Access to medical care for children and adolescents in the United States

To evaluate access to health care for American children and adolescents, a telephone survey of a national random sample of households was conducted in which 2182 children 17 years or younger were studied. Approximately 10% had no medical insurance; 10% had no regular source of care; and 18% identified emergency rooms, community clinics, or hospital outpatient departments as their usual site of medical care. Children who were uninsured, poor, or nonwhite were less likely to have seen a physician in the past year (P less than .001), and uninsured children were less likely to have up-to-date immunizations. Logistic regression analyses revealed that poor, uninsured, or nonwhite children less frequently had a regular source of care; more frequently used emergency rooms, community clinics, and hospital outpatient departments as their regular providers; and more frequently encountered financial barriers to health care. Low-income or nonwhite children had much less access to care compared with children from more affluent or white families, independent of insurance status or health status.     

Gastrointestinal symptoms and use of medical care associated with child day care and health care plan among preschool children.

OBJECTIVES: This study examined whether out-of-home day care increases the risk of gastrointestinal symptoms for children <6 years of age and whether there is an association between gastrointestinal symptoms and medical care utilization. METHODS: The study population comprised members of 2 health plans residing in 2 South Carolina counties: 417 families from an health maintenance organization (HMO) plan; and 643 families from a Medicaid plan. Participants were followed for 18 months by either bimonthly telephone interviews or personal interviews. The survey/interview collected familial, personal, day-care and disease-related information and medical care utilization. The analyses controlled for both family characteristics and the type of health care plan. RESULTS: Children attending out-of-home day care had higher incidence rates for most gastrointestinal symptoms studied than did children staying at home (2.51 vs. 1.61 episodes of mild gastrointestinal symptoms and 1.63 vs. 1.08 episodes of moderate gastrointestinal symptoms for the HMO group; 1.72 vs. 1.28 episodes of moderate gastrointestinal symptoms for the Medicaid group). Nearly one-fourth of the annual physician visits by children younger than 6 years were attributed to gastrointestinal symptoms, and more than one-fourth of the children with gastrointestinal symptoms were prescribed antibiotics. When displaying gastrointestinal symptoms, children in the Medicaid group were significantly more likely to visit a doctor and receive antibiotics than those in the HMO group. CONCLUSIONS: Although the type of health plan has negligible influence on the frequency of reported gastrointestinal symptoms, it exerts a strong influence on medical care utilization.     

The effects of regular source of care and health need on medical care use among rural adolescents

OBJECTIVE: To examine those factors associated with the use of different types of ambulatory health services in a rural adolescent population. METHODS: The student bodies of 2 middle schools and 2 high schools in rural areas in a mid Atlantic state (N = 1615) were surveyed using a self-administered health status and health services use instrument. Logistic regression was used to assess factors predicting receipt of (1) preventive services, (2) problem-focused services, and (3) emergency services. RESULTS: One third of the rural youth reported having received preventive services within the previous 3 months; 41% received problem-focused care, and 18% received emergency services. Having the same provider for both preventive and illness care was the most consistent and significant predictor of receipt for all types of ambulatory services. Of special note is the greater use of emergency services when subjects did not have a consistent provider for both preventive and illness care. Health need variables, measured across a wide range of domains, were additionally predictive, and their significance varied according to the type of services received. CONCLUSIONS: This study provides compelling evidence that for rural adolescents, having a regular source of care and medical need are the most important predictors of use across a variety of types of ambulatory care.     

Consent for emergency medical services for children and adolescents

Parental consent generally is required for the medical evaluation and treatment of minor children. However, children and adolescents might require evaluation of and treatment for emergency medical conditions in situations in which a parent or legal guardian is not available to provide consent or conditions under which an adolescent patient might possess the legal authority to provide consent. In general, a medical screening examination and any medical care necessary and likely to prevent imminent and significant harm to the pediatric patient with an emergency medical condition should not be withheld or delayed because of problems obtaining consent. The purpose of this policy statement is to provide guidance in those situations in which parental consent is not readily available, in which parental consent is not necessary, or in which parental refusal of consent places a child at risk of significant harm.     

Consent for emergency medical services for children and adolescents

Pediatric patients frequently seek medical treatment in the emergency department (ED) unaccompanied by a legal guardian. Current state and federal laws and medical ethics recommendations support the ED treatment of minors with an identified emergency medical condition, regardless of consent issues. Financial reimbursement should not limit the minor patient's access to emergency medical care or result in a breach of patient confidentiality. Every clinic, office practice, and ED should develop policies and guidelines regarding consent for the treatment of minors. The physician should document all discussions of consent and attempt to seek consent for treatment from the family or legal guardian and assent from the pediatric patient. Appropriate medical care for the pediatric patient with an urgent or emergent condition should never be withheld or delayed because of problems with obtaining consent. This statement has been endorsed by the American College of Surgeons, the Society of Pediatric Nurses, the Society of Critical Care Medicine, the American College of Emergency Physicians, the Emergency Nurses Association, and the National Association of EMS Physicians.     

Physician attitudes toward confidential care for adolescents

We examined factors that determine whether pediatricians will grant confidential care to adolescents. Through four vignettes, in which adolescents of different ages and maturity requested confidential care, we assessed the willingness of physicians to give such care for four problems: request for contraceptive, diagnosis of gonorrhea, intrauterine device found incidentally on x-ray study, and illicit drug use. A random sample of 932 physicians responded to the vignettes. Overall, physicians agreed to give confidential care to adolescents in 75% of the vignettes. They were more likely to give confidentiality in cases involving sexual activity. They supported confidential care for 87% of patients requesting contraceptives, but for only 54% reporting illicit drug use. The proportion of physicians supporting confidentiality increased with age and maturity of the minors. Seventeen-year-old mature adolescents seeking contraceptives were given confidentiality by 97% of physicians. Thus physician responses to vignettes indicated that they strongly support confidential care for adolescents as represented in the clinical vignettes.     

A physical activity screening measure for use with adolescents in primary care

OBJECTIVE: To develop a reliable and valid physical activity screening measure for use with adolescents in primary care settings. STUDY DESIGN: We conducted 2 studies to evaluate the test-retest reliability and concurrent validity of 6 single-item and 3 composite measures of physical activity. Modifications were based on the findings of the 2 studies, and a best measure was evaluated in study 3. Accelerometer data served as the criterion standard for tests of validity. RESULTS: In study 1 (N = 250; mean age, 15 years; 56% female; 36% white), reports on the composite measures were most reliable. In study 2 (N = 57; mean age, 14 years; 65% female; 37% white), 6 of the 9 screening measures correlated significantly with accelerometer data. Subjects, however, had great difficulty reporting bouts of activity and distinguishing between intensity levels. Instead, we developed a single measure assessing accumulation of 60 minutes of moderate to vigorous physical activity. Evaluated in study 3 (N = 148; mean age, 12 years; 65% female; 27% white), the measure was reliable (intraclass correlation, 0.77) and correlated significantly (r = 0.40, P<.001) with accelerometer data. Correct classification (63%), sensitivity (71%), and false-positive rates (40%) were reasonable. CONCLUSION: The "moderate to vigorous physical activity" screening measure is recommended for clinical practice with adolescents.