Contribution of Social Determinant of Health Factors to Rural-Urban Preventive Care Differences Among Medicaid Enrollees

Objective1) Assess whether rural-urban disparities are present in pediatric preventive health care utilization; and 2) use regression decomposition to measure the contribution of social determinants of health (SDH) to those disparities.MethodsWith an Ohio Medicaid population served by a pediatric Accountable Care Organization, Partners For Kids, between 2017 and 2019, we used regression decomposition (a nonlinear multivariate regression decomposition model) to analyze the contribution of patient, provider, and SDH factors to the rural-urban well-child visit gap among children in Ohio.ResultsAmong the 453,519 eligible Medicaid enrollees, 61.2% of urban children received a well-child visit. Well-child visit receipt among children from large rural cities/towns and small/isolated towns was 58.2% and 55.5%, respectively. Comparing large rural towns to urban centers, 55.8% of the 3.0 percentage-point difference was explained by patient, provider, and community-level SDH factors. In comparing small/isolated town to urban centers, 89.8% of the 5.7 percentage-point difference was explained by these characteristics. Of provider characteristics, pediatrician providers were associated with increased well visit receipt. Of the SDH factors, unemployment and education contributed the most to the explained difference in large rural towns while unemployment, education, and food deserts contributed significantly to the small/isolated town difference.ConclusionsThe receipt of pediatric preventive care is slightly lower in rural communities. While modest, the largest part of the rural-urban preventive care gap can be explained by differences in provider type, poverty, unemployment, and education levels. More could be done to improve pediatric preventive care in all communities.     

Dental Care Differences Among the Behavioral Health Population in an Accountable Care Organization: A Retrospective Cohort

ObjectiveTo compare dental utilization and expenditures between children with and without behavioral health (BH) diagnoses in an accountable care organization.MethodsThis retrospective cohort study used enrollment and claims data of Medicaid-enrolled children in Ohio. Children with 7 years of continuous enrollment from 2013 to 2019 were included. We calculated 5 dental utilization outcomes: 1) Diagnostic only visits, 2) Preventive visits, 3) Treatment visits, 4) Treatment visits under general anesthesia (GA), and 5) Orthodontic visits. Total 7-year cumulative expenditures were calculated for each outcome. Multivariable logistic regression models were run for each outcome adjusting for demographics and medical comorbidities.ResultsAmong 77,962 children, 23% had ≥1 BH diagnosis. No utilization differences were noted between children with and without BH for diagnostic only visits, treatment visits, and orthodontic visits. BH status modified the likelihood of having a preventive visit and dental GA visits based on medical comorbidity. For example, children with BH diagnoses had significantly lower odds of a preventive visit (eg, non-complex chronic comorbidity: odds ratio [OR] = 0.87, 95% confidence interval [CI]: 0.85–0.89), and significantly higher odds of a dental treatment under general anesthesia visit (eg, non-chronic comorbidity: OR = 3.69, 95% CI: 3.26–4.18). The total cumulative dental expenditures were $10.5M greater for children with BH.ConclusionsChildren with BH diagnoses were significantly less likely to have preventive visits and more likely to have dental GA visits, which was expensive. Early identification and intervention could alter treatment approaches, improve care, reduce risk of harm, and achieve cost-savings within a pediatric accountable care organization.     

Association of Parent Preventive Care with their Child's Recommended Well-Child Visits

BackgroundReceipt of recommended well-child care is lowest for children without insurance, many of whom receive care in community health centers (CHCs).ObjectiveTo understand if there is an association between parent preventive care and their children's well-child visits.MethodsWe used electronic health record data to identify children and link them to parents both seen in an OCHIN network (CHC; n = 363 clinics from 17 states), randomly selected a child aged 3 to 17 with ≥1 ambulatory visit between 2015 and 2018. We employed a retrospective, cohort study design and used general estimating equations Poisson regression to estimate yearly rates of well-child visits based on parent preventive care adjusted for relevant covariates and stratified by child age for 3 linked samples: mother only, father only, and two parents.ResultsWe included 75,398 linked mother only pairs, 12,438 in our father only, and 4,156 in our 2-parent sample. Children in the mother only sample had a 6% greater rate of yearly well-child visits when their mother received preventive care (adjusted rate ratio [ARR] = 1.06; 95% CI = 1.03–1.08) compared to no preventive care. Children in the father only sample had a 7% greater rate of yearly well-child visits when their father received preventive care (ARR = 1.07; 95% CI = 1.04–1.11) versus no preventive care. Children in the two parent sample had an 11% greater rate of yearly well-child visits when both parents received preventive care (ARR = 1.11; 95% CI = 1.03–1.19) compared to neither receiving preventive care.ConclusionsThese findings suggest focusing on receipt of healthcare for the whole family may improve well-child visit rates.     

