Maternal and Child Health Library
This and past issues of the MCH Alert are available at http://www.mchlibrary.info/alert/archives.html.
February 6, 2009
1. Briefing Features New Reports and Other Resources on
Trends in Children's Health Coverage
2. Journal Supplement Considers the Complex Determinants
of Tobacco Use Through an Ecologic Agent-Host-Vector-Environment Model
3. Study Explores Effects of Transportation Brokerage
Services on Access to Care and Expenditures in Medicaid
4. Article Examines Feasibility and Effectiveness of
Implementation of Developmental Screening in Urban Pediatric Practices
5. Authors Assess Outcomes Associated with Elective Term
Delivery
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1. BRIEFING FEATURES NEW REPORTS AND OTHER RESOURCES ON TRENDS IN
CHILDREN'S HEALTH COVERAGE
Children's Health Coverage: What's Next, a January 23, 2009, policy
briefing sponsored by the Kaiser Family Foundation's Commission on
Medicaid and the Uninsured, examines trends in health coverage for
children and parents and implications for the future. As part of the
briefing, the foundation released the following survey and issue briefs:
* Challenges of Providing Health Coverage for Children and Parents in a
Recession: A 50 State Update on Eligibility Rules, Enrollment and
Renewal Procedures, and Cost-Sharing Practices in Medicaid and SCHIP in
2009 presents findings from an annual survey carried out in the summer
and early fall of 2008, through telephone interviews with state
Medicaid and State Children's Health Insurance Program administrators.
The report, prepared by the Center on Budget and Policy Priorities and
the Kaiser Commission on Medicaid and the Uninsured, includes key
survey findings on the current status of coverage for children and
parents and state actions during 2008. The report is available at http://www.kff.org/medicaid/upload/7855.pdf.
* Next Steps in Covering Uninsured Children: Findings from the Kaiser
Survey of Children's Health Coverage provides findings from the 2007
Kaiser Survey of Children's Health Coverage, a telephone survey of
parents that was conducted to learn more about children's access to
coverage and care and the pressures related to health care costs facing
their families. The brief examines how uninsured, privately insured,
and publicly insured children and their families fare on a core set of
measures. The brief is available at http://www.kff.org/uninsured/upload/7844.pdf.
* Covering Uninsured Children: Reaching and Enrolling Citizen Children
with Non-Citizen Parents examines health insurance among children from
families with low incomes (below 200% of the federal poverty level or
$33,200 per year for a family of three in 2007) in mixed-status
families (i.e., families in which the child is a citizen and the parent
is not) and identifies some of the specific enrollment barriers for
these children. The brief is available at http://www.kff.org/uninsured/upload/7845.pdf.
The foundation has also updated several related resources. A webcast
and transcript of the January 23, 2009, briefing, the survey and issue
briefs, and other resources are available at http://www.kff.org/medicaid/kcmu012309pkg.cfm.
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2. JOURNAL SUPPLEMENT CONSIDERS THE COMPLEX DETERMINANTS OF TOBACCO USE
THROUGH AN ECOLOGIC AGENT-HOST-VECTOR-ENVIRONMENT MODEL
The January 2009 supplement to Preventive Medicine focuses on the
epidemic of tobacco smoking. The supplement, supported by the National
Cancer Institute, is partly based on proceedings from the National
Tobacco Monitoring, Research and Evaluation Workshop held in November
2002 in Bethesda, MD, and sponsored by the Office on Smoking and Health
of the Centers for Disease Control and Prevention, the American Legacy
Foundation, and the Robert Wood Johnson Foundation. The supplement
contains five papers aimed at critically evaluating the current
situation and proposing further means to improve it. The overview paper
summarizes research on monitoring the tobacco use epidemic, discusses
recommendations made at the November 2002 workshop on the topic of
tobacco surveillance and evaluation, and discusses the current state of
affairs. Additional topics include the following: (1) findings and
recommendations of the Agent Working Group of the November 2002
workshop and key surveillance and evaluation systems that monitor
characteristics, attitudes, and behaviors of tobacco users that are
crucial for tobacco-control efforts; (2) data sources and methods that
can be used to monitor tobacco marketing and recommendations for
creating a national surveillance system; and (3) surveillance and
evaluation systems that monitor influences on tobacco use, such as
smoke-free laws and other legislation, excise taxes, mass media, and a
broad range of tobacco-control activities. The supplement is available
at http://www.sciencedirect.com/science?_ob=PublicationURL&_tockey=%23TOC%236990%232009%23999519998.8998%23876061%23FLA%23&_cdi=6990&_pubType=J&_auth=y&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=48d2504635656556b341e0f01752b5d9.
