Person:

Perrin, James

Background: The "gatekeeping" model of access to specialty care has been an essential managed care tool, intended to control costs of care and promote coordination between generalists and specialists. Objective: To investigate the impact of removing gatekeeping on specialist utilization. Methods: A capitated multispecialty group discontinued a gatekeeping system on April 1, 1998. We assessed the overall number and distribution of patient visits to primary care physicians and specialists and initial patient visits to specialists before and after the removal of gatekeeping. We performed focused analyses for specific specialties, children with chronic conditions, and children with specific diagnoses. Results: Elimination of gatekeeping was not associated with changes in the mean number of visits to specialists (0.28 visits per 6 months before and after gatekeeping was removed) or the percentage of all child visits to specialists (11.6% vs 12.1%; 95% confidence interval, 11.3%-11.9% vs 11.8%-12.4%). The proportion of all specialist visits that were initial consultations increased after gatekeeping was removed, from 30.6% (95% CI, 29.4%-31.8%) to 34.8% (95% CI, 33.6%-36.1%). Visits to any specialist by children with chronic conditions increased from 18.6% (95% CI, 17.7%-19.1%) to 19.8% (95% CI, 19.0%-20.7%). New patient visits to specialists by children with chronic conditions as a proportion of all specialist visits increased from 28.1% (95% CI, 25.9%-30.2%) to 32.3% (95% CI, 30.1%-34.5%). Conclusions: Replacing a gatekeeping system with open access to all specialty physicians in a managed care organization resulted in minimal changes on the utilization of specialists. Visits to specialists by children with chronic conditions increased after the removal of gatekeeping.

The number of conditions included in newborn screening panels has increased rapidly in the United States during the past decade, and many more conditions are under consideration for addition to state panels. The rare nature of candidate conditions for newborn screening makes their evaluation challenging. The scarcity of data on the costs of screening, follow-up, treatment, and long-term disability must be addressed to improve the evaluation process for nominated conditions. Decision analyses and economic evaluations can help inform policy decisions for newborn screening programs by providing a systematic approach to synthesizing available evidence and providing projected estimates of long-term clinical and economic outcomes when long-term data are not available. In this review, we outline the types of data required for the development of decision analysis and cost-effectiveness models for newborn screening programs and discuss the challenges faced when applying these methods in the arena of newborn screening to help inform policy decisions.

Purpose: To assess if dispositional optimism is associated with adiposity and explore if dispositional optimism mediates the relationship between parent education and adiposity (BMI z score). Methods: Multivariable regression analyses of data collected from 1298 non-Hispanic black and white 12–19 year olds from a single Midwestern public school district. Results: Less optimistic adolescents had higher BMI z scores (r = −0.09, p < 0.001). Addition of dispositional optimism to the regression model caused an approximately 10% attenuation of the parent education and BMI z score relationship. Sobel tests confirmed that this attenuation indicated partial mediation. Conclusion: Lower dispositional optimism is associated with higher adiposity and this association accounts for some of the influence of parent education on adolescent adiposity.

Objectives: To examine whether the medical home, care coordination, or family-centered care was associated with less impact of type 1 diabetes (T1D) on families’ work, finances, time, and school attendance. Study design: Using the 2005–2006 National Survey of Children with Special Health Care Needs, we compared impacts among children with T1D (n=583), with other special health care needs (n=39,944), and without special health care needs (n=4,945). We modeled the associations of the medical home, care coordination and family-centered care with family impacts in T1D. Results: In families of children with T1D, 75% reported a major impact versus 45% of families of children with special health care needs (p<0.0001) and 17% of families of children without special health care needs (p<0.0001). In families of children with T1D, 35% reported restricting work, 38% reported financial impact, 41% reported medical expenses >$1000/year, 24% reported spending ≥11 hours/week caring or coordination care and 20% reported ≥11 school absences/year. The medical home, care coordination and family-centered care were associated with less work and financial impacts. Conclusions: In childhood T1D, most families experience major impacts. Better systems of health care delivery may help families reduce some of these impacts.

The authors of this paper identify risks to health and other factors that determine the need for health care services among children and adolescents. They document service utilization patterns in the areas of well-child care and immunizations, acute ambulatory care and hospital services, and injury prevention. They also acknowledge the special health care needs of adolescents and of children with chronic illnesses. It appears that neither the traditional personal health service delivery system nor the public health system alone can effectively provide all of the health services children need. Collaboration between public health and personal health service providers is essential to future efforts to improve the health of children and adolescents. Recommendations include development of community-based preventive care programs in all parts of the country, extension of current traditional primary care capabilities, assurance of access to primary care services, enhancement of public health activities, expansion of specialized adolescent health programs, and coordination of a comprehensive set of medical and other services for children with chronic illness and their families. The authors conclude that, to be effective, future health system reforms must be implemented through a coordinated program of care rather than through competing systems of services.

