Moira Inkelas

Rethinking Well-Child Care in the United States: An International Comparison

BACKGROUND. The increasing scope of health supervision recommendations challenges well-child care delivery in the United States. Comparison of the United States with other countries’ delivery systems may highlight different assumptions as well as structural approaches for consideration. OBJECTIVE. Our goal was to describe the process of well-child care delivery in industrialized nations and compare it to the US model of child health care. METHODS. Literature reviews and international experts were used to identify 10 countries with unique features of well-child care delivery for comparison to the United States. Key-informant interviews using a structured protocol were held with child health experts in 10 countries to delineate the structural and practice features of their systems. Site visits produced additional key informant data from 5 countries (Netherlands, England, Australia, Sweden, and France). RESULTS. A primary care framework was adapted to analyze structural and practice features of well-child care in the 10 countries. Although well-child care content is similar, there are marked differences in the definitions of well-child care and the scope of practice of primary care professionals and pediatricians specifically who provide this care across the 10 countries. In contrast to the United States, none of the countries place all well-child care components under the responsibility of a single primary care provider. Well-child care services and care for acute, chronic, and behavioral/developmental problems are often provided by different clinicians and within different service systems. CONCLUSIONS. Despite some similarities, well-child care models from other countries differ from the United States in key structural features on the basis of broad financing differences as well as specific visions for effective well-child care services. Features of these models can inform child health policy makers and providers in rethinking how desired improvements in US well-child care delivery might be sought.

Access to Care for Youth with Special Health Care Needs in the Transition to Adulthood

PURPOSE To describe access to care and identify factors associated with access for low-income young adults who aged out of a public program for children with special health care needs (CSHCN). METHODS This was a cross-sectional survey of graduates of the Title V CSHCN program in one California county. Subjects were 77 graduates (55% female) aged 21-24 years with ongoing health care needs. Measures of access to care included having the following: a regular source of care for the main health condition; all needed care since turning 21 years of age; any delayed or forgone care in the past 6 months; health insurance; and continual insurance since turning age 21. Individuals lacking any one access measure were defined as experiencing an adverse transition event. RESULTS Of the subjects, 24% lacked a usual source of health care, 27% had gone without some needed health care since turning 21, and 39% had delayed needed care. Although 10% of respondents were uninsured at the time of the survey; 40% had a gap in insurance coverage since turning age 21. Overall, 65% reported at least one adverse transition event affecting access to care. Factors associated with experiencing no adverse transition event were receiving Supplemental Security Income (SSI, p = .007), having received special education services (p = .003), and having been born with the main health condition (p = .013). CONCLUSIONS Insurance gaps and delayed care are prevalent among these low-income young adults despite ongoing health problems. Greater transition support might improve access by linking them with a usual source of care, identifying insurance options, and encouraging regular use of care.

Recidivism in child protective services

Abstract Recurrent maltreatment of children previously discharged from child protective services is an indicator of how well the child welfare system is performing. Using administrative data from the California Social Services, this study examines trends in child protective case openings in California to identify patterns of service provision and factors associated with recidivism. Prior protective service case openings were found in nearly 50 percent of cases in 1993, representing a 55 percent increase from 1985 to 1993. Nearly two-thirds of cases investigated in 1993 by the Emergency Response component of Californias child protective service system were discharged after the assessment process, despite frequent substantiation of maltreatment and previous case openings for maltreatment. Few children discharged from the system received medical or social services or referral to services. Repeated case openings may indicate that potentially vulnerable children are returned to high risk environments without sufficient services to reduce risk; that risks are overestimated; or that a growing number of children hover at a risk level that is just above the threshold for intervention. Recidivism may be reduced through improved risk assessment, provision of appropriate services targeted to children and families in need, and post-termination follow-up with families. The data for this study were obtained from the California Department of Social Services Information Services Bureau. The authors thank Neal Kaufman, M.D., M.P.H. for thoughtful comments and Connie Hudson and Carl Laya of the California Department of Social Services Information Services Bureau for their helpful review of this paper. This study was supported in part by the Bureau of Maternal and Child Health and Resources Development (MCJ-069500). The interpretations and conclusions are those of the authors and do not necessarily represent the views of the data collection agency or the funding institutions.

