Regional Racial and Ethnic Differences in Mortality for Congenital Heart Surgery in Children May Reflect Unequal Access to Care

The objective of this study was to explore racial differences in mortality for congenital heart surgery. We performed a population-based retrospective cohort study using hospital discharge abstract data from four states in 1996. The outcome measure was risk-adjusted in-hospital mortality. Cases of pediatric congenital heart surgery were classified into six risk categories using the Risk Adjustment in Congenital Heart Surgery method. Differences in risk-adjusted in-hospital mortality among racial groups were explored. Analyses stratified by state were used to identify regional differences. Of 5791 cases, 4822 (83%) were assigned to a risk group for analysis. Surgical mortality differed for whites compared to non-whites (3.7 vs 5.1%, p = 0.02). Among non-white groups, unadjusted mortality rates varied: Asian, 5.3%; black, 4.1%; Hispanic 4.9%; other, 7.3%; and missing, 7.6% (p = 0.008). Adjusted mortality also differed by race but was inconsistent across regions, making explanatory factors based solely on biology implausible. For example, compared to whites, blacks had a higher risk of dying in Massachusetts [odds ratio (OR) = 6.39, p = 0.08] but lower in Pennsylvania (OR = 0.41, p = 0.009). Adding insurance type to models did not eliminate racial differences. In risk-adjusted analyses, non-white groups had a higher risk of dying after congenital heart surgery than whites. Inconsistent effects among regions suggest that differential mortality is due to unequal access to care rather than biology.     

Racial and Insurance Disparities in Hospital Mortality for Children Undergoing Congenital Heart Surgery

Many studies of racial and insurance disparities after congenital heart surgery have used limited regional data over short periods. This study examines the association of race and insurance with hospital mortality using a national hospitalization database spanning almost a decade. A retrospective, repeated cross-sectional analysis was performed. All the admissions from the Kids' Inpatient Database from 1997 through 2006 that fit a Risk Adjustment for Congenital Heart Surgery-1 category were examined. Multivariate logistic regression models examining hospital mortality, nonelective admission, and referral to high-mortality hospitals were constructed. Medicaid insurance [odds ratio (OR) 1.26, 95% confidence interval (CI) 1.09-1.46] and nonwhite race (OR 1.36, 95% CI 1.19-1.54) were independent risk factors for mortality. Furthermore, Medicaid insurance (OR 1.23, 95% CI 1.15-1.31) and nonwhite race (OR 1.26, 95% CI 1.19-1.34) were associated with nonelective admission for congenital heart surgery. Finally, children with Medicaid insurance (OR 1.18, 95% CI 1.10-1.27) and black children (OR 1.30, 95% CI 1.17-1.44) had higher odds of referral to high-mortality hospitals. Over the past decade, children undergoing congenital heart surgery continued to experience admission, referral, and survival disparities based on insurance and racial status.     

Racial and Ethnic Disparities in Mortality Following Congenital Heart Surgery

Our objective was to assess risk-adjusted racial and ethnic disparities in mortality following congenital heart surgery. We studied 8483 congenital heart surgical cases from the Kids' Inpatient Database 2000. Black sub-analysis was performed using predetermined regional categories. For our Hispanic sub-analyses, we categorized Hispanics into state groups according to a state's predominant Hispanic group: West (Mexican-American), Southeast (Cuban-American), Northeast (Puerto Rican), and Mixed/Heterogeneous. Risk adjustment was performed using the Risk Adjustment for Congenital Heart Surgery method. Multivariate analyses assessed the effect of race/ethnicity and Hispanic state group on mortality and explored the effects of gender, income, insurance type, and region. Black children had a higher risk for death than Whites odds ratio (OR), [1.65; p = 0.003]. Hispanics and the Cuban-American state group showed a trend toward a higher death risk (Hispanic: OR, 1.24; p = 0.16; Southeast Cuban-American: OR 1.55; p = 0.08). Disparities were not influenced by insurance. Among Blacks, disparities were greatest in the Northeast region (OR, 2.25; p = 0.007). After adjusting for gender, income, and region, Blacks (OR, 1.76; p = 0.002) and Hispanics (OR, 1.34; p = 0.05) had a higher death risk. Racial and ethnic disparities in risk-adjusted mortality following congenital heart disease exist for Blacks and Hispanics. These disparities are not due to insurance but are partially explained by gender and region.     

