of the Effectiveness of a School-Based Influenza Vaccination Program

Objective. The objective of this study was to evaluate the feasibility of a school-based influenza immunization program. Methods. Pupils and their families from 3 demographically similar elementary schools participated in this pilot, unblinded, controlled intervention study. Live attenuated influenza vaccine (FluMist) was made available to all eligible pupils in 1 target school during regular school hours. Two schools where vaccine was not offered served as control schools. All families from the 3 study schools were sent an anonymous questionnaire requesting 7-day recall data on fever or respiratory illness (FRI)-related medical visits, medications purchased, and days of school or paid work lost during the peak influenza week. Changes in weekly pupil absenteeism were also examined. Results. One hundred eighty-five (40%) of the target school pupils received vaccine, of whom >50% were vaccinated ≤3 weeks before the influenza outbreak period. Questionnaires were returned by 43% to 51% of households. Significant (45–70%) relative reductions in FRI-related outcomes, including doctor visits by adults or children, prescription or other medicines purchased, and family schooldays or workdays missed, were observed for target school households, compared with control school households. The increases in absenteeism rates during the influenza outbreak period, compared with baseline rates earlier in the fall, were not significantly different between target and control schools. Within the target school, however, the increase in absenteeism rates was significantly smaller for the FluMist-vaccinated pupils, compared with the non–FluMist-vaccinated pupils. Conclusions. This school-based influenza immunization program was associated with significant reductions in FRI-related outcomes in households of pupils attending an intervention school. These results might have underestimated the potential impact of FluMist, because the majority of children received intraepidemic vaccination.

The Respective Racial and Ethnic Diversity of US Pediatricians and American Children

Background. Much effort has been directed toward increasing the training of physicians from underrepresented minority groups, yet few direct comparisons have examined the diversity of the racial/ethnic backgrounds of the physicians relative to the patient populations they serve, either currently or into the future. This has been particularly true in the case of pediatrics, in which little information has emerged regarding the racial/ethnic backgrounds of pediatricians, yet evidence points to ever-growing diversity in the US child population. Objective. We embarked on a comparative analysis to examine trends in the racial and ethnic composition of pediatricians vis-a-vis the patient population they serve, Americas infants, children, adolescents, and young adults. Methods. Data on US pediatricians sorted by racial/ethnic group came from Association of American Medical Colleges distribution data and is based on the cohort of pediatricians graduating from US medical schools between 1983 and 1989 extrapolated to the total number of pediatricians actively practicing in 1996. Data on the demographic diversity of the US child population came from the US Census Bureau. We derived pediatrician-to-child population ratios (PCPRs) specific to racial/ethnic groups to measure comparative diversity between and among groups. Results. Our results show that the black PCPR, currently less than one third of the white PCPR, will fall from 14.3 pediatricians per 100 000 children in 1996 to 12 by 2025. The Hispanic PCPR will fall from 16.9 in 1996 to 9.2 in 2025. The American Indian/Alaska Native PCPR will drop from 7.8 in 1996 to 6.5 by the year 2025. The PCPR specific to the Asian/Pacific Islander group will decline from 52.9 in 1996 to 26.1 in 2025. For whites, the PCPR will increase from 47.8 to 54.2 during this period. For 1996, each of the 5 PCPRs is significantly different from the comparison ratio. The same is true for 2025. For the time trend comparison (between 1996 and 2025), there is a significant difference for each ratio except for American Indian/Alaska Native. Conclusion. The racial and ethnic makeup of the US child population is currently far more diverse than that of the pediatricians who provide their health care services. If child population demographic projections hold true, and no substantial shifts transpire in the composition of the pediatric workforce, the disparities will increase substantially by the year 2025.

Live attenuated influenza vaccine induces cross-reactive antibody responses in children against an A/Fujian/411/2002-like H3N2 antigenic variant strain

Serum antibody titers against the A/Panama/2007/99(H3N2) and A/Fujian/411/2002(H3N2)-like viruses were determined in children 6–35 months of age who received either 1 dose of the inactivated influenza vaccine or the live attenuated influenza vaccine containing the A/Panama strain. Results indicated that the live vaccine induced higher antibody responses than the inactivated vaccine against the A/Panama and A/Fujian-like viruses.

Hepatitis B virus transmission between children in day care.

We investigated two situations involving hepatitis B virus exposure among children in day care. In the first a 4-year-old boy who attended a day care center developed acute hepatitis B; another child at the center, who had a history of aggressive behavior (biting/scratching), was subsequently found to be a hepatitis B carrier. No other source of infection among family and other contacts was identified and no other persons at the center became infected. In the second situation a 4-year-old boy with frequently bleeding eczematous lesions was discovered to be a hepatitis B carrier after having attended a day care center for 17 months. Testing of contacts at the center revealed no transmission to other children or staff (representing 887 person months of exposure). Nationwide surveillance data showed that for the period 1983 to 1987, 161 children 1 to 4 years of age were reported with acute hepatitis B. After children with known hepatitis B risk factors were excluded, 25% (7 of 28) of children with known day care status were reported as day care attendees, a percentage comparable to national estimates of day care attendance by this age group. This is the first reported case of hepatitis B virus transmission between children in day care in the United States. Although it appears that day care transmission of hepatitis B is infrequent, further studies are needed to define the risk more accurately.