An analysis of the immunization status of preschool children enrolled in a statewide Medicaid managed care program.

OBJECTIVES: To measure immunization coverage rates for children enrolled in a statewide Medicaid managed care program and determine the impact of sociodemographic characteristics and the type of primary care provider site on immunization coverage. STUDY DESIGN: A random sample of 2000 was chosen from children between the ages of 19 and 35 months who had been continuously enrolled in the Medicaid managed care program for 1 year. Sociodemographic data and a list of primary care providers for the study children were obtained from administrative databases. Immunization histories were determined by medical record review. RESULTS: Vaccine-specific immunization rates for diphtheria-tetanus-pertussis, polio, Haemophilus influenzae type b, hepatitis B, and measles-mumps-rubella ranged from 87% to 94%, with an overall coverage rate of 75%. Overall immunization status varied by primary care provider site as follows: office-based, 72%; community health center, 75%; hospital-based clinic, 79%; and staff model health maintenance organization, 85% (chi(2) test, P =.008). CONCLUSIONS: Immunization rates compare favorably with national rates for this low-income group. Sociodemographic characteristics were not important predictors of underimmunization, but rates did vary by the type of primary care provider site.

A statewide assessment of lead screening histories of preschool children enrolled in a Medicaid managed care program.

OBJECTIVES: Despite the prominence of lead poisoning as a public health problem, recent Government Accounting Office reports indicate that only one fifth of children who are covered by Medicaid have been screened for lead poisoning. The purpose of this study was to examine the lead screening histories of children who were enrolled in a statewide, Medicaid managed care plan to determine the relative impact of the type of primary care provider site and family sociodemographic characteristics on the likelihood of being screened. The study also examined the prevalence of and risk factors for lead poisoning of children who had been screened. METHODS: A random sample of 2000 preschool-age children was chosen from those who were enrolled continuously in the statewide, expanded, Medicaid managed care program for a 1-year period and between the ages of 19 and 35 months at the end of that year. Sociodemographic characteristics and lists of primary care providers were obtained from administrative data sets. Medical record audits at primary care provider sites were performed to obtain the lead screening histories of the children, including test dates and results. RESULTS: Data on 1988 children were used for study analyses, and 80% of these children had at least 1 documented blood lead level. Children whose primary care provider was an office-based physician were less likely to be screened as compared with patients of health centers, hospital-based clinics, and staff model health maintenance organizations (68%, 86%, 89%, and 91% respectively). Variation in screening rates persisted in a multivariate analysis controlling for family sociodemographic characteristics and practice level variation. Of the 1587 children who had a documented blood lead test, 467 children (29%) had a blood lead level of >/=10 mg/dL on at least 1 test. CONCLUSIONS: Blood lead screening rates in Rhode Island's Medicaid managed care program are dramatically higher than national estimates for children who are enrolled in Medicaid. Potential explanations for this finding are 1) a high sensitization to the problem of lead poisoning in Rhode Island, 2) the primary care focus of the Medicaid program in Rhode Island facilitates the delivery of preventive services, and 3) the medical record audit approach used in this study was more comprehensive in identifying blood lead screens than techniques used in national studies. The high prevalence of elevated blood lead levels found in this study emphasizes the importance of screening among children who are enrolled in Medicaid.

The impact of outreach efforts in reaching underimmunized children in a Medicaid managed care practice.

