Differences in pneumonia treatment between high-minority and low-minority neighborhoods with clinical decision support system implementation.

BACKGROUND: The relationship between clinical decision support systems (CDSS) and quality is a relatively new, and in light of the new health information technology (HIT) legislation, policy-relevant area. Moreover, very few studies exist examining the link between HIT and healthcare disparities. The purpose of this article is to examine the association between CDSS and the treatment of pneumonia care within high-minority (≥29.1% non-White, non-Hispanic) and low-minority (<29.1%) Zip Code Tabulation Areas (ZCTAs). RESEARCH DESIGN: This study employed a cross-sectional design and used 2009 data from the American Hospital Association, the Centers for Medicare and Medicaid Services and the Research Triangle Institute. Adjusted analysis controlled for a hospital's propensity to use CDSS. RESULTS: In the unadjusted analysis, hospitals in high-minority ZCTAs had lower pneumonia quality composite scores than their low-minority counterparts. When adjusting for other hospital and ZCTA-level variables, we found that CDSS use had stronger positive associations with quality in high-minority hospitals. CONCLUSIONS: Results support policy directives may support higher quality improvements by focusing CDSS adoption in high-minority hospitals.

The metabolic syndrome: are rural residents at increased risk?

PURPOSE: The purpose of this study was to estimate the differences in prevalence of metabolic syndrome and its individual components across rural-urban populations, as well as to determine the risk factors associated with metabolic syndrome and examine how they contribute toward rural-urban disparity. METHODS: Data came from the 1999-2006 National Health and Nutrition Examination Survey, restricting to 6,896 participants aged 20 years or more with complete information. Metabolic syndrome was defined using the National Cholesterol Education Program's Adult Treatment Panel III criteria. Residence was measured at the census tract level using the Rural-Urban Commuting Area Codes. We estimated the prevalence of metabolic syndrome and its components by residence. Multiple logistic regression models were used to examine urban-rural differences after adjusting for sociodemographic, health, dietary, and lifestyle factors. RESULTS: The prevalence of metabolic syndrome was higher in rural than urban residents (39.9% vs 32.8%), among both men (39.7% vs 33.3%) and women (40.2% vs 32.3%, respectively). The age and sex adjusted OR for metabolic syndrome in rural as compared to urban residents was 1.23 (95% CI, 1.02-1.49), which was attenuated to 1.06 (95% CI, 0.90-1.25) after adjusting for covariates. Older age, lower physical activity, higher screen time, higher meat intake, and skipping breakfast were associated with increased odds of metabolic syndrome. CONCLUSION: Rural dwelling was associated with higher prevalence of metabolic syndrome among adults in the Unites States, which can be attributed to the differences in demographic composition and obesity-related behavioral factors between urban and rural residents.

Differences in dental service utilization by rural children with and without participation in Head Start.

PURPOSE: The purpose of this study was to assess differences in dental and medical care utilization for dental problems between rural Head Start (HS) participants and a nonexposed group. METHODS: A matched retrospective cohort study was conducted using chi-square, Poisson, and logistic regression models. We linked Medicaid claims and HS enrollment data for 7 rural counties in South Carolina to examine oral health service utilization in dental, primary care (PC), and emergency room (ER) settings. The exposed group included 985 HS participants during the 2007/2008 school year and the nonexposed group included 1,969 children enrolled in Medicaid but not HS. RESULTS: HS participants were more than twice as likely to visit dentists for preventive, diagnostic, and restorative care (P<.001). The odds ratio of HS participants relative to the nonexposed group for PC visits for oral health problems was 1.94 (P=.03). No differences between HS participants and the nonexposed group for oral health-related ER visits were observed (P=0.33). CONCLUSIONS: Head Start participants accessed dental care with greater frequency than the nonexposed group. Findings provide evidence that Head Start grantees positively impact dental service utilization for their children. Future research should examine the programmatic features to which the outcomes can be attributed and whether utilization trends continue after Head Start completion.

Differences in readiness between rural hospitals and primary care providers for telemedicine adoption and implementation: findings from a statewide telemedicine survey.

