Disparities in the National Prevalence of a Quality Medical Home for Children With Asthma

doi:10.1016/j.acap.2009.01.006

Academic Pediatrics

Volume 9, Issue 4, July–August 2009, Pages 234-241

https://doi.org/10.1016/j.acap.2009.01.006 Get rights and content

Objective

The aim of this study was to examine sociodemographic disparities in having a quality medical home among a nationally representative sample of children with asthma.

Methods

The study examined data from the 2003 National Survey of Children's Health to identify 8360 children aged 2–17 years with asthma. Risk factors including nonwhite race/ethnicity, income <200% of the federal poverty level (FPL), uninsured, parent education less than high school, and non-English language, were examined individually and as a profile of risk in relation to a quality medical home. Fourteen questions were used to measure 5 medical home features: access, continuity, comprehensiveness, family-centered care, and coordination. A poorer quality medical home was defined as ≤66 on a 100-point scale—corresponding to the feature being present less than “usually”—for each feature and for an overall score.

Results

Before and after adjustment for demographics and asthma difficulties, most risks except less than high school parent education were related to a poorer quality medical home. Uninsured children had the highest odds of a poorer quality medical home overall (adjusted odds ratio [OR] 5.19, 95% confidence interval [CI] 3.52–7.65) and across most features, except for coordination. Children experiencing 3+ risks had 8.56 times the odds of a poorer quality medical home overall (95% CI 4.95–14.78) versus zero risks.

Conclusions

This study demonstrates large national disparities in a quality medical home for children with asthma. That disparities were most prevalent for the uninsured (insurance being a modifiable risk factor) suggests increasing coverage is essential to assuring that children obtain a quality medical home.

Section snippets

Data Source and Sampling

This study uses nationally representative data from the NSCH conducted by the National Center for Health Statistics and the Federal Maternal and Child Health Bureau. The NSCH was carried out from January 2003 to July 2004 as a module of the State and Local Area Integrated Telephone Survey, which employs a random digit-dial sample of households. It contains 102 353 completed interviews obtained with a final response rate of 55.3% (the product of the resolution, screener, and questionnaire

Results

Table 1 shows that nationally, a large percentage of children with asthma are at risk for poor access and quality of care. Almost half (45.3%) of children with asthma are in families with income <200% of FPL and 44.3% are nonwhite. Nationally, 5.9 % of children with asthma are uninsured, 7.0% live in a family where English is not spoken as the primary language, and 7.2% live in a household where no adult has graduated from high school. Many children experience multiple risk factors. Nearly one

Discussion

This study finds large disparities in the prevalence of a quality medical home for children with asthma. The relationship between the number of risk factors a child has and the proportion with a poorer quality medical home reveals a dose response–like gradient, with a 10-fold difference between the lowest and highest risk children. Having a quality medical home may be particularly important for those children with more difficult asthma, due to the higher level of care coordination that is

Acknowledgment

The study was supported by Maternal and Child Health Bureau of the Department of Health & Human Services (R40-MC-07844-01, Gregory D. Stevens, principal investigator).

