Quality of Life and Treatment Modalities in Patients with Interstitial Cystitis: The Patients' Perspective.

BACKGROUND: Quality of life (QoL)-based outcomes are hardly incorporated into interstitial cystitis/bladder pain syndrome (IC/BPS) guidelines, because studies are limited and outdated. Therefore, guidelines might not reflect the current clinical situation accurately. Secondly, guidelines suggest using a multimodal approach for BPS/IC management, but data on the patient-perceived efficacy of these therapies are limited. The aim of this study is to investigate the perception of IC/BPS patients of their QoL, to determine which treatments they have received, and to examine how they evaluate the efficacy of these various (alternative) therapies. METHODS: A quantitative retrospective database evaluation was performed, with data from an existing IC/BPS patient survey (n = 217) that was conducted in 2021. This survey contained QoL data based on validated questionnaires such as EQ-5D 5L. RESULTS: The QoL of patients is affected significantly by IC/BPS. This is evident from the various affected domains on the EQ-5D 5L. The symptom severity was negatively affected by a delay in diagnosis, and there were clear differences in QoL domains between females and males. Secondly, coagulation therapy and intravesical glycosaminoglycan (GAG) therapy were most appreciated by patients. Other (alternative) treatments were commonly utilized, although some had doubtful results and high discontinuation rates. CONCLUSION: QoL is considerably impaired in IC/BPS patients. The diverse responses and adherence to various treatments warrant a personalized approach (phenotype-oriented therapy). To achieve QoL improvement, it is important to incorporate the patient's perspective in treatment guidelines.

Restoring the barrier of chronically damaged urothelium using chondroitin sulfate glycosaminoglycan-replenishment therapy.

PURPOSE OF REVIEW: This study aims to further understand the physiological mechanism of chondroitin sulfate treatment on the urinary bladder in cases of inflammation, by investigating the effect of chondroitin sulfate therapy on recovery of urothelial barrier in an in-vitro chronic injury model. RECENT FINDINGS: With inflammatory bladder conditions, the urothelial barrier seems decreased. Glycosaminoglycan (GAG) replacement therapy is supposed to help restore this barrier. Clinical studies on inflammatory bladder conditions are complicated because of the heterogeneous patient population, hence the need for preclinical models. SUMMARY: In a model using porcine urothelial cells, functional barrier (TEER) and barrier markers were assessed. Chronic urothelial damage was simulated through protamine sulfate instillations with and without subsequent chondroitin sulfate instillations during 3 days. Chondroitin sulfate instillations significantly improved TEER compared to protamine sulfate treatment only (TEER difference 310 Ω.cm 2 , P  < 0.001). This consistent effect over 3 days resulted in a significant higher mean TEER value in the chondroitin sulfate treated group (difference 1855 Ω.cm 2 , P  < 0.001). Enhanced recovery of chondroitin sulfate and other barrier markers was observed.Chondroitin sulfate therapy shows promise in facilitating the recovery of the urothelial barrier in cases of chronic damage. This preclinical study lends support to the use of clinical GAG replenishment therapy for patients with a chronically impaired urothelium.

Molecular Processes in Stress Urinary Incontinence: A Systematic Review of Human and Animal Studies.

Stress urinary incontinence (SUI) is a common and burdensome condition. Because of the large knowledge gap around the molecular processes involved in its pathophysiology, the aim of this review was to provide a systematic overview of genetic variants, gene and protein expression changes related to SUI in human and animal studies. On 5 January 2021, a systematic search was performed in Pubmed, Embase, Web of Science, and the Cochrane library. The screening process and quality assessment were performed in duplicate, using predefined inclusion criteria and different quality assessment tools for human and animal studies respectively. The extracted data were grouped in themes per outcome measure, according to their functions in cellular processes, and synthesized in a narrative review. Finally, 107 studies were included, of which 35 used animal models (rats and mice). Resulting from the most examined processes, the evidence suggests that SUI is associated with altered extracellular matrix metabolism, estrogen receptors, oxidative stress, apoptosis, inflammation, neurodegenerative processes, and muscle cell differentiation and contractility. Due to heterogeneity in the studies (e.g., in examined tissues), the precise contribution of the associated genes and proteins in relation to SUI pathophysiology remained unclear. Future research should focus on possible contributors to these alterations.