Preventive health care utilization. Prenatal and the first 3 years in a Utah population

The utilization of preventive health care services prenatally and for children up to 3 years old was determined by mailed questionnaire. The parents surveyed were randomly chosen from birth records provided by the Utah Bureau of Vital Records. "Adequate use of preventive services" was defined as six prenatal visits for a full-term pregnancy and as seven well-child visits during the first 3 years of life. Responses, received from 219 (36.5%) parents, indicated only 1 percent did not utilize adequate prenatal care. Women made an average of 11.3 visits during their pregnancies; 83 percent saw their prenatal health care provider at least 10 times. Well-child visits were less adequately utilized, an average of 6.3 visits per child. Fifty-six percent made fewer than seven visits; only 23 percent made all of the nine visits recommended by the American Academy of Pediatrics. Patients who made seven or more well-child visits were more likely to have received their fourth diphtheria, pertussis, tetanus (DTP) immunization and to have health insurance policies that paid for preventive health care services. Results indicate that families use preventive services more consistently before the birth of their children than after. Use of preventive services is associated with adequate insurance coverage and results in more thorough immunization.     

Timeliness of Immunizations in CenteringParenting

ObjectiveTo evaluate the timeliness of immunizations of children in CenteringParenting (Centering), a group well-child model, compared to children in individual well-child care.MethodsWe conducted a retrospective cohort study of infants born October 1, 2014 to February 18, 2019 with a 2-month and subsequent well-child visit, both Centering or individual, at an academic pediatric practice in an urban, low-income community. In Centering, same age infants/mothers and a provider meet for 10, 2-hour group visits, and facilitated discussions. Providers are trained in group facilitation and participate in both Centering and individual visits. Primary outcome was timeliness of immunizations at 7, 13, 19, and 25 months. Analyses were by intention to treat.ResultsThe study population included 1735 children (Centering n = 342, individual n = 1393). By 25 months, 62% of children in Centering were up to date with all recommended immunizations compared to 44.2% of children in individual care, a 17.8% higher rate (P < .001). By 25 months, children in Centering made 3 additional well-child visits (9.2 vs 6.2, P < .001). Mediation analysis showed 82% of the effect on up to date status was due to increased attendance to well-child visits (P < .001); the remaining 18% was due to a Centering effect beyond the visit increase.ConclusionsOur study showed a strong association of CenteringParenting with timeliness of immunizations and adherence to well-child visits compared to individual visits in a low income community. These findings warrant further exploration of the impact of Centering in reducing health disparities in communities at risk.     

How much time is spent on well-child care and vaccinations?

CONTEXT: Because well-child care represents the most important prevention opportunity in the health care system, a growing number of activities and indicators have been proposed for it. OBJECTIVE: To measure the time spent in the various components of well-child care. DESIGN: Time-and-motion study. SETTING: Five private pediatric practices and 2 public providers in Rochester, NY. PARTICIPANTS: One hundred sixty-four children younger than 2 years. MAIN OUTCOME MEASURE: Duration of family's encounters with the primary care provider (physician or nurse practitioner), nurse, and other personnel. RESULTS: The median encounter times and their component parts in minutes were: (1) primary care provider, 16.3 (physical examination, 4.9; vaccination discussion, 1.9; discussion of other health issues, 9.5; vaccination administration, 0); (2) nurse, 5.6 (physical examination, 3.5; vaccination discussion, 0; other health discussion, 0; vaccine administration, 1.6); and (3) other personnel, 0 for all categories. Public provider setting, African American race of the child, and administration of 4 vaccinations were significantly associated with an increase (3-4 minutes) in the duration of the primary care provider encounter. Only 8 (5%) of families read vaccine information materials. CONCLUSIONS: Depending on whether a child makes the usual 3 or recommended 6 number of well-child visits, the total time of well-child care is 45 to 90 minutes during the first year of life and declines to less than 30 minutes per year thereafter as the number of recommended visits diminish. Because high-risk children make half as many well-child care visits as other children, a 3 to 4 minute increase in encounter time is insufficient to provide them with the same level of care as other children.     