BACKGROUND: National immunization standards call for all primary care providers to implement immunization tracking systems that include contacting families when children are overdue for vaccines. The restructuring of Medicaid systems toward managed care models with a greater emphasis on having defined medical homes for children presents opportunities to expand the use of immunization recall systems among low-income children. OBJECTIVE: To assess the impact of telephone, mail, and a combined approach to reaching underimmunized children enrolled in a hospital-based Medicaid managed care practice. DESIGN AND METHODS: All underimmunized children younger than 6 years who had been continuously enrolled in the hospital-based Medicaid managed care practice for 3 months were randomly assigned to 1 of 4 groups: (1) control group with no intervention, (2) telephone reminder group, (3) mail reminder group, or (4) sequential mail/telephone reminder group. After a 10-week follow-up, medical records and the hospital's computerized appointment scheduling system were reviewed to determine the effect of the outreach effort on appointments made, visits attended, immunizations received, and immunization status. RESULTS: Outreach efforts had a positive impact on the proportion of children immunized and on the resulting immunization coverage rates. The percentage of children receiving immunizations during the 10-week follow-up was 4.2% (3/71) for the control group, 16.7% (10/60) for the telephone reminder group, 19.0% (12/63) for the mail reminder group, and 25.7% (18/70) for the sequential mail/telephone reminder group. The percentage of children up-to-date for all immunizations at the end of the 10-week follow-up was 2.8% (2/71) for the control group, 13.3% (8/60) for the telephone reminder group, 14.3% (9/63) for the mail reminder group, and 17.1% (12/70) for the sequential mail/telephone reminder group. Forty-eight children were seen during follow-up without receiving all indicated vaccines. CONCLUSIONS: Outreach efforts were modestly successful in reaching underimmunized children in a Medicaid managed care practice, although the lack of accurate information on telephone numbers and addresses limited the effectiveness. Missed opportunities for immunization also reduced the impact of outreach on immunization coverage. Arch Pediatr Adolesc Med. 2000;154:1243-1247.

Immunization status of children enrolled in a hospital-based medicaid managed care practice: the importance of the timing of vaccine administration.

OBJECTIVES: To evaluate the immunization status of children enrolled in a hospital-based Medicaid managed care practice and to assess the impact of the timing of vaccine administration on measured immunization rates. DESIGN AND METHODS: The medical records of all children between the ages of 19 and 35 months who were continuously enrolled in the Medicaid managed care practice for the last 6 months of 1996 were reviewed. Immunization status was determined for the following vaccines: diphtheria-tetanus-pertussis/diphtheria-tetanus-acellular pertussis (4 doses); Haemophilus influenzae type b (3 doses); poliovirus (3 doses); hepatitis B (3 doses); measles-mumps-rubella (1 dose); and overall for the basic series. Two assessment methods were used to determine the immunization status of the study children: (1) a count of all documented vaccines ("count"); and (2) only including vaccines that met minimal age and spacing intervals based on American Academy of Pediatrics and CDC recommendations ("interval assessment"). RESULTS: With the count method vaccine-specific immunization rates ranged from 88 to 95%, with overall coverage of 80% for the basic series. With the interval assessment method vaccine-specific immunization rates ranged from 74 to 92%, with overall coverage of 53% for the basic series. CONCLUSIONS: When all documented vaccines were included in the assessment, vaccine-specific immunization rates approached national goals, although overall coverage remained below 90% in this Medicaid managed care practice. The substantially lower immunization rates obtained by the interval assessment method demonstrate the importance of considering the issue of vaccine timing when interpreting immunization rates and the need for policies for revaccinating children who were immunized at less than recommended intervals. The results also have implications for provider education regarding the early administration of vaccines.

Literacy promotion for Hispanic families in a primary care setting: a randomized, controlled trial.

BACKGROUND: Reading aloud is an important activity to prepare children to succeed in learning to read. Many Hispanic children have reading difficulties and therefore are at increased risk for school failure. METHODS: We conducted a prospective, randomized, controlled study to evaluate the effectiveness of a literacy promoting intervention delivered to low-income Hispanic families with infants. We consecutively enrolled 135 low-income Hispanic parents of healthy 5 to 11 month old infants. Families were randomly assigned to an intervention (n = 65) or control (n = 70) group. At enrollment and at two consecutive well-child visits, pediatricians gave intervention families: 1) an age-appropriate bilingual children's book, 2) a bilingual handout explaining the benefits of reading to children, and 3) literacy-promoting anticipatory guidance. Ten months after enrollment we reinterviewed 130 parents. RESULTS: Both groups were comparable at baseline. At follow-up, intervention parents were more likely to read books with their child at least 3 days/week (intervention = 66% vs control parents = 24%) and to report that reading books was one of their three most favorite things to do with their child (intervention = 43% vs controls = 13%). Intervention families also had a greater number of children's books and total books at home. Using a multiple logistic regression model, controlling for child and parental age, reading habits, and English proficiency, we found that the odds of parents reading to their child at least 3 days/week were 10 times greater in intervention families (OR 10.1, 95% CI 4.0-25.6) compared with control families. CONCLUSIONS: This simple, culturally appropriate intervention significantly increased literacy behaviors in low-income Hispanic families.