Networks in Canadian paediatric surgery: Time to get connected

There has been a recent trend of improved outcomes for most infants born with surgically correctable congenital malformations, despite the fact that current surgical treatment is not standardized, with wide variations in practice among institutions. Because care for these infants is multidisciplinary, it is difficult to ascertain with clarity the specific role of neonatal surgery in determining outcomes. Moreover, the lack of validated measures of illness severity for most complex congenital malformations makes risk adjustment difficult. For these reasons, the utility of randomized controlled trials in determining best surgical practice in neonatal surgery for congenital malformations is impractical, and another means of deriving medical evidence to justify ‘optimal’ treatment is necessary.The Canadian Paediatric Surgical Network (CAPSNet) was developed specifically to address these issues. Patterned after the highly successful Canadian Neonatal Network, CAPSNet collects standardized data on every case of gastroschisis and congenital diaphragmatic hernia evaluated in the 16 referral perinatal centres in Canada. These centres serve as provincial referral centres for perinatal care, and, therefore, the data set created is population-based for gastroschisis and congenital diaphragmatic hernia in Canada. In addition to neonatal data fields recorded in the Canadian Neonatal Network, CAPSNet collects specific prenatal data, and details on surgical treatment and outcomes within each of the 16 participating centres. It is hoped that by using advanced analytical techniques, including outcomes modelling and multiple logistic regression analysis of risk-adjusted outcome variations by type of surgery performed, optimal treatment paradigms will be identified that will lead to further outcome improvement in babies born with complex birth defects.     

A comparison of health care experiences for medicaid and commercially enrolled children in a large, nonprofit health maintenance organization.

BACKGROUND: Proponents of Medicaid managed care have argued that this type of care offers the potential to provide mainstream health care for poor children and the elimination of the 2-tier system of care that has long existed for poor and nonpoor children. However, few studies have attempted to assess whether differences in access, utilization, and satisfaction exist between Medicaid and commercially sponsored children who are enrolled in the same managed care plan. OBJECTIVE: To systematically answer the following research question: Within the same large, nonprofit, group-model health maintenance organization (HMO), how do children enrolled in Medicaid compare with children enrolled commercially across the domains of access, utilization, and satisfaction with care? METHODS: We compared access, satisfaction, and utilization of services between Medicaid and commercially sponsored children enrolled in Kaiser Permanente of Northern California during 1998 through use of a telephone survey and administrative data. Kaiser Permanente is a nonprofit, integrated, group HMO that serves 2.8 million members in more than 15 counties in northern California. The sample for this survey included 510 Medicaid-enrolled children and 512 commercially enrolled children. An overall response rate of 82% was achieved. Bivariate and multivariate analyses were used to compare Medicaid and commercially enrolled children. RESULTS: We found few differences between commercial and Medicaid enrollees across the domains of access, utilization, and satisfaction. Where access differences were present (problems in finding a personal care provider, problems getting care overall, and experiencing 1 or more barriers to care), the differences favored Medicaid-enrolled children. That is, Medicaid enrollees were reported to experience significantly fewer access problems and barriers than commercial enrollees, even after adjustment for confounding factors. Only one difference was found between Medicaid and commercial enrollees across the 6 utilization variables examined (volume of emergency department visits), and no differences were found among the 4 satisfaction and 2 global assessments of care received. Taken together, our results suggest that Medicaid-enrolled children experience as good as or better care than their commercially enrolled counterparts. However, there are other possible explanations for our findings. It may be that families of Medicaid-enrolled children hold their care providers to a lower standard than families of commercially enrolled children, given historic inequities in care between poor and nonpoor families. In addition, some degree of selection bias may be present in our sample, although that is true for both the Medicaid and commercial populations. CONCLUSIONS: Our findings suggest that large commercial HMOs are capable of eliminating the access barriers and stigma traditionally associated with the Medicaid program. However, this conclusion must be tempered with the knowledge that other explanations for our findings may also be at play.     