The Impact of the 2007 Expert Committee Recommendations on Childhood Obesity Preventive Care in Primary Care Settings in the United States

ObjectivesIn this study we examined the impact of the Expert Committee Recommendations (ECRs) on childhood obesity preventive care during well-child visits in the United States.MethodsData from the 2006-2009 National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey–outpatient department were used to examine frequencies of diet/nutrition and exercise counseling during well-child visits by children aged 2 to 18 years. Differences in rates of the counseling before and after the ECRs were made were compared.ResultsOnly 37% and 22% of all patients in 2006-2007 and 33% and 18% of all patients in 2008-2009 were provided with diet/nutrition and exercise counseling, respectively. The frequencies of counseling for patients with a diagnosis of obesity showed no change. Socioeconomically disadvantaged children received counseling less frequently after the ECRs were made.ConclusionOverall, rates of obesity preventive care were low in all years, with no evidence of improvement after the ECRs were made. Systematic approaches are needed to improve delivery of obesity preventive care irrespective of the socioeconomic backgrounds of children.     

Income-Based Disparities in a Yearly Dental Visit in United States Adults and Children: Trend Analysis 1997 to 2016

ObjectiveTo determine how income-based disparities in a yearly dental visit (the Healthy People 2020 Leading Health Indicator for Oral Health) changed since legislation to expand dental coverage and to compare disparity trends in children and adults.MethodsWe analyzed Medical Expenditure Panel Survey 1997 to 2016 to determine yearly dental visit rates for US children and adults by family income. We determined measures of income disparity, including the Slope Index of Inequality and the Relative Index of Inequality and examined trends in yearly dental visit, Slope Index of Inequality, and Relative Index of Inequality using joinpoint regression.ResultsIncome-based disparities, absolute and relative, narrowed over time for children. Steady upward trends in yearly dental visit rates were observed for poor and low-income/poor children and no joinpoint was identified that corresponded to legislation expanding dental care coverage for lower income children. Relative income-based disparities in yearly dental visit rates widened for adults over 20 years. After declining for 14 years, yearly dental visit rate increased for poor adults from 2013 to 2016 suggesting a possible positive effect in adult dental care use trends following enactment of the Affordable Care Act.ConclusionsIn 1997, US children and adults had similar levels of income-based disparity in yearly dental visits, but by 2016, they differed markedly. Trends in income-based disparities in yearly dental visit rate narrowed for children but widened for adults. There are lessons from the expansion of dental care coverage for children that could be applied to improve access to dental care for adults.     

Preventive Asthma Care Delivery in the Primary Care Office: Missed Opportunities for Children With Persistent Asthma Symptoms

ObjectiveTo describe which National Heart Lung and Blood Institute preventive actions are taken for children with persistent asthma symptoms at the time of a primary care visit and determine how care delivery varies by asthma symptom severity.MethodsWe approached children (2 to 12 years old) with asthma from Rochester, NY, in the waiting room at their doctor's office. Eligibility required current persistent symptoms. Caregivers were interviewed via telephone within 2 weeks after the visit regarding specific preventive care actions delivered. Bivariate and regression analyses assessed the relationship between asthma symptom severity and actions taken during the visit.ResultsWe identified 171 children with persistent asthma symptoms (34% black, 64% Medicaid) from October 2009 to January 2011 at 6 pediatric offices. Overall delivery of guideline-based preventive actions during visits was low. Children with mild persistent symptoms were least likely to receive preventive care. Regression analyses controlling for demographics and visit type (acute or follow-up asthma visit vs non-asthma-related visit) confirmed that children with mild persistent asthma symptoms were less likely than those with more severe asthma symptoms to receive preventive medication action (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.14–0.84), trigger reduction discussion (OR 0.39, 95% CI 0.19–0.82), recommendation of follow-up (OR 0.40, 95% CI 0.19–0.87), and receipt of action plan (OR 0.37, 95% CI 0.16–0.86).ConclusionsMany children with persistent asthma symptoms do not receive recommended preventive actions during office visits, and children with mild persistent symptoms are the least likely to receive care. Efforts to improve guideline-based asthma care are needed, and children with mild persistent asthma symptoms warrant further consideration.     

Oral health care for children – a call for action

Oral health is a fundamental component of overall health. All children and youth should have access to preventive and treatment-based dental care. Canadian children continue to have a high rate of dental disease, and this burden of illness is disproportionately represented by children of lower socioeconomic status, those in Aboriginal communities and new immigrants. In Canada, the proportion of public funding for dental care has been decreasing. This financial pressure has most affected low-income families, who are also less likely to have dental insurance. Publicly funded provincial/territorial dental plans for Canadian children are limited and show significant variability in their coverage. There is sound evidence that preventive dental visits improve oral health and reduce later costs, and good evidence that fluoridation therapy decreases the rate of dental caries, particularly in high-risk populations. Paediatricians and family physicians play an important role in identifying children at high risk for dental disease and in advocating for more comprehensive and universal dental care for children.     