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Medical home disparities between children with public and private insurance
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Citation Excerpt :
Third, the medical home composite was used as an all-or-none measure. Although this is the structure most commonly used and advocated by the authors of the National Survey of Children's Health,7,10,11,27,28,30 other constructs of the measure have been implemented.27,43 With the absence of strong validation of any specific medical home measure, we chose the form most commonly used in the literature.
To compare the prevalence of a medical home for children with public versus private insurance and identify components of the medical home that contribute to any differences.
We performed a secondary data analysis of the 2007 National Survey of Children's Health. A medical home was defined as meeting each of 5 components: 1) usual source of care; 2) personal doctor/nurse; 3) family-centered care; 4) care coordination, if needed; and 5) no problems getting a referral, if needed. We estimated the national prevalence of the medical home and its components for children with public versus private insurance. Comparisons were made using logistic regression, unadjusted and adjusted for sociodemographic factors.
A total of 67% of privately insured children met all 5 components of the medical home, compared with only 45% of publicly insured children (P < .001). The gap in medical home prevalence between public and private groups remained significant after controlling for sociodemographic characteristics (public vs private adjusted odds ratio [AOR] 0.82; 95% confidence interval [95% CI] 0.73–0.92). Over 90% of children in both groups reported having a usual source of care and a personal doctor/nurse. Only 58% of publicly insured children reported family-centered care, compared with 76% of privately insured children (P < .001). This difference was significant after adjustment for sociodemographic characteristics (public vs private AOR 0.87; 95% CI 0.77–0.99).
Significant medical home disparities exist between publicly and privately insured children, driven primarily by disparities in family-centered care. Efforts to promote the medical home must recognize and address determinants of family-centered care.
The children's health insurance program reauthorization act quality measures initiatives: Moving forward to improve measurement, care, and child and adolescent outcomes
2011, Academic Pediatrics
Citation Excerpt :
However, none of the recommended measures had been validated for assessing medical homeness at the time the article was initially prepared. Since then, there has been more attention to assessing relationships between medical homeness and desirable child health outcomes, which could improve the possibility of including a medical home measure in one of the improved core sets.37–39 In addition, a broader concept of integration, the pediatric accountable care organization, was included in the ACA and will be tested in demonstration projects.40
In 2009, a publicly transparent evidence-informed process responded to the requirement of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) legislation to identify an initial core set of recommended children’s health care quality measures for voluntary use by Medicaid and the Children’s Health Insurance Program, which together cover almost 40 million of America’s children and adolescents. Future efforts under CHIPRA will be used to improve and strengthen the initial core set, develop new measures as needed, and post improved core measure sets annually beginning in January 2013.
This supplement aims to make available useful information about issues surrounding the initial core set and key concepts for moving forward toward improvement of children’s health care quality measures, children’s health care quality, and children’s health outcomes. The set of articles in this supplement includes a detailed description of how the identification of a balanced, grounded, and parsimonious core set of children’s health care quality measures was accomplished by means of an open, public process combined with an evidence-informed evaluation methodology. Additional articles note that Medicaid and Children’s Health Insurance Program (CHIP) officials put a high priority on children’s health care quality and desire better measures; that publicly insured children are more likely than privately insured children to experience severe, complex chronic conditions and experience poorer quality in some respects; and that some key CHIPRA topics did not yet have valid, feasible measures (eg, availability of services, duration of enrollment and coverage, most integrated health care settings, and some aspects of family experiences of care).
Key stakeholders and observers provide commentary noting the unprecedented scope and nature of the CHIPRA legislation as well as noting areas in which the nation still needs to move to improve health care quality, including its measurement. These areas include greater engagement of families and health care providers in the quality measurement and improvement enterprises, collaboration across federal agencies, more emphasis on clinical effectiveness research to enhance the validity of children’s health care services and quality measures, and a need to maintain an emphasis on children as the nation expands health care coverage and attention to quality for all populations.
This overview also notes areas of future priorities for measure enhancement and development, including inpatient specialty, health outcomes, and a focus on inequity.
We and others contributing to this supplement consider the identification of the initial core set to be a significant initial accomplishment under CHIPRA. With sufficient attention to making the measures feasible for use across Medicaid and CHIP programs, and with technical assistance, voluntary use should be facilitated. However, the initial core set is but one step on the road toward improved quality for children. The identification of future challenges and opportunities for measure enhancement will be helpful in setting and implementing a future pediatric quality research agenda.
A national and state profile of leading health problems and health care quality for US children: Key insurance disparities and across-state variations
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Parent/consumer–reported data is valuable and necessary for population-based assessment of many key child health and health care quality measures relevant to both the Children’s Health Insurance Program Reauthorization Act (CHIPRA) of 2009 and the Patient Protection and Affordable Care Act of 2010 (ACA).
The aim of this study was to evaluate national and state prevalence of health problems and special health care needs in US children; to estimate health care quality related to adequacy and consistency of insurance coverage, access to specialist, mental health and preventive medical and dental care, developmental screening, and whether children meet criteria for having a medical home, including care coordination and family centeredness; and to assess differences in health and health care quality for children by insurance type, special health care needs status, race/ethnicity, and/or state of residence.
National and state level estimates were derived from the 2007 National Survey of Children’s Health (N = 91 642; children aged 0–17 years). Variations between children with public versus private sector health insurance, special health care needs, specific conditions, race/ethnicity, and across states were evaluated using multivariate logistic regression and/or standardized statistical tests.
An estimated 43% of US children (32 million) currently have at least 1 of 20 chronic health conditions assessed, increasing to 54.1% when overweight, obesity, or being at risk for developmental delays are included; 19.2% (14.2 million) have conditions resulting in a special health care need, a 1.6 point increase since 2003. Compared with privately insured children, the prevalence, complexity, and severity of health problems were systematically greater for the 29.1% of all children who are publicly insured children after adjusting for variations in demographic and socioeconomic factors. Forty-five percent of all children in the United States scored positively on a minimal quality composite measure: 1) adequate insurance, 2) preventive care visit, and 3) medical home. A 22.2 point difference existed across states and there were wide variations by health condition (autism, 22.8, to asthma, 39.4). After adjustment for demographic and health status differences, quality of care varied between children with public versus private health insurance on all but the following 3 measures: not receiving needed mental health services, care coordination, and performance on the minimal quality composite. A 4.60 fold (gaps in insurance) to 1.27 fold (preventive dental and medical care visits) difference in quality scores was observed across states. Notable disparities were observed among publicly insured children according to race/ethnicity and across all children by special needs status and household income.
Findings emphasize the importance of health care insurance duration and adequacy, health care access, chronic condition management, and other quality of care goals reflected in the 2009 CHIPRA legislation and the ACA. Despite disparities, similarities for public and privately insured children speak to the pervasive nature of availability, coverage, and access issues for mental health services in the United States, as well as the system-wide problem of care coordination and accessing specialist care for all children. Variations across states in key areas amenable to state policy and program management support cross-state learning and improvement efforts.
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The Breathmobile program: A good investment for underserved children with asthma
2010, Annals of Allergy, Asthma and Immunology
Citation Excerpt :
Specialty care has been shown to improve asthma outcomes and increase the use of preventive medications.8–10 However, despite these improved outcomes, few underserved children are referred to specialty services owing to limited available providers, lack of insurance coverage, and possible lack of primary care provider appreciation of the benefits of specialty care.11–16 Furthermore, although there are many studies that show the benefit of school-based programs in improving outcomes in children with asthma, competing priorities in the educational system often crowd out their full-scale implementation.17–19
The Breathmobile, a specialty-based mobile asthma clinic, provides free care to underserved children. The cost of symptom-free day (SFD) improvement in this population has not been previously reported.
To examine the clinical impact and cost-effectiveness of the Baltimore Breathmobile.
Existing computerized data were analyzed for Breathmobile patient visits between 2002 and 2007. All SFDs were calculated, and direct medical cost savings attributable to decreased emergency department visits and hospitalizations (after program utilization vs the previous year) were compared with annual operating costs. Incremental cost-effectiveness ratios were determined by calculating the incremental costs of Breathmobile care per additional SFD gained per child per year.
The analysis included 255 patients enrolled in the program for at least 1 year. Most participants were black (93.3%), and 54.9% were male. At baseline, patients reported a mean (SD) of 199 (118) SFDs in the year before enrollment. After 1 year in the program, patients had a mean (SD) improvement of 44 (9) SFDs. The program resulted in overall cost savings of $79.43 per SFD gained, with greater cost savings for children aged 5 to 11 years (−$116.84 per SFD gained) and those with intermittent asthma (−$126.71 per SFD gained).
The Baltimore Breathmobile program has demonstrated significant improvement in SFDs, with direct medical cost savings of the program outweighing the operational costs. These data support the need to continue to sustain and expand Breathmobile programs for children at high risk for asthma exacerbations and to conduct a randomized clinical trial to estimate the cost-effectiveness of the Breathmobile.