The Aristotle method: a new concept to evaluate quality of care based on complexity

PURPOSE OF REVIEW: Evaluation of quality of care is a duty of the modern medical practice. A reliable method of quality evaluation able to compare fairly institutions and inform a patient and his family of the potential risk of a procedure is clearly needed. It is now well recognized that any method that purports to evaluate quality of care should include a case mix/risk stratification method. No valuable method was available until recently in pediatric cardiac surgery. RECENT FINDINGS: The Aristotle method is a new concept of evaluation of quality of care in congenital heart surgery based on the complexity of the surgical procedures. Involving a panel of expert surgeons, the project started in 1999 and included 50 pediatric surgeons from 23 countries. The basic score adjusts the complexity of a given procedure and is calculated as the sum of potential for mortality, potential for morbidity and anticipated technical difficulty. The Comprehensive Score further adjusts the complexity according to the specific patient characteristics (anatomy, associated procedures, co-morbidity, etc.). The Aristotle method is original as it introduces several new concepts: the calculated complexity is a constant for a given patient all over the world; complexity is an independent value and risk is a variable depending on the performance; and Performance = Complexity x Outcome. SUMMARY: The Aristotle score is a good vector of communication between patients, doctors and insurance companies and may stimulate the quality and the organization of heath care in our field and in others.     

Streptococcus pneumoniae-related illnesses in young children: secular trends and regional variation

BACKGROUND: Children <2 years old have been targeted for routine pneumococcal conjugate vaccine. Laboratory-confirmed illnesses represent a minority of all medical care utilization for pneumococcal disease. OBJECTIVES: To evaluate trends in medical care utilization for Streptococcus pneumoniae-related illnesses before introduction of pneumococcal conjugate vaccine (1995 to 1999) and to evaluate regional variation in utilization. METHOD: Retrospective cohort analysis with the use of computerized billing data of children <2 years old enrolled in Tennessee (Medicaid program) and the Rochester, NY area (commercial and Medicaid managed care plans). Secular trends (1995 to 1999) analysis included 316 519 person-years in Tennessee Medicaid. Regional variation (1998 to 1999) analysis included 130 525 person-years in Tennessee and 26 140 and 3184 person-years in commercial and Medicaid plans, respectively, in the Rochester, NY area. RESULTS: From 1995 to 1999 in Tennessee, the net increase in medical care visits was 12% for pneumococcal and nonspecific pneumonia and invasive disease, 11% for otitis media and 11% for other acute respiratory conditions. Analysis of trends indicated that a significant vaccine effect could be detected if utilization rates declined by 32, 9 and 21%, respectively. In the Tennessee Medicaid population, rates of pneumococcal and nonspecific pneumonia and invasive disease were 60% higher than in either the New York Medicaid or the commercial populations. Children with commercial insurance had the highest medical care utilization for otitis media. CONCLUSIONS: Geographic variation and large population differences in medical care utilization among children < 2 years old in three study populations suggest that the benefits of vaccination may vary by region and by population. In the Tennessee Medicaid population, temporal trends and year-to-year variability of pneumococcal-related outcomes were observed from 1995 to 1999. In this population a 10% decline in otitis media visits after the introduction of pneumococcal conjugate vaccine could be detected by trend analysis.     