Parental Perceptions of Culturally Sensitive Care and Well-Child Visit Quality

ObjectiveIncorporating culturally sensitive care into well-child visits may help address pediatric preventive care disparities faced by racial and ethnic minorities, families with limited English proficiency, and immigrants. We explored parents’ perspectives about the extent to which their children's pediatric care is culturally sensitive and potential associations between culturally sensitive care and well-child visit quality.MethodsWe conducted cross-sectional surveys with parents attending a well-child visit for a child ages 3 to 48 months. To measure culturally sensitive care, we created a composite score by averaging 8 subscales from an adapted version of the Clinicians’ Cultural Sensitivity Survey. We assessed well-child visit quality through the Promoting Healthy Development Survey. Multivariate linear regression was used to understand associations between demographic characteristics and parent-reported culturally sensitive care. We used multivariate logistic regression to examine associations between culturally sensitive care and well-child visit quality.ResultsTwo hundred twelve parents (71% of those approached) completed the survey. Parents born abroad, compared with those born in the United States, reported significantly higher culturally sensitive care scores (+0.21; confidence interval [CI]: 0.004, 0.43). Haitian parents reported significantly lower culturally sensitive care scores compared with non-Hispanic white parents (−0.49; CI: −0.89, −0.09). Parent-reported culturally sensitive care was significantly associated with higher odds of well-child visit quality including receipt of anticipatory guidance (adjusted odds ratio: 2.68; CI: 1.62, 4.62) and overall well-child visit quality (adjusted odds ratio: 2.54; CI: 1.59, 4.22).ConclusionsConsistent with prior research of adult patients, this study demonstrates an association between parent-reported culturally sensitive care and well-child visit quality. Future research should explore best practices to integrating culturally sensitive care in pediatric preventive health care settings.     

Differences in Frequency of Visits to Pediatric Primary Care Practices and Emergency Departments by Body Mass Index

ObjectivesTo examine differences in utilization across health care settings among children by body mass index (BMI) categories to help identify opportunities for interventions.MethodsA retrospective study was conducted using 1 year of electronic health records following an index primary care visit for children 3 to 17 years old in 2016. Index visits occurred at >40 pediatric practices affiliated with a Northeastern health system. Using normal BMI as a reference group, we examined the extent to which children's BMI percentile categories were associated with primary care visits, emergency department (ED) visits, hospitalizations, and ED visit acuity. Age, sex, race/ethnicity, and insurance status were used as covariates.ResultsOf those with biologically plausible values for height and weight (n = 30,352), the prevalences of overweight, obesity, and severe obesity were 16.3%, 12.4%, and 5.7%, respectively. Children outside of the normal BMI range made more primary care visits; however, relative patterns of ED utilization were not consistent. Children with obesity versus normal BMI were less likely to have ED visits of high acuity. Risk of hospitalization was higher among children with overweight or severe obesity.ConclusionsChildren's BMI categories were associated with health care utilization, specifically primary care visits, ED visits, and hospitalizations. Further investigation is needed to explore the drivers of these differences in utilization, such as the impact of stigma and perceived weight bias on care-seeking patterns, and to examine the role of settings outside of primary care in pediatric weight management.     

Dental concerns unrelated to trauma in the pediatric emergency department: barriers to care

OBJECTIVES: To describe patients with nontraumatic dental problems treated in our pediatric emergency department (PED) and to determine if barriers to access prompted seeking care in the PED rather than from a dentist or dental clinic. DESIGN: Questionnaire administered to a convenience sample of patients with nontraumatic dental complaints. SETTING: An urban PED. MAIN OUTCOME MEASURES: Insurance status, primary medical and dental care, duration of symptoms, diagnosis, and reason for seeking care in the PED. RESULTS: Two hundred patients were enrolled. Median age was 17 years (range, 1-22 years). Forty-five percent were African American. Forty-nine percent had Medicaid. Fifty percent identified a regular dentist, whereas 71% had a primary care physician. Thirty-four percent of patients 4 years and older had not seen a dentist in more than a year. Children younger than 13 years were more likely than teenagers to identify a regular dentist (odds ratio [OR] = 2.8; 95% confidence interval [CI], 1.3-6.1). Those with a regular medical provider were more likely to have a regular dentist (OR = 7.7; 95% CI, 3.4-18). The most common reasons for not going to a dentist were as follows: dentist closed, 34%; lack of dental insurance or money, 17%; and lack of a dentist, 16%. Patients with symptoms for more than 72 hours were more likely to cite lack of a dentist as their reason for coming to the PED (OR = 7.4; 95% CI, 1.9-33). CONCLUSIONS: Many pediatric patients do not have regular dental care, and this is associated with a lack of primary medical care. Access barriers to acute dental care include lack of insurance or funds, lack of a dentist, and limited hours of dental care sites. Improved insurance reimbursement, active enrollment of adolescents into preventive dental care, and expansion of provider hours may limit PED dental visits and improve the health of patients.     