Characteristics of US Adults Delaying Dental Care Due to the COVID-19 Pandemic.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has disrupted the delivery of health care services, including dental care. The objective of this study was to quantify and describe US adults who delayed dental care due to the COVID-19 pandemic. METHODS: We analyzed cross-sectional responses collected from a nationally representative and long-running panel survey of US adults conducted in late May and early June 2020 (response rate = 70%). The survey included questions about dental care delayed due to the COVID-19 pandemic, purpose of the delayed dental visits, timing of future dental visits, and demographic information. Pearson's chi-square tests were used to determine if rates of delayed dental care varied by subgroup. A multivariable regression model, adjusted for age, race, Hispanic ethnicity, census division, and rurality, was estimated to predict the odds of reporting delayed dental care. RESULTS: Nearly half of respondents (46.7%) reported delaying going to the dentist or receiving dental care due to the COVID-19 pandemic. Among adults who reported delaying dental care due to the pandemic, 74.7% reported delaying a checkup, 12.4% reported delaying care to address something that was bothering them, and 10.5% reported delaying care to get planned treatment. About 44.4% of adults reported that they planned to visit the dentist within the next 3 mo. In the multivariable regression model, only living in an urban (vs. rural) area was associated with significantly higher odds of delayed dental care due to the pandemic (odds ratio: 1.5; 95% confidence interval: 1.1, 2.1). CONCLUSIONS: Nearly half of US adults reported delaying dental care due to the COVID-19 pandemic during the spring of 2020. Our results offer insight into the experiences of patients seeking dental care this spring and the economic challenges faced by dental providers due to the pandemic. KNOWLEDGE TRANSFER STATEMENT: This article describes US adults who delayed dental care due to the COVID-19 pandemic. Results can be used by clinicians and policymakers to understand delayed care during the pandemic.

Genetic variants and expression changes in urgency urinary incontinence: A systematic review.

AIM: To perform a systematic review summarizing the knowledge of genetic variants, gene, and protein expression changes in humans and animals associated with urgency urinary incontinence (UUI) and to provide an overview of the known molecular mechanisms related to UUI. METHODS: A systematic search was performed on March 2, 2020, in PubMed, Embase, Web of Science, and the Cochrane library. Retrieved studies were screened for eligibility. The risk of bias was assessed using the ROBINS-I (human) and SYRCLE (animal) tool. Data were presented in a structured manner and in the case of greater than five studies on a homogeneous outcome, a meta-analysis was performed. RESULTS: Altogether, a total of 10,785 records were screened of which 37 studies met the inclusion criteria. Notably, 24/37 studies scored medium-high to high on risk of bias, affecting the value of the included studies. The analysis of 70 unique genes and proteins and three genome-wide association studies showed that specific signal transduction pathways and inflammation are associated with UUI. A meta-analysis on the predictive value of urinary nerve growth factor (NGF) levels showed that increased urinary NGF levels correlate with UUI. CONCLUSION: The collective evidence showed the involvement of two molecular mechanisms (signal transduction and inflammation) and NGF in UUI, enhancing our understanding of the pathophysiology of UUI. Unfortunately, the risk of bias was medium-high to high for most studies and the value of many observations remains unclear. Future studies should focus on elucidating how deficits in the two identified molecular mechanisms contribute to UUI and should avoid bias.

Do Oral Health Services in Medical Offices Replace Pediatric Dental Visits?

In the United States, state Medicaid programs pay for medical and dental care for children from low-income families and support nondental primary care providers delivering preventive oral health services (POHS) to young children in medical offices ("medical POHS"). Despite the potential of these policies to expand access to care, there is concern that they may replace dental visits with medical POHS. Using Medicaid claims from 38 states from 2006 to 2014, we conducted a repeated cross-sectional study and used linear probability regression to estimate the association between the annual proportion of children in a county receiving medical POHS and the probability that a child received 1) dental POHS and 2) a dental visit in a given year. Models included county and year fixed effects and controlled for child- and county-level factors, and standard errors were clustered at the state level. In a weighted population of 45.1 million child-years (age, 6 mo to <6 y), we found no significant nor substantively important association between the proportion of children in a county receiving medical POHS and the probability that a child received dental POHS or a dental visit. Additionally, we found an almost zero probability (<0.001) that the reduction in dental POHS was at least as large as the expansion in medical POHS (full substitution) and a 0.50 probability that increased medical POHS was associated with an increase in dental POHS of at least 6.6% of the expansion of medical POHS. Results were similar when receipt of dental visits was examined. This study failed to find evidence that medical POHS replaced dental visits for young children enrolled in Medicaid and, in fact, offers evidence that increased medical POHS was associated with increased utilization of dental care. Given lower-than-desired rates of dental visits for this population, delivery of medical POHS should be expanded.