Comparisons of Health Care Utilization Outcomes in Children With Asthma Enrolled in Private Insurance Plans Versus Medicaid

ObjectivesVery few studies have captured the differences in the outcomes of pediatric patients based on the patients’ type of health insurance plan. The purpose of this retrospective cohort study was to examine the impact of the type of health insurance plan (public insurance vs. private insurance) on outcomes (health care utilization and medication adherence) in children with asthma.MethodsThis retrospective cohort study analyzed Medicaid/commercial data from eight states licensed under Thomson Medstat. Subjects were 11,027 children with asthma (6435 enrolled in Medicaid and 4592 enrolled in a commercial health maintenance organization) who newly started asthma pharmacotherapy and were followed up for 12 months before and after the index anti-asthmatic medication fill. Data on health care utilization and medication adherence were examined to compare health care utilization–based outcomes. Quantile regression analysis was used to study medication adherence, and Poisson regression was used to determine health care utilization.ResultsPatients with a private insurance plan had significantly higher medication adherence rates (p < .01) compared with those who had a Medicaid plan. Patients with Medicaid plans also were associated with 20% more inpatient hospitalizations and 48% increased odds of emergency department visits, but they had 42% fewer outpatient visits compared with those who had a private plan (all p < .05).ConclusionChildren with asthma who are enrolled in Medicaid receive fairly comprehensive coverage of medical services, and thus further research is needed to determine the reasons for poor health care utilization–related outcomes in this population.     

Congenital heart disease among school children in Alexandria, Egypt: an overview on prevalence and relative frequencies

A study was undertaken to determine the prevalence and relative frequencies of congenital heart diseases diagnosed by echocardiography among school children in Alexandria, Egypt. The study was conducted during a 1-year period (1 May 1995-1 May 1996) at the Students' Health Insurance Hospital, which is a referral center for all health insurance units, providing an echocardiography service. The prevalence of congenital heart diseases (CHD) among school children accounted for 1.01/1,000. There was a male predominance in cases of pulmonary stenosis and single ventricle, while in cases of patent ductus arteriosus, mitral valve prolapse, and partial atrioventricular canal there was a female predominance. The commonest cardiac defects were ventricular septal defects, pulmonary stenosis, and atrial septal defects. Pulmonary stenosis ranked the second commonest defect and is a peculiar finding in our Egyptian population. The mere presence of these cardiac defects in school children is an indicator of the poor quality of care provided to this growing childhood population.     

Multicenter Study of the Effectiveness of Implantable Cardioverter Defibrillators in Children and Young Adults With Heart Disease

Implantable cardioverter defibrillators (ICDs) are being used with increasing frequency in children and young adults. Our aim was to examine the appropriateness and frequency of ICD discharges in children and young adults, to compare the effectiveness of ICDs when placed for primary or secondary prevention, and to provide time-dependent analysis of ICD discharges. Data were collected from seven institutions on 210 patients <30 years of age who underwent ICD implantation from October 1992 to January 2007. Median age at implant was 15.4 years with a follow-up average of 3.3 years. Heart disease was categorized as electrical (n = 90, 42%), cardiomyopathic (n = 62, 30%), or congenital heart disease (n = 58, 28%). ICDs are increasingly placed for primary prevention. There are increased appropriate ICD discharges for ICDs placed for secondary prevention (52%) versus primary prevention (14%) at 5 years. There is no difference in the risk of inappropriate discharges between primary and secondary prevention indications. There is an increased risk for inappropriate therapy in the congenital heart disease population. An increasing number of ICDs are being placed for primary prevention in young patients, a marked shift in practice during the last two decades. The benefits of ICDs remain greater in secondary than in primary-prevention patients. In both groups, approximately 25% of patients received inappropriate discharges within 5 years of implant. Patients with congenital heart disease are the most affected by inappropriate discharges.     

Comparison of preventive care in Medicaid managed care and Medicaid fee for service in institutions and private practices.