PURPOSE: Published advantages of and challenges with telemedicine led us to examine the scope of telemedicine adoption, implementation readiness, and barriers in a southern state where adoption has been historically low. We hypothesized that rural hospitals and primary care providers (RPCPs) differ on adoption, readiness, and implementation barriers. We examined the degree to which they differ on (a) telemedicine adoption or readiness; (b) telemedicine training needs; (c) current use of technology for patient care; and (d) environmental concerns in facilities for telemedicine. METHODS: Paper surveys were sent to rural hospitals and RPCPs with response rates of 50% (n = 38) and 25.9% (n = 339), respectively. Three of 4 hospitals were represented. Chi-square analyses were used to test for differences between rural hospitals and RPCPs. FINDINGS: Compared to RPCPs, rural hospitals were significantly more likely to report higher rates of telemedicine knowledge (P= .0007); planning for or implementing telemedicine (P < .0001); and reporting their disaster recovery data systems (P= .0002) and availability and location of outlets and connections (P= .03) as adequate for telemedicine. Rural hospitals were less likely to report having no telemedicine education needs (P= .04). CONCLUSIONS: Telemedicine continues to be a viable solution for bridging geographic access gaps to a variety of specialty care. Users need assistance in understanding legal implications, care coordination, billing for services, and disaster data recovery. In rural areas, hospitals appear to best embody characteristics of facilities that successfully implement telemedicine and have the greatest degree of readiness.

Postpartum screening for diabetes among Medicaid-eligible South Carolina women with gestational diabetes.

PURPOSE: To examine the rate of timely postpartum screening for diabetes among Medicaid-eligible women with gestational diabetes mellitus (GDM). METHODS: We examined a retrospective cohort of Medicaid women with a live birth between 2004 and 2007. Women with singleton live births at greater than 28 weeks gestation were included in the cohort and their screening receipt tracked. Only the first qualifying pregnancy within the observation period was assessed. Birth certificate records were linked with hospital discharge data, outpatient prenatal care claims to identify women with GDM (n = 6,239). Medicaid postpartum claims for these women were examined to determine receipt of postpartum screening for diabetes within 5 to 13 weeks. Women with any indication of a dedicated plasma glucose test identified by CPT codes 82947, 82950, 82951, and 82952 during this time period were considered to meet the definition of screening. RESULTS: Approximately 3.4% of women identified as having GDM were screened for diabetes postpartum. Adjusted analysis found women not attending the postpartum visit (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.37-0.91) and women receiving inadequate prenatal care (OR, 0.57; 95% CI, 0.34-0.95) were less likely to receive postpartum screening for diabetes. Conversely, women 20 to 34 years of age (OR, 1.79; 95% CI, 1.21-2.66) and women who were obese (OR, 2.28; 95% CI, 1.56-3.32) were more likely to be screened. CONCLUSIONS: Medicaid is a primary source of insurance for many women; however, for most coverage ends at 60 days postpartum, leaving a narrow window of opportunity for postpartum screening. Extended periods of coverage may be beneficial in ensuring the opportunity to receive adequate postpartum care, including screening for diabetes.

Rural-urban differences in dental service utilization among an early childhood population enrolled in South Carolina Medicaid.

Our exploratory study examined rural-urban differences in dental care utilization during early childhood among Medicaid-enrolled children aged younger than 4 years in South Carolina. We conducted a secondary data analysis using Medicaid data. Dependent variables included preventive dental visits, use of medical settings (emergency room [ER] and primary care [PC] offices) for dental reasons, receipt of fluoride varnish, and dental home status. The primary independent variable was child's area of residence, rural or urban. The control variables were child's age, gender, race, and special healthcare need status. In adjusted analyses, rural children were found to have significantly higher odds of lacking preventive dental visits, fluoride varnishes, and dental homes as well as using medical settings for dental reasons compared to urban children. This difference, however, was not a simple function of rural residence. Other variables such as race and special healthcare need status interacted with rurality in explaining the differences in the outcomes of interest except visiting medical settings for dental reasons. Children under age of 2 years had higher odds of undesirable outcomes compared to those aged older than 2 years. Significant disparities in dental care utilization were evident among rural, Medicaid-enrolled preschool-aged children in South Carolina. While the state has addressed Medicaid reimbursement and related policies for nearly 10 years, their impact may be disproportionately effective.