Is continuity of care preserved in children who utilize the pediatric emergency department?

OBJECTIVE: Inner city families often use multiple sites for nonemergent medical care, including the pediatric emergency department. This practice raises concerns about continuity of care. The present study examined one aspect of continuity of care: Do children who receive care in a pediatric emergency department return to their primary care site so that appropriate follow up may be obtained? METHODS: Over a 4-week period two groups of neighborhood health center children were studied: Those who sought care at the pediatric emergency department and those who were "walk-ins" at the health centers. All visits during the 4-week study period which resulted in a recommendation for the child to be seen within 6 weeks at the health centers were included in the analysis. RESULTS: During the study period there were 87 patient visits to the pediatric emergency department with a documented physician instruction to be seen at their health center within 6 weeks. In 66 (76%) of the cases, the patient was seen at one of the health centers during the 6 weeks following the pediatric emergency department visit. There were 146 "walk-in" visits to the health centers with a documented physician instruction to be seen again at the health centers during the 6 weeks following the walk-in visit. In 111 (76%) of the cases, the patient was seen during the 6-week period. CONCLUSION: Our study shows that revisit rates were comparable for the two groups. We conclude that the rate of compliance with follow-up recommendations is similar for those who utilized the pediatric emergency department versus those who used the primary care site.

Current approaches to measuring health outcomes in pediatric research.

Because improving health is the ultimate goal of a health care system, the measurement of health outcomes in research is a logical and important goal for the evaluation of the impact of health services. Although health can be defined in various ways, here we employ a conceptualization that has several domains including longevity, disease, comfort, perceived well being, activity, achievement, and resilience. Given that health is such a broad concept, the difficult task for outcomes research is to provide the means of measuring it. As this brief summary of current work indicates, a number of approaches have been used in recent pediatric studies. Most focus on a small subset of health concerns. However, some studies have attempted to broaden the assessment of health outcome either by using multiple health measures or developing multidimensional instruments for measuring health. Care must be taken in evaluating the usefulness of any of the instruments until sufficient data are obtained as to their reliability and validity. Further work in this area is needed, particularly with regards to multidimensional approaches, which are beginning to provide a more sensitive and comprehensive means of assessing the impact of health services.

Isopropyl alcohol intoxication in a neonate through chronic dermal exposure: a complication of a culturally-based umbilical care practice.

A 21-day-old boy presented to our emergency department hypotonic, lethargic, and intermittently unresponsive to pain. A workup for ketoacidosis, sepsis, and central nervous system hemorrhage was negative. A urine drug screen collected eight hours after hospitalization showed 39 mg/dl of isopropyl alcohol and 76 mg/dl of acetone. The first serum drug analysis was not performed until 18 hours after admission, at a time when there had been clinical improvement. The isopropyl alcohol concentration was 8 mg/dl, and the acetone concentration was 203 mg/dl. Management was supportive, and the patient stabilized. He was discharged from the hospital in good health in three days. A further review of the history showed no evidence for an oral exposure to isopropyl alcohol. However, since leaving the maternity hospital the mother had been applying gauze pads or cotton balls soaked with isopropyl alcohol to the umbilicus with every diaper change. We conclude that the child suffered from an isopropyl alcohol intoxication that occurred by absorption through the umbilical area.

Management of elevated cholesterol levels by New Hampshire primary care physicians.

While experts are reaching a consensus on the appropriate management of abnormal blood lipid levels, the attitudes and behaviors of practicing clinicians are not well defined. This study addresses the attitudes and management practices regarding blood lipids of a representative sample of family physicians and general internists in the state of New Hampshire as determined by a questionnaire mailed during late 1986. Physicians consider blood lipid testing to be important in adults, but vary widely in their idea of what levels represent high risk for coronary heart disease. Over 40 percent felt that cholesterol levels need to be 7.80 mmol/L (300 mg/dL) or greater to constitute a high risk for coronary heart disease for patients aged 40 to 59 years. In addition, physicians feel much less effective in managing lipid abnormalities than in managing hypertension. Family physicians and general internists did not differ significantly in behavior or attitudes. To implement new expert recommendations, substantial efforts will be required to convince physicians to adopt lower cholesterol levels as indicating high risk for coronary heart disease and to feel more effective in patient management.