OBJECTIVE: To compare preventive screening for children in Medicaid managed care (MMC) with children in Medicaid fee for service (M-FFS) in private and institutional settings. METHODS: The sample included randomly selected institutions and private practice physicians in New York City. Within setting, children in MMC and M-FFS were sampled randomly and charts reviewed for immunizations and lead and anemia screening. RESULTS: In both institutions and private practices, children enrolled in MMC appeared more likely to be up-to-date than their M-FFS counterparts for immunizations (institution, P <.01; private practice, P <.05), lead screening (institution, P <.01; private practice, P <.01), and anemia screening (institution, P <.01; private practice, P <.01). However, children in MMC had more visits (P <.01) and were followed up for a longer time (P <.01). After controlling for these variables, effects of MMC diminished and only remained significant for screening among private physicians. When considering 10 different attributes of managed care plans, no clear pattern of association with better preventive care services was observed. CONCLUSION: The positive effect of managed care on preventive care services was largely explained by more visits and longer follow-up time; however, there were differences between institutions and private practices, with enrollment in MMC associated with some positive effect on screenings in private practices.     

"Narrowing the Gap": decreasing emergency department use by children enrolled in the Medicaid program by improving access to primary care

OBJECTIVE: To evaluate the effectiveness of increased primary care access created by North Carolina's Medicaid managed care plan, Carolina Access (CA), in reducing unnecessary emergency department (ED) use in Guilford County. METHODS: Emergency department records of pediatric visits before and after the implementation of CA were analyzed. Variables included patient age, International Classification of Diseases, Ninth Revision discharge diagnosis, insurance status, date of visit, time of visit, and ZIP code. Visits were classified as either urgent or nonurgent based on discharge diagnosis. Rates of ED use per 1000 persons were calculated using county population and Medicaid enrollment figures. RESULTS: A total of 54,742 ED visits occurred between January 1, 1995, and December 31, 1997. Thirty-eight percent of these visits were by children (defined as those aged 0-18 years in this study) enrolled in the Medicaid program. After the implementation of CA, monthly ED rates per 1000 children with Medicaid insurance decreased 24% from 33.5 +/- 5.3 to 25.6 +/- 2.3 (P<.001), which translates to 158 fewer visits per month by children enrolled in the Medicaid program. Nonurgent visits among the population enrolled in the Medicaid program decreased from an average monthly rate per 1000 of 17.9 +/- 3.5 to 11.2 +/- 2.5 after the implementation of CA (P<.001), accounting for most of the decrease in total visits. (All data are given as mean +/- SD.) The rates of total and nonurgent visits among the population not enrolled in the Medicaid program increased slightly. CONCLUSIONS: For children with Medicaid insurance, we found a strong temporal relation between decreased visits to the ED and increased access to primary care services, services that were made available by the implementation of North Carolina's Medicaid managed care plan, CA. Specific services that may be responsible for the decreased ED use include the expanded availability of primary care physicians and the use of telephone triage systems. No similar decrease in ED use was seen among the non-Medicaid-insured group. Arch Pediatr Adolesc Med. 2000;154:791-795     

Congenital heart disease in India: A status report

Pediatric cardiac care in India is still in its infancy. We have no data on congenital heart disease (CHD) prevalence at birth or on proportional mortality from CHD. The resources are not only limited but also are at times improperly utilized. There are very few specialized pediatric cardiology training programs, those that are, are concentrated in certain regions of India and are often imparted through combined adult and pediatric programs. The existing number of trained personnel for pediatric cardiology and pediatric cardiac surgery is inadequate. Above all there is no national policy for pediatric heart care. Increasing awareness of the problem amongst the pediatricians through CMEs, seminars, symposia is likely to be most helpful in early diagnosis and timely referral of cases. Training programs exclusively dedicated to pediatric cardiology and pediatric cardiac surgery need to be established in centres with good standards of pediatric cardiac care.     