Objective: To extend development of a pediatric inflammatory bowel disease (IBD) health-related quality of life (HRQoL) measure by determining its factor structure and associations of factors with generic HRQoL measures and clinical variables. Patients and Methods: Cross-sectional survey of children and adolescents ages 8 years to 18 years and their parents attending any of 6 US IBD centers, recruited from either existing registry of age-eligible subjects or visits to participating centers. The survey included generic (Pediatric Quality of Life Inventory) and IBD-specific (Impact Questionnaire) quality of life measures, disease activity, and other clinical indicators. We carried out factor analysis of Impact responses, comparing resulting factors with results on the generic HRQoL and the clinical measures. Results: We included 220 subjects (161 with Crohn disease and 59 with ulcerative colitis). Initial confirmatory factor analysis did not support the 6 proposed Impact domains. Exploratory factor analysis indicated 4 factors with good to excellent reliability for IBD responses: general well-being and symptoms, emotional functioning, social interactions, and body image. Two items did not load well on any factor. The 4 factors correlated well with the Pediatric Quality of Life Inventory and subscales. Children with higher disease activity scores and other indicators of clinical activity reported lower HRQoL. Conclusions: This study provides further characteristics of a HRQoL measure specific to pediatric IBD and indicates ways to score the measure based on the resulting factor structure. The measure correlates appropriately with generic HRQoL measures and clinical severity indicators.

Objective: In 2007 in Massachusetts, a settlement of a class-action lawsuit on behalf of Medicaid beneficiaries mandated that primary care practices perform developmental, behavioral and mental health screening using formal tools. We aimed to assess perspectives from providers and practice staff about implementing developmental and mental health screening in response to the judicial ruling. Methods: In this qualitative study, we conducted semi-structured interviews with eighteen physicians and staff from eleven pediatric and medicine-pediatric primary care practices in Eastern Massachusetts between April 2009–November 2010. Using an interview guide we asked about barriers and facilitators to implementing developmental and mental health screening, how practices selected tools and what processes or changes made screening routine. Clinicians were asked how screening changed the quality and/or content of well-child care visits. Interviews were transcribed and coded. Using thematic analysis, we generated overarching themes. Results: Participants were motivated to comply with the mandate, and most practices reported implementing routine screening for developmental and mental health problems over several months. While certain aspects of screening were endorsed, many perceived that screening added little to quality of care, primarily because tools lacked sensitivity and specialty resources were too scarce to address concerns adequately. Practices’ receptivity to change and physicians’ sense of duty to comply facilitated implementation. No practice developed processes specifically to track and follow up abnormal results. Conclusions: Implementation of mandated developmental and mental health screening could be facilitated by providing assistance with practice change, improving the quality of screening tools, and assuring adequate referral resources.

Objective: To compare costs of redetermining disability to direct savings in SSI payments associated with different strategies for implementing Continuing Disability Reviews (CDRs) among children potentially enrolled in SSI from 2012–2021. Methods: We reviewed publicly available reports from the Social Security Administration (SSA) and Government Accountability Office (GAO) to estimate costs and savings. We considered CDRs for children ages 1–17 years, excluding mandated Low-Birth Weight and Age 18 Redeterminations that SSA has routinely carried out. Results: If SSA in 2012 performs the same number of CDRs for children as in 2010 (16,677, 1% of eligibles) at a cessation rate of 15%, the agency would experience net savings of approximately $145 million in benefit payments. If CDR numbers increased to the highest level ever (183,211, 22% of eligibles, in 1999) at the same cessation rate, the agency would save approximately $1.6 billion in benefit payments. Discussion: Increasing the numbers of CDRs for children represents a considerable opportunity for savings. Recognizing the dynamic nature of disability, the agency could reassess persistence of disability systematically. Doing so could free up resources from children who are no longer eligible and help the agency better direct its benefits to recipients with ongoing disability and whose families need support to meet the extra costs associated with raising a child with a major disability.

School-based health centers (SBHC) have substantial potential to improve the recognition and treatment of adolescents’ mental health problems. This study was undertaken as a quality improvement project to evaluate utility of the Pediatric Symptom Checklist when completed by youth (PSC-Y) among 383 adolescents seen at a SBHC, and the extent to which identification of psychosocial dysfunction and referral to mental health services improved academic functioning. Adolescents identified by the PSC-Y were significantly more likely to be insured by Medicaid, be a teen-age parent, and to have higher rates of absenteeism and tardiness in comparison to those not identified. Adolescents identified with the PSC-Y who were referred to mental health services significantly decreased their rates of absences and tardiness. Study results provide support for the utility of psychosocial screening and referral in the SBHC environment in facilitating recognition and treatment of adolescent mental health problems and improving student academic functioning.

Objective: To understand the relationship between several measures of child health status and the employment of parents. Design: A cross-sectional study using 1994 National Health Interview Survey on Disability data. Participants: A nationally representative sample of children and their parents. Outcome Measures: Maternal and paternal employment (measured separately). Intervention: We use a series of logistic regression models with maternal and paternal employment as the dependent variables and the health status of the child with the poorest health status in the family as the primary independent variable. Models additionally include sociodemographic correlates of employment. Results: Having a child with poor health status, as measured by general reported health, hospitalizations, activity limitations, and chronic condition or disability status, is associated with reduced employment of mothers and fathers. For example, the odds ratios of being employed for having a child with an activity limitation are 0.75 for mothers (95% confidence interval, 0.67-0.85) and 0.66 for fathers (95% confidence interval, 0.53-0.82). Conclusions: Having a child with poor health status is associated with reduced maternal and paternal employment. Further studies are needed to determine whether poor child health status causes reductions in parental labor force participation. If such a causal relationship exists, it has important implications for social policy, employment policy, and clinical anticipatory guidance.