Prevalence and correlates of high-quality basic pediatric preventive care.

Background. The list of recommended pediatric preventive services has grown considerably in the past decade, and clinician variability, clinician distribution, and other correlates of provision of these basic preventive services (BPS) are not known. Objective. To describe the proportion of high-quality basic pediatric preventive services, exclusive of immunizations, reported by parents and to identify sociodemographic and health system predictors and health service correlates of provision of these services. Study Design. The study used cross-sectional data on 2041 children, 4 to 35 months of age, in the 2000 National Survey of Early Childhood Health. Outcome Measures. The BPS measure assesses the receipt of (1) developmental assessment, (2) injury prevention counseling, (3) screening for parental smoking, (4) guidance on reading to the child, and (5) guidance on 14 other topics (assessed as a composite score). The BPS scale categorizes the receipt of services as excellent, good, fair, or poor. Results. Most children received excellent (34.9%) or good (31.5%) care, but many received fair (24.9%) or poor (8.7%) care. Sociodemographic and health care factors such as race/ethnicity, insurance, and practice setting were not associated with BPS levels. Higher BPS scores were associated with parental reports of longer well-child visits, more counseling regarding family and community risk factors, lower rates of delayed or missed care, and greater satisfaction. Conclusions. Two thirds of children receive good or excellent basic preventive care, as determined with this composite, and no disparities according to race/ethnicity, income, or health insurance status of families (which are often found to be associated with health care access) were found. This equitable distribution of high-quality care suggests a high level of clinician professionalism. Duration of visits may be a key factor to improve quality of care. Because of its association with other services, processes, and outcomes of care, the BPS scale may serve as a useful construct for monitoring quality and stimulating efforts to improve national pediatric preventive care.

Childbirth education classes: sociodemographic disparities in attendance and the association of attendance with breastfeeding initiation.

Objectives: To examine sociodemographic disparities in attendance at childbirth classes, and to evaluate the association of attendance with breastfeeding initiation. Methods: Parents of a nationally representative, cross-sectional sample of 2068 children ages 4–35 months were surveyed by telephone. The responses of 1540 mothers were included in the analysis. They were asked whether they had attended a childbirth class before giving birth. Disparities in attendance at childbirth classes and the association between attendance and breastfeeding initiation were examined using bivariate and multivariate logistic regression analyses. Results: Two thirds (66%) of the childrens mothers had ever attended a childbirth class. White mothers were twice as likely (OR 2.15, CI 1.39, 3.31) as African American mothers to have ever attended. Attendance also varied by education, household income, and marital status. Attendance at childbirth classes was associated with a 75% increase in the odds that a child will be breastfed (OR 1.75, CI 1.18, 2.60). Conclusions: Significant sociodemographic disparities exist in attendance at childbirth classes. Further research is needed to determine whether improving utilization of childbirth education classes reduces sociodemographic disparities in breastfeeding initiation.

Racial and Ethnic Disparities in Pediatric Experiences of Family-Centered Care

Background:Previous studies have examined racial and ethnic disparities in the receipt of family-centered care among children with special health care needs and health plan enrollees, but the extent of disparities in the general pediatric population remains unclear. Objective:To examine racial and ethnic disparities in the receipt of family-centered care among a general population of US children. Methods:Linked data from the Medical Expenditure Panel Survey and the National Health Interview Survey (2003–2006) were used to study 4 family-centered care items and an overall composite measure of family-centered care. Adjusted models examined the extent to which child characteristics, socioeconomic, and access to care factors explained racial and ethnic disparities in the provision of family-centered care. Results:Black children have similar experiences as white children on overall family-centered care and on each of the 4 components of family-centered care in models that adjust for child characteristics and socioeconomic factors. In contrast, differences in dimensions of and overall family-centered care between white children and Latino children, irrespective of interview language, persist after multivariate adjustment. Conclusions:Future research should examine the extent to which Latino-white differences in the receipt of family-centered care can be narrowed with programs and policies geared at improving parental education, health literacy, the quality of provider communication, and quality improvement strategies for health care systems.