Intravesical hyaluronic acid and chondroitin sulfate for recurrent urinary tract infections: systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: The objective was to assess the efficacy of intravesical hyaluronic acid (HA) and chondroitin sulfate (CS), alone or in combination, for recurrent urinary tract infections (RUTIs) in adult female patients using a systematic review and meta-analysis. METHODS: English-language articles were obtained from the MEDLINE, Embase, and Cochrane databases through November 2016, by manual searching and cross-referencing. Randomized and nonrandomized trials of adult female patients with a documented history of RUTIs who received HA, CS or HA plus CS were included. The random effects model was applied to all pooled analyses. Risk of bias was assessed for individual studies and across studies. RESULTS: Two randomized (n = 85) and six nonrandomized (n = 715) studies met the inclusion criteria. These studies assessed HA ± CS; studies of CS alone were not identified in the search. HA ± CS decreased the UTI rate per patient-year (pooled mean difference [MD] -2.56; 95% confidence interval [CI] -3.86, -1.26; p < 0.001) and increased the time to first UTI recurrence (pooled MD 130.05 days; 95% CI 5.84, 254.26; p = 0.04). There was heterogeneity in most outcomes considered, and publication bias in many studies. The standard of trial reporting was low. The patient population size, and the number of studies included, were small. CONCLUSIONS: HA ± CS appears to reduce the rate of UTI and increase the time to recurrence in women with RUTI. As randomized controlled studies are available only for HA plus CS, the quality of evidence is higher for the combination than for HA alone.

ls clinical practice aligned with the latest scientific evidence on GAG therapy?

The role of glycosaminoglycans (GAGs) as key components of the protective bladder barrier is well accepted. Replenishment of the GAG layer could restore the normal protective barrier function of the damaged bladder urothelium and re-establish normal permeability. A number of bladder diseases, including interstitial cystitis/bladder pain syndrome, recurrent urinary tract infections, radiation cystitis, and other forms of cystitis may benefit from GAG therapy.

TRPV4 mediates afferent pathways in the urinary bladder. A spinal c-fos study showing TRPV1 related adaptations in the TRPV4 knockout mouse.

The role of transient receptor potential vanilloid subtype 4 (TRPV4) channels in urinary bladder afferent neural pathways was investigated using spinal c-fos measurements in mice. Anesthetized wild type and TRPV4 knockout (-/-) mice underwent noxious bladder distention and treatment with either intravesical instillation with lipopolysaccharide (LPS), or the TRPV1 agonist resiniferatoxin (RTX), vehicle or an intraperitoneal injected TRPV4 antagonist (HC067047). Mice underwent paraformaldehyde perfusion for rapid fixation and L6-S1 spinal cord sections were removed followed by immunohistochemical staining for c-fos. A number of c-fos expressing neurons in the dorsal horns of L6-S1 spinal cord transections were quantified. Groups were compared using univariate ANOVA. Even with the absence of bladder inflammation on H&E, the TRPV4 -/- mice still have a significant twofold higher c-fos expression (n = 39, SD 2) after noxious bladder distention compared to wild type mice (n = 20, SD 3). A twofold increase in c-fos expression was observed after LPS treatment in wild types (n = 42, SD 5), but no increase was seen in TRPV4 -/- mice (n = 42, SD 2). After desensitization of primary afferent C-nerve fibers with RTX, c-fos expression in TRPV4-/- mice decreased significantly (threefold) (n = 12, SD 4). Results imply that TRPV4 channels are important for bladder afferent signaling. TRPV4 -/- mice bladders generate more noxious sensory output, which is predominantly mediated through TRPV1 expressing high threshold nerve fibers. This study reveals TRPV1 related adaptive changes in afferent pathways of the TRPV4 -/- mouse. We propose that this effect is caused by a congenital impairment of low threshold nerves that mediate normal bladder filling sensations.