Outcomes following surgery for congenital heart disease in low-birthweight infants

AIM: To describe cardiac surgery, survival and outcomes for low-birthweight (< or = 2500 g) infants undergoing surgery for congenital heart disease. METHODS: Using data from a prospectively collected population-based database of admissions to neonatal intensive care units in New South Wales and the Australian Capital Territory, we identified all low-birthweight infants undergoing cardiac surgery between 1992 and 2001. Infants with only a persistent ductus arteriosus were excluded. Two-year cardiac and neurodevelopmental outcome data were sought from hospital medical records. RESULTS: A total of 121 low-birthweight infants underwent cardiac surgery, of whom 34% had a congenital syndrome or non-cardiac birth defect. Most (81%) underwent a palliative surgical procedure in the neonatal period. There were 19 early (15.7%) and 19 late deaths giving a 2-year mortality of 31%. Factors associated with mortality included birthweight below 1500 g (P = 0.006), low weight at surgery (P = 0.028) and Apgar score at 1 min (P = 0.019). No single factor predicted 30-day mortality. By 2 years of age, 27 (33% of survivors) were known to have neurodevelopmental delay. Although 22 children are known to be developing normally, the neurodevelopmental status of 34 children was not known. CONCLUSIONS: These surgical data were comparable to previous single-institution studies. This group had a high risk of disability due to prematurity, low birthweight and associated conditions. There is a need to prospectively assess and manage neurodevelopmental outcomes in this group.     

HIV infection and in-hospital mortality at an academic hospital in South Africa.

AIM: To document the impact that rapid increases in HIV infection in hospitalised children at Chris Hani Baragwanath Hospital has had on in-hospital mortality. METHODS: Hospital discharge summaries from January 1992 to the end of 1996 were reviewed. RESULTS: There were 20 733 admissions in the five year period; 7985 (39%) were tested for HIV. In tested admissions above 15 months of age, 4.9% were HIV infected in 1992, increasing to 35% in 1996. Under 15 months of age, 9% of tested admissions were positive in 1992, increasing to 46% in 1996. The proportion of all hospital deaths occurring in children considered HIV infected (ELISA testing together with clinical features if 15 months or younger) increased from 6.7% in 1992 to 46. 1% in 1996 (p < 0.001). In-hospital mortality for all children increased by 21% from 4.3% in 1992 to 5.2% in 1996. Mortality rates declined in uninfected children from 5.4% in 1992 to 4.5% in 1996 (chi(2) trend 3.3; p = 0.06). CONCLUSION: The mortality rate of children has increased at Chris Hani Baragwanath Hospital as a result of HIV infection. Almost half the deaths were HIV related in 1996. HIV infection is threatening the advances that have been made on child survival in South Africa over the last few decades.     

Application of a Complication Screening Method to Congenital Heart Surgery Admissions

There have been comprehensive screening methods developed to identify unwanted inpatient events. A comprehensive assessment of complication diagnoses during congenital heart surgery admissions has not been performed. We examined the frequency of complications identified by a complication screening method and their relationship to patient characteristics among congenital heart surgery admissions. Data were obtained from the Healthcare Cost and Utilization Project Kids' Inpatient Database 2000. Among congenital heart surgery admissions, age < or =20 years, we identified International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) codes indicating complication. Complication diagnoses were categorized as related to drug/biologic, procedures, devices, implants and grafts, and radiation. We used the Risk Adjustment for Congenital Heart Surgery risk categories (1-6) to examine the association between case complexity and complications. Multivariate analyses estimated the odds for a complication diagnosis by patient characteristics, including age, prematurity, chromosomal anomalies, noncardiac structural anomalies, and surgical risk category. Among 12,717 cases, 4014 (32%) had at least 1 complication diagnosis code. Procedure-related complication diagnoses represented 75% of complication diagnoses; device, implant, or graft represented 21%; drug/biologic represented 4% and radiation represented 0%. Multivariate analyses demonstrated that higher surgical case complexity and older age had a greater risk for a complication diagnosis: Risk Category 2, odds ratio (OR) 1.8; 3 OR 2.9; 4 OR 2.9; 5 OR 5.0; 6 OR 4.1, relative to category 1, all p < 0.01; age > or =12 years, OR 1.3, p < 0.001; <1 year OR 1.1, p = 0.31. Premature cases had decreased odds OR 0.4, p < 0.001. This complication screening method indicates that unwanted patient events occur frequently during congenital heart surgery admissions. Children undergoing complex congenital heart surgery are at greatest risk for these unwanted events. Further study of these events is needed to determine their preventability and severity.     