Variation in Excessive Fetal Growth across Levels of Prenatal Care among Women with Gestational Diabetes.

OBJECTIVE: Examine the association between prenatal care and excessive fetal growth outcomes among mothers with gestational diabetes mellitus (GDM). METHODS: We conducted a retrospective analysis of 2004-2007 singleton live births to South Carolina women, limited to those for whom both birth certificate and hospital discharge data were available (N = 179 957). Gestational diabetes mellitus was identified from birth certificate and/or hospital discharge claims. Measures of excessive fetal growth were large for gestational age (90th and 95th percentiles) and macrosomia (birth weight > 4500 g). The Adequacy of Prenatal Care Utilization index was used to measure prenatal care. RESULTS: Gestational diabetes mellitus was recorded for 6.9% of women in the study population. Women with GDM were more likely than other women to have an infant with excessive fetal growth, regardless of the level of prenatal care; however, there was a significant interaction between GDM status and levels of prenatal care. All women with GDM had increased odds for large infant outcomes. However, those receiving inadequate prenatal care were markedly more likely to experience excessive fetal growth outcomes (odds ratio = 1.38, confidence interval = 1.15-1.66) than women also with GDM and intermediate/adequate prenatal care. Similar patterns were noted for large for gestational age (95th) and macrosomia (total birth weight ≥ 4500 g). CONCLUSIONS: Observed associations suggest a link between inadequate prenatal care and a higher risk for excessive fetal growth among women with GDM. Further research is needed to clarify the nature of the association and suggest ways to get high-risk women into care sooner.

Effect of having a personal healthcare provider on access to dental care among children.

BACKGROUND: The current study examines the relationship between having a personal healthcare provider (PHP) and a child's receipt of dental visits during the preceding year. Whether the PHP relationship ameliorates rural/urban differences among US children was also examined. METHODS: We conducted a cross-sectional analysis of data from the 2003 National Survey of Children's Health augmented with county-level ecological data from the 2003 Area Resource File. Independent variables were preventive dental visits and any dental visits. Control variables were demographic variables, special healthcare needs, health insurance, dental insurance, and primary care and dental HPSA status. Multiple logistic regression models were used to adjust for covariate effects. RESULTS: Children with PHPs were more likely to have received preventive dental care and less likely to have received no dental care at all. Children who lacked PHPs were less likely to have received preventive care and more likely to lack any dental visit. Rural children, regardless of PHP status, were less likely to have received preventive care and more likely to have made no dental visit. CONCLUSION: While having a PHP improves the likelihood a child will have dental visits in a year, the effect is not as strong for rural as for urban.

Continuity of health insurance coverage and perceived health at age 40.

While a lack of health insurance or interrupted coverage has been shown to lead to poorer health status among preretirement populations, this phenomenon has not been examined among a large population of younger, working-age adults. We analyzed a nationally representative data set of persons born between 1957 and 1961, the National Longitudinal Survey of Youth-1979, to examine the links between insurance continuity and self-assessed physical and mental health at age 40. Among respondents turning 40 in 1998 or 2000, 59.8% had been continuously insured during the decade before they reached age 40. In unadjusted analysis, persons who were continuously covered had the highest scores for both physical and mental health. After controlling for respondent characteristics, insurance coverage was not significantly associated with perceived physical or mental health.

Medical homes for children with special health care needs: a program evaluation.

PURPOSE: The purpose of the current study is to evaluate the effectiveness of a pilot project providing a medical home to children with special health care needs (CSHCN). This study differs from previous work in that it monitors a cohort of CSHCN one year prior to and two years after participation in a medical home intervention utilizing a quasi-experimental design. RESULTS: The groups being compared demonstrated descriptive differences in emergency room (ER) and preventive visits. Statistically significant differences in ER visits were achieved by the second intervention year. CONCLUSIONS: The current research demonstrates that a medical home can have demonstrable effect on utilization of preventive and emergency care by CSHCN. Limitations of the current research include small sample size and lack of information on acuity and quality of life.