A new, straightforward ex vivo organoid bladder mucosal model for preclinical research.

PURPOSE: We developed an experimental ex vivo organoid bladder mucosal model that can be used for experimental research purposes to create alternatives to current animal models. MATERIALS AND METHODS: We developed an ex vivo organoid bladder mucosal model by immobilizing a type I collagen scaffold on the bottom of a Transwell® insert, creating a 2-compartment system. Mucosal biopsies from porcine bladders were placed on top of the scaffold and cultured in different mediums. We evaluated the morphological aspects of biopsy tissue. Cultured samples were assessed by scanning electron microscopy, and immunohistochemical and histochemical staining for cell identification, proliferation and morphology. RESULTS: Cells remained viable in Dulbecco's modified Eagle's medium/F-12 and smooth muscle cell medium for up to 3 weeks. The mucosa retained normal morphological characteristics for up to 1 week. Cells (mostly urothelial cells) proliferated and fully covered the scaffold surface within 3 weeks. CONCLUSIONS: We developed an experimental ex vivo organoid model of bladder mucosa for preclinical experimental research. This model could be used for high volume screening for pharmacology and toxicology experiments. It has the potential to replace currently used animal models.

The distribution and function of chondroitin sulfate and other sulfated glycosaminoglycans in the human bladder and their contribution to the protective bladder barrier.

PURPOSE: Glycosaminoglycan replenishment therapies are commonly applied to treat bladder inflammatory conditions such as bladder pain syndrome/interstitial cystitis. Although there is evidence that these therapies are clinically effective, much is still unknown about the location and function of different types of glycosaminoglycans in the bladder. We investigated the location of sulfated glycosaminoglycans in the bladder and evaluated their contribution to the urothelial barrier. MATERIALS AND METHODS: The location of different glycosaminoglycans (heparan sulfate, chondroitin sulfate and dermatan sulfate) in human and porcine bladders was investigated with immunofluorescence staining and isolating glycosaminoglycans using selective urothelial sampling techniques. Barrier function was evaluated with transepithelial electrical resistance measurements (Ω.cm(2)) on primary porcine urothelial cell cultures. The contribution of different glycosaminoglycans to the bladder barrier was investigated with specific glycosaminoglycan digesting enzymes and protamine. RESULTS: High glycosaminoglycan concentrations are located around the urothelial basal membrane and at the urothelial luminal surface. After removing the glycosaminoglycan layer, urothelial permeability increased. Natural recovery of the glycosaminoglycan layer takes less than 24 hours. Chondroitin sulfate was the only sulfated glycosaminoglycan that was located on the urothelial luminal surface and that contributed to urothelial barrier function. CONCLUSIONS: This study reveals an important role for chondroitin sulfate in bladder barrier function. Therapies aiming at restoring the luminal glycosaminoglycan layer in pathological conditions such as bladder pain syndrome/interstitial cystitis are based on a sound principle.

Cost-effectiveness of disease-modifying therapy for multiple sclerosis: a population-based study.

OBJECTIVE: To evaluate the cost-effectiveness of disease-modifying therapies (DMTs) in the United States compared to basic supportive therapy without DMT for patients with relapsing multiple sclerosis (MS). METHODS: Using data from a longitudinal MS survey, we generated 10-year disease progression paths for an MS cohort. We used first-order annual Markov models to estimate transitional probabilities. Costs associated with losses of employment were obtained from the Bureau of Labor Statistics. Medical costs were estimated using the Centers for Medicare and Medicaid Services reimbursement rates and other sources. Outcomes were measured as gains in quality-adjusted life-years (QALY) and relapse-free years. Monte Carlo simulations, resampling methods, and sensitivity analyses were conducted to evaluate model uncertainty. RESULTS: Using DMT for 10 years resulted in modest health gains for all DMTs compared to treatment without DMT (0.082 QALY or <1 quality-adjusted month gain for glatiramer acetate, and 0.126-0.192 QALY gain for interferons). The cost-effectiveness of all DMTs far exceeded $800,000/QALY. Reducing the cost of DMTs had by far the greatest impact on the cost-effectiveness of these treatments (e.g., cost reduction by 67% would improve the probability of Avonex being cost-effective at $164,000/QALY to 50%). Compared to treating patients with all levels of disease, starting DMT earlier was associated with a lower (more favorable) incremental cost-effectiveness ratio compared to initiating treatment at any disease state. CONCLUSION: Use of DMT in MS results in health gains that come at a very high cost.