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Medical HomeDisparities in the National Prevalence of a Quality Medical Home for Children With Asthma

Objective

Methods

Results

Conclusions

Section snippets

Data Source and Sampling

Results

Discussion

Acknowledgment

Ann Epidemiol

Ambul Pediatr

Ambul Pediatr

Asthma Prevalence, Health Care Use, and Mortality: United States, 2003–05

Disparities in asthma hospitalization in Massachusetts

Am J Public Health

Trends in childhood asthma: prevalence, health care utilization, and mortality

Pediatrics

Self-reported physician practices for children with asthma: are national guidelines followed?

Pediatrics

Asthma symptoms, morbidity, and antiinflammatory use in inner-city children

Pediatrics

Providers underestimate symptom severity among urban children with asthma

Arch Pediatr Adolesc Med

American Academy of Pediatrics. Policy statement: organizational principles to guide and define the child health care system and/or improve the health of all children

Pediatrics

Nonfinancial barriers to care for children and youth

Annu Rev Public Health

Children's access to primary care: differences by race, income and insurance status

Pediatrics

Factors for accessing a medical home vary among CSHCN from different levels of socioeconomic status

Matern Child Health J

Does access to a medical home differ according to child and family characteristics, including special-health-care-needs status, among children in Alabama?

Pediatrics

Medical homes for children with special healthcare needs in North Carolina

N C Med J

Access to the medical home: results of the National Survey of Children with Special Health Care Needs

Pediatrics

Medical Home
Disparities in the National Prevalence of a Quality Medical Home for Children With Asthma