Receipt of asthma subspecialty care by children in a managed care organization.

BACKGROUND: Although proper outpatient asthma management sometimes requires care from subspecialists, there is little information on factors affecting receipt of subspecialty care in a managed care setting. OBJECTIVE: To determine factors associated with receipt of subspecialty care for children with asthma in a managed care organization. METHODS: We conducted an analysis of the claims from 3163 children with asthma enrolled in a university-based managed care organization from January 1998 to October 2000. We used logistic regression analysis to determine factors associated with an outpatient asthma visit with an allergist or pulmonologist. RESULTS: Of the 3163 patients, 443 (14%) had at least 1 subspecialist visit for asthma; 354 (80%) were seen by an allergist, 63 (14%) were seen by a pulmonologist, and 26 (6%) were seen by both. In multivariate analysis, patients with more severe asthma (odds ratio [OR], 3.81; 95% confidence interval [CI], 2.99-4.86) and older patients (OR, 1.04; 95% CI, 1.02-1.07) were more likely to receive care from a subspecialist. Compared with Medicaid patients, both non-Medicaid patients with copayment (OR, 2.52; 95% CI, 1.85-4.43) and non-Medicaid patients without any copayment (OR, 3.40; 95% CI, 2.35-4.93) were more likely to receive care from an asthma subspecialist. CONCLUSIONS: Children insured by Medicaid are less likely to receive care from subspecialists for asthma. Reasons may be due to health care system-related factors, such as accessibility of subspecialists, to physician referral decisions, and/or to patient factors, such as adherence to recommendations to see a subspecialist. Our findings suggest a need to further investigate health care system barriers, physician referral, and patient acceptance and completion of subspecialty referral.     

Evaluating medicaid managed care programs for children.

Nearly every state has implemented some form of managed care for Medicaid recipients, partly in response to rapid increases in Medicaid expenditures. The unique features of children's health and the differences among states in the implementation and scope of their Medicaid managed care programs provide child health services researchers many opportunities to identify program features that result in favorable health outcomes and those that are less successful. Key stakeholders with interest in this information include state governments and managed care organizations charged with developing and implementing efficient delivery systems, as well as providers interested in understanding the best mechanisms for delivering care to children. This paper outlines potential approaches to evaluating Medicaid managed care programs for children, focusing on identification of appropriate data sources and selection of quality measures encompassing the structure, processes, and outcomes of health care.     

HIV infection and in-hospital mortality at an academic hospital in South Africa

AIM—To document the impact that rapid increases in HIV infection in hospitalised children at Chris Hani Baragwanath Hospital has had on in-hospital mortality.METHODS—Hospital discharge summaries from January 1992 to the end of 1996 were reviewed.RESULTS—There were 20 733 admissions in the five year period; 7985 (39%) were tested for HIV. In tested admissions above 15 months of age, 4.9% were HIV infected in 1992, increasing to 35% in 1996.Under 15 months of age, 9% of tested admissions were positive in 1992, increasing to 46% in 1996. The proportion of all hospital deaths occurring in children considered HIV infected (ELISA testing together with clinical features if 15 months or younger) increased from 6.7% in 1992 to 46.1% in 1996 (p < 0.001). In-hospital mortality for all children increased by 21% from 4.3% in 1992 to 5.2% in 1996. Mortality rates declined in uninfected children from 5.4% in 1992 to 4.5% in 1996 (χ² trend 3.3; p = 0.06).CONCLUSION—The mortality rate of children has increased at Chris Hani Baragwanath Hospital as a result of HIV infection. Almost half the deaths were HIV related in 1996. HIV infection is threatening the advances that have been made on child survival in South Africa over the last few decades.