Administrative Barriers to the Adoption of High-Quality Mental Health Services for Children in Foster Care: A National Study

While the need to provide appropriate mental health services to children in foster care is well recognized, there is little information on administrative barriers to assuring that such services are provided. This article presents results from a national survey of mental health agencies to profile their awareness of currently available practice standards, the roles these standards play in guiding practice of mental health agencies, common reimbursement strategies in use for mental health services, and collaborations between mental health and child welfare agencies that enhance children’s access to appropriate mental health care. Implications and recommendations for mental health policymakers are discussed.

Race/ethnicity, language, and asthma care: findings from a 4-state survey.

BACKGROUND Latino and African American children have poorer asthma control than non-Latino white children, but few studies examine the association among race/ethnicity, language, and specific processes of asthma care. OBJECTIVE To evaluate the association of race/ethnicity and language with the quality of asthma care. METHODS A random sample of children from birth to the age of 17 years with asthma within 4 states (California, Texas, Illinois, and Alabama) was selected for the National Asthma Survey conducted by the National Center for Health Statistics from March 1, 2003, to March 10, 2004. Parents completed a telephone survey that included measures of asthma care quality. The final sample was 1,517 children. RESULTS According to parental report, only 41.4% of children had an asthma management plan and 48.5% were ever advised by a clinician to control asthma by changing the childs home and school environment. African American and Latino children with persistent asthma had lower odds of taking controller medication than non-Latino white children. In multivariate analysis adjusting for annual income, insurance, and age, Latino children with Spanish parental interview, but not African American and Latino children with English parental interview, had poorer experiences with care than white children (ever taught what to do during an attack: odds ratio, 0.4 [95% confidence interval, 0.2-0.6]; and ever advised to change childs home and school environment: odds ratio, 0.5 [95% confidence interval, 0.3-0.8]). CONCLUSIONS Differences in asthma care quality and controller use persist among racial/ethnic and language groups despite similar rates of planned encounters for asthma. Improving use of controller medications and counseling on environmental modifications are important for reducing asthma disparities.

Applying A 3.0 Transformation Framework To Guide Large-Scale Health System Reform

Implementation of the Affordable Care Act is unleashing historic new efforts aimed at reforming the US health system. Many important incremental improvements are under way, yet there is a growing recognition that more transformative changes are necessary if the health care system is to do a better job of optimizing population health. While the concept of the Triple Aim-dedicated to improving the experience of care, the health of populations, and lowering per capita costs of care-has been used to help health care providers and health care systems focus their efforts on costs, quality, and outcomes, it does not provide a roadmap for a new system. In this article we describe the 3.0 Transformation Framework we developed to stimulate thinking and support the planning and development of the new roadmap for the next generation of the US health care system. With a focus on optimizing population health over the life span, the framework suggests how a system designed to better manage chronic disease care could evolve into a system designed to enhance population health. We describe how the 3.0 Transformation Framework has been used and applied in national, state, and local settings, and we suggest potential next steps for its wider application and use.

Access to and Utilization of Health Care by Subgroups of Latino Children

Background:Latinos make up the largest group of minority children in the United States. Despite great diversity among Latino children, studies have traditionally treated them as a monolithic group. Few studies have examined patterns and determinants of access to and use of health care for different subgroups of Latino children. Objectives:To delineate differences in access and utilization patterns between white and subgroups of Latino children, after adjusting for important predisposing, enabling, and need factors. Research Design:National Health Interview Survey data (1998–2006) were used to study children of Mexican, Puerto Rican, Cuban, and other Latino ancestry, as well as white children. Data were adjusted for predisposing, enabling, and need factors in incremental models. Additional analyses were conducted to test for effect modification of health insurance and language use on the associations between the subgroups and health care access and utilization. Results:Children of Mexican ancestry were found to have the most consistent pattern of poorer access to health care and use of services compared with the other subgroups. Multivariate analyses demonstrated persistent variability between Latino subgroups. Adjustment for predisposing, enabling, and need factors did not fully explain subgroup differences. Conclusions:Efforts to understand health care services for Latino children will require further examination of specific subgroups, and interventions to improve access and utilization should not be limited to health insurance coverage and language services.