Association Between Insurance Type and Fluoride Varnish Application During Well-Child Visits in Massachusetts

ObjectiveTo compare rates of fluoride varnish (FV) applications during well-child visits for children covered by Medicaid and private medical insurance in Massachusetts.MethodsThis cross-sectional study analyzed well-child visits for children aged 1 to 5 years paid by Medicaid and private insurance during 2016.Çô18 in Massachusetts. Multivariate regression models, with all covariates interacting with insurance type, were used to calculate odds ratios and adjusted predicted probabilities of fluoride varnish during well-child visits by calendar year and age.ResultsAcross 957,551 well-child visits, 40.0% were paid by private insurers. Unadjusted rates of fluoride varnish were significantly lower among well-child visits paid by private insurers (6.6%) than visits paid by Medicaid (14.2%). In the fully interacted regression model, the odds of a visit including fluoride varnish were significantly lower for older children than for children aged 1 for visits paid by both insurance types. Adjusted rates of fluoride varnish increased significantly from 2016 to 2018 for both insurance types. Moreover, rates were higher among visits for children covered under Medicaid than privately insured children in all years, and the differences by insurance type declined over time (2016: 8.0% points, 95% confidence interval.á=.á.êÆ8.7 to .êÆ7.3, 2018: 5.3% points, 95% confidence interval.á=.á.êÆ6.6 to .êÆ3.9).ConclusionsRates of fluoride varnish applications during well-child visits were low for both Medicaid and private insurance despite growth from 2016 to 2018 in Massachusetts. Low rates are concerning because this is a recommended service with the potential to help address racial, geographic, and income-based disparities in access and oral health outcomes.     

Utilization of well-child care services for African-American infants in a low-income community: results of a randomized, controlled case management/home visitation intervention

OBJECTIVE: To evaluate a case management/home visitation intervention to improve access to and utilization of well-child care (WCC) visits. STUDY DESIGN: Randomized, controlled trial with baseline and follow-up interview surveys. Mothers and infants in the intervention group were assigned to a case manager who made at least four home visits during the infant's first year of life. In addition, the case managers contacted clients by telephone and mail to see if they had kept their WCC appointments and to follow up on other issues. SAMPLE AND DATA COLLECTION: A population-based random sample of African-American mothers of newborns from South Central Los Angeles: 185 mothers in the intervention group and 180 in the control group completed both interview surveys. The principal outcome variable was number of WCC visits. Additional outcome variables included the child's type of insurance, the number of months with insurance coverage during the first year of life, age when first enrolled in Medi-Cal, age at the first WCC visit, usual source of WCC, travel time to the usual source of care, whether the child had a regular provider, and whether the child ever needed care but did not get it. RESULTS: There was little change in the overall distribution of number of WCC visits during the first year of life. Comparisons of the cumulative numbers of visits for each possible cutoff showed that children in the intervention group were more likely than children in the control group to have at least four visits (81% vs 70%). Because this split was identified empirically rather than through an antecedent hypothesis, we conducted a Smirnov test to account for multiple comparisons. This test showed a reduced level of significance. Other outcome variables did not show significant differences for the control and intervention groups. CONCLUSIONS: In light of the high expense of this intervention, our evaluation shows that our moderate-intensity case management and home visitation program is not an effective way to increase the number of WCC visits.     

Missing documentation of weight and height at preventive visits for children

Despite the importance of measuring weight and height at well-child visits, there are limited data on frequency of anthropometric documentation. The authors aimed to identify characteristics associated with missing weight and height documentation at preventive visits for children. Among preventive visits for children from birth to 18 years old, recorded in the National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys for 2005-2009, the authors found that 20.8% had missing weight and/or height (n = 19 033) documentation. Compared with infants younger than 2 years, school-age children (odds ratio [OR] = 1.30; 95% confidence interval [CI] = 1.03-1.64), and adolescents (OR = 1.61; 95% CI = 1.26-2.04) were more likely to lack documentation. Missing documentation was also more likely for visits with nonphysicians (OR = 4.53; 95% CI = 3.17-6.48) and nonpediatricians (OR = 2.63; 95% CI = 2.02-3.41) compared with pediatricians. Efforts to improve weight and height surveillance should be directed to clinics in which midlevel providers and nonpediatric physicians are caring for school-age children and adolescents.