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3. STUDY EXPLORES EFFECTS OF TRANSPORTATION BROKERAGE SERVICES ON
ACCESS TO CARE AND EXPENDITURES IN MEDICAID
"Our results . . . highlight the importance of transportation to health
services," state the authors of an article published in the February
2009 issue of Health Services Research. Non-emergency medical
transportation (NEMT) services are federally mandated Medicaid services
to meet the transportation needs of vulnerable populations. Many states
found that transportation costs were high under fee-for-service
arrangements, in which transportation providers typically billed
Medicaid based on reported trips and miles. By 2001, 21 states had
contracted with brokers (i.e., profit or nonprofit organizations) to
manage NEMT services on a capitated basis (set fee per patient) for
Medicaid beneficiaries. Under transportation brokerage services, all
NEMT services are included in capitated rates that are adjusted by
beneficiaries' health status and by geographic area (e.g., rural or
urban). This article examines how transportation brokerage services
affect Medicaid beneficiaries' access to care, expenditures, and health
services use.
Georgia and Kentucky were chosen to study the effects of transportation
brokerage services because they were similar in the pre-period, and
they implemented similar programs at different times. Georgia
implemented statewide transportation brokerage services in October
1997. In Kentucky, 53 counties in 1998 and 67 counties in 1999
implemented transportation brokerage services. The staggered
implementation of transportation brokerage services in Georgia and
Kentucky provided a natural experiment to study how measures of access
to care and health services use changed after the implementation of
transportation brokerage services for two specific populations defined
by chronic illnesses: children with asthma and adults with type 2
diabetes.
Data were drawn from the claims and eligibility files of all Medicaid
beneficiaries under age 65 in both states. Measures included
outpatient, inpatient, pharmacy, emergency room, ambulance, and NEMT
expenditures, as well as total expenditures. Two specific measures of
monthly health services use attributable to the selected medical
conditions (asthma and diabetes) were also analyzed: any emergency room
use and ambulatory care-sensitive condition (ACSC) admissions. The
analysis estimated separate effects for probability of any health care
use in a month and logged monthly expenditures for the period 1996
through 1999.
The authors found that
- NEMT expenditures increased among children with asthma but
decreased among adults with diabetes.
- Even though NEMT expenditures increased among children with
asthma, access improved as measured by any health service, and total
monthly expenditures declined on average by $18 per month, more than
offsetting the increase in transportation expenses.
- Both transportation expenditures and Medicaid health service
expenditures decreased for adults with diabetes, although access as
measured by use of any service increased, and ACSC admissions declined.
"Because evidence from this study indicates that access to care and
health outcomes are not adversely affected by the transportation
brokerage services, the decrease in overall Medicaid expenditures
reflects a more efficient system from an economic perspective," the
authors conclude.
Kim J, Norton EC, Stearns SC. 2009. Transportation brokerage services
and Medicaid beneficiaries' access to care. HSR: Health Services
Research 44(1):145-161. Abstract available at http://www3.interscience.wiley.com/journal/121420112/abstract.
Readers: More information is available from the following MCH Library
resource:
- Cost-Effectiveness and Cost-Benefit Analysis in MCH: Resource Brief at
http://www.mchlibrary.info/guides/costeffective.html
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4. ARTICLE EXAMINES FEASIBILITY AND EFFECTIVENESS OF IMPLEMENTATION OF
DEVELOPMENTAL SCREENING IN URBAN PEDIATRIC PRACTICES
"This quality improvement initiative succeeded in incorporating
validated developmental screening into real-life practice settings and
increased identification rates of children with developmental and
behavioral concerns without burdening practitioners," state the authors
of an article published in the February 2009 issue of Pediatrics. The
American Academy of Pediatrics recommends developmental surveillance at
every well-child primary care visit, with use of validated
developmental screening tools at 9, 18, and 30 months and when
otherwise indicated. A growing literature addresses the real-life
challenges and successes of implementing routine developmental
screening in pediatric practices using validated, standardized tools.
The Parents' Evaluation of Developmental Skills (PEDS) is a validated
screening tool that can be completed by parents in 5 minutes or less in
the clinic. This article describes real-world use of the PEDS within
large, urban practices.
The PEDS was implemented in January 2006 at two clinical sites, each
serving a largely urban population: Children's Hospital Primary Care
Center and Joseph Smith Community Health Center. Provider surveys and a
focus group were used to learn more about the feasibility of the PEDS
implementation, and a medical chart review was conducted to assess the
effectiveness of the implementation. Thirty providers (88.2%) responded
to the pre-PEDS survey and 24 (70.6% ) to the post-PEDS survey. The
researchers reviewed medical charts for 616 children (338 pre-PEDS and
278 post-PEDS).
The authors found that
- A total of 61.4% of 2-year-olds and 61.6% of 3-year-olds were
screened with the PEDS in the post-implementation chart review.