The mechanoreceptor TRPV4 is localized in adherence junctions of the human bladder urothelium: a morphological study.

PURPOSE: TRPV4 (transient receptor potential vanilloid 4 channel) is a nonselective cation channel involved in different sensory functions that was recently implicated in bladder mechanosensation. We investigated the cellular site of TRPV4 in bladder urothelium and explored a molecular connection between TRPV4 and urothelial adherence junctions. MATERIALS AND METHODS: We obtained healthy tissues sections from cystectomy in humans due to cancer in 3 and noncancerous conditions in 2. Besides human biopsies tissues from 7 normal and 7 TRPV4-/-mice, and the urothelial cell line RT4 were also used. Experiments were done with polyclonal antibody against TRPV4 (against the N-terminus of rat TRPV4). A molecular connection between TRPV4 and different adherence junction components was investigated using immunofluorescence, Western blot and immunoprecipitation. RESULTS: Results revealed TRPV4 on urothelial cell membranes near adherence junctions. Results were comparable in the urothelial cell line, human bladders and mouse bladders. Subsequent immunoprecipitation experiments established a molecular connection of TRPV4 to α-catenin, an integral part of the adherence junction that catenates E-cadherin to the actin-microfilament network. CONCLUSIONS: Results provide evidence for the location of TRPV4 in human bladder urothelium. TRPV4 is molecularly connected to adherence junctions on the urothelial cell membrane. TRPV4 coupling to a rigid intracellular and intercellular structural network would agree with the hypothesis that TRPV4 can be activated by bladder stretch.

Quantifying the risks and benefits of natalizumab in relapsing multiple sclerosis.

Using published data, we quantified the risk and benefits of natalizumab in relapsing multiple sclerosis using quality-adjusted life years (QALYs) as a metric. Over the first 2 years of therapy, the negative health effects from progressive multifocal leukoencephalopathy were small (loss of 0.001 QALYs) relative to the positive effects on relapses and disability resulting in 0.033 QALYs (12 quality-adjusted days) gained. For context, we performed an analogous calculation for interferon beta-1a, which also had a net health benefit of 0.033 QALYs (12 quality-adjusted days).

Evaluation of children's health insurance: from New York State's CHild Health Plus to SCHIP.

BACKGROUND: The legislation and funding of the State Children's Health Insurance Program (SCHIP) in 1997 resulted in the largest public investment in child health care in 30 years. The program was designed to provide health insurance for the estimated 11 million uninsured children in the United States. In 1991 New York State implemented a state-funded program-Child Health Plus (CHPlus)-intended to provide health insurance for uninsured children who were ineligible for Medicaid. The program became one of the prototypes for SCHIP: This study was designed to measure the association between CHPlus and access to care, utilization of care, quality of care, and health care costs to understand the potential impact of one type of prototype SCHIP program. METHODS: The study took place in the 6-county region of upstate New York around and including the city of Rochester. A before-and-during design was used to compare children's health care for the year before they enrolled in CHPlus versus the first year during enrollment in CHPlus. The study included 1828 children (ages 0-6.99 years at enrollment) who enrolled between November 1, 1991 and August 1, 1993. A substudy involved 187 children 2 to 12.99 years old who had asthma. Data collection involved: 1) interviews of parents to obtain information about demographics, sources of health care, experience and satisfaction with CHPlus, and perceived impact of CHPlus; 2) medical chart reviews at all primary care offices, emergency departments, and health department clinics in the 6-county region to measure utilization of health services; 3) claims analysis to assess costs of care during CHPlus and to impute costs before CHPlus; and 4) analyses of existing datasets including the Current Population Survey, National Health Interview Survey, and statewide hospitalization datasets to anchor the study in relation to the statewide CHPlus population and to assess secular trends in child health care. Logistic regression and Poisson regression were used to compare the means of dependent measures with and without CHPlus coverage, while controlling for age, prior insurance type, and gap in insurance coverage before CHPlus. ENROLLMENT: Only one third of CHPlus-eligible children throughout New York State had enrolled in the program by 1993. Lower enrollment rates occurred among Hispanic and black children than among white children, and among children from lowest income levels. PROFILE OF CHPlus ENROLLEES: Most enrollees were either previously uninsured, had Medicaid but were no longer eligible, or had parents who either lost a job and related private insurance coverage or could no longer afford commercial or private insurance. Most families heard about CHPlus from a friend, physician, or insurer. Television, radio, and newspaper advertisements were not major sources of information. Nearly all families had at least 1 employed parent. Two thirds of the children resided in 2-parent households. Parents reported that most children were in excellent or good health and only a few were in poor health. The enrolled population was thus a relatively low-risk, generally healthy group of children in low-income, working families. ACCESS AND UTILIZATION OF HEALTH CARE: Utilization of primary care increased dramatically after enrollment in CHPlus, compared with before CHPlus. Visits to primary care medical homes for preventive, acute, and chronic care increased markedly. Visits to medical homes also increased for children with asthma. There was, however, no significant association between enrollment in CHPlus and changes in utilization of emergency departments, specialty services, or inpatient care. QUALITY OF CARE: CHPlus was associated with improvements in many measures involving quality of primary care, including preventive visits, immunization rates, use of the medical home for health care, compliance with preventive guidelines, and parent-reported health status of the child. (ABSTRACT TRUNCATED)

Evolution of a children's health insurance program: lessons from New York State's Child Health Plus.

The State Children's Health Insurance Program (SCHIP) was passed by Congress in 1997. It provides almost $40 billion in federal block grant funding through the year 2007 for states to expand health insurance for children. States have the option of expanding their Medicaid programs, creating separate insurance programs, or developing combination plans using both Medicaid and the private insurance option. New York State's child health insurance plan, known by its marketing name Child Health Plus, was created by the New York Legislature in 1990. New York's program, along with similar ones from several other states, served as models for the federal legislation, especially for state health insurance plans offered through private insurers. New York's program provides useful data for successful implementation of SCHIP.

Evaluation of New York State's Child Health Plus: methods.

BACKGROUND: The State Children's Health Insurance Program (SCHIP) is the largest public investment in child health care in 30 years, targeting 11 million uninsured children, yet little is known about the impact of health insurance on uninsured children. In 1991 New York State implemented Child Health Plus (CHPlus), a health insurance program that was a prototype for SCHIP. A study was designed to measure the association between CHPlus and access to care, utilization of services, and quality of care. METHODS: The setting was a 6-county region in upstate New York (population 1 million) around and including the city of Rochester. A before-and-during design was used to compare children's health care for the year before they enrolled in CHPlus versus the first year during CHPlus, for 1828 children (ages 0-6.99 years at enrollment) who enrolled between November 1, 1991 and August 1, 1993. An additional study involved 187 children 2 to 12.99 years old who had asthma. Parents were interviewed to assess demographic characteristics, sources of health care, experience with CHPlus, and impact of CHPlus on their children's quality of care and health status. Medical charts were reviewed to measure utilization and quality of care, for 1730 children 0 to 6.99 years and 169 children who had asthma. Charts were reviewed at all primary care offices and at the 12 emergency departments and 6 public health department clinics in the region. CHPlus claims files were analyzed to determine costs during CHPlus and to impute costs before CHPlus from utilization data. ANALYSES: Logistic regression and Poisson regression were used to compare the means of dependent measures with and without CHPlus coverage, while controlling for age, prior insurance type, and gap in insurance coverage before CHPlus. CONCLUSIONS: This study developed and implemented methods to evaluate the association between enrollment in a health insurance program and children's health care. These methods may also be useful for evaluations of SCHIP.

A profile of the population enrolled in New York State's Child Health Plus.

BACKGROUND: The recently enacted State Children's Health Insurance Program (SCHIP), designed to provide affordable health insurance for uninsured children, was modeled in part on New York State's Child Health Plus (CHPlus), which was implemented in 1991. All SCHIP programs involve voluntary enrollment of eligible children. Little is known about characteristics of children who enroll in these programs. OBJECTIVES: To provide a profile of children enrolled in