- Focus group participants consistently stated that the PEDS was
easy to use and that use of the PEDS actually saved time during the
visit.
- Across the age groups, there was a significant increase in the
identification of both developmental concerns (20.7% vs. 26.3%) and
behavioral concerns (8.0% vs. 12.2%) after PEDS implementation, but the
pattern of change differed by age. Among 2-year-olds, the rates of
identification of behavioral concerns doubled, but identification of
developmental concerns did not change. In contrast, among 3-year-olds,
identification of developmental concerns increased, whereas behavioral
concern identification rates were unchanged.
- Overall referral rates for 2-year-olds remained similar pre-PEDS
and post-PEDS implementation, whereas referral rates increased for
3-year-olds.
- In general, the types of developmental-behavioral concerns did
not differ significantly after the PEDS was implemented. The most
common types of referrals for 2-year-olds were to audiology and early
intervention. For 3-year-olds, the most common types of referrals were
to school-based testing and audiology.
"Our study extends the growing literature regarding implementation of
standardized screening tools into primary care by depicting the
experiences and outcomes in 2 urban settings," conclude the authors.
Schonwald A, Huntington N, Chan E, et al. 2009. Routine developmental
screening implemented in urban primary care settings: More evidence of
feasibility and effectiveness. Pediatrics 123(2):660-668. Abstract
available at http://pediatrics.aappublications.org/cgi/content/abstract/123/2/660.
Readers: More information is available from the following MCH Library
resource:
- Child Developmental Screening: Bibliography at
http://www.mchlibrary.info/action.lasso?-database=Biblio&-layout=Web&-response=/databases/BibLists/bib_devscrn.html&-MaxRecords=all&-DoScript=auto_search_devscrn&-search
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5. AUTHORS ASSESS OUTCOMES ASSOCIATED WITH ELECTIVE TERM DELIVERY
"Our data demonstrate increased neonatal morbidity associated with
elective delivery before 39 weeks' gestation," write the authors of an
article published in the February 2009 issue of the American Journal of
Obstetrics and Gynecology. Delivery before 37 completed weeks'
gestation has traditionally been defined as preterm, that between 37
and 41 weeks as term, and that at 42 weeks and beyond as postterm. Much
has been written about potential adverse newborn effects of preterm and
postterm birth, but little attention has been given to differential
neonatal outcomes of infants delivered at 37-41 weeks' gestation. The
study described in this article sought to quantify adverse neonatal and
maternal outcomes associated with elective term delivery at less than
39 weeks' completed gestation.
Between May 1, 2007, and July 31, 2007, the authors prospectively
collected data variables in all women undergoing planned term delivery
at 27 hospitals within the Hospital Corporation of America system.
Facilities were selected before data collection to be representative of
the population as a whole, both in terms of geographic location and
delivery volume.
The authors found that
- Of the 17,794 total deliveries, 14,955 (84%) occurred at term (37
or more weeks' gestation). Of term deliveries, 6,562 (44%) were planned
rather than spontaneous. Among the planned deliveries, 4,645 (71%) were
elective.
- Among the 4,645 planned deliveries, 17.8% of infants delivered
without medical intervention at 37-38 weeks and 8% of those delivered
without medical intervention at 38-39 weeks required admission to a
newborn special care unit for an average of 4.5 days, compared with
4.6% of infants delivered electively without medical intervention at 39
weeks or beyond.
- Cesarean delivery rates in women undergoing planned induction of
labor were not heavily influenced by gestational age; cesarean rates of
13.9%, 10.0%, and 13.5% were seen for women induced at 37, 38, and 39+
weeks, respectively.
- Cesarean delivery rates were heavily influenced by initial
cervical dilation in both nulliparous and multiparous women (ranging
from a rate of 0% for multiparous women induced at 5cm dilation or more
to a rate of 50% for nulliparous women induced at 0 cm dilation).
The authors conclude that "for over 2 decades, the American College of
Obstetricians and Gynecologists (ACOG) has advocated the restriction of
elective term delivery to women with a confirmed gestational age of at
least 39 weeks. Our data support the ongoing validity and importance of
these recommendations, as well as the fact that they are disregarded in
at least 10% of all deliveries."
Clark SL, Miller DD, Belfort MA, et al. 2009. Neonatal and maternal
outcomes associated with elective term delivery. American Journal of
Obstetrics and Gynecology 200(2):156.e1-156e4. Abstract available at http://www.ajog.org/article/S0002-9378(08)01037-5/abstract.
Readers: More information is available from the following MCH Library
resource:
- Maternal Morbidity and Mortality: Organizations Resource List at
http://www.mchlibrary.info/action.lasso?-database=Organizations&-layout=Web&-response=/databases/OrgLists/orgs_matmort.html&-MaxRecords=all&-DoScript=auto_search_matmort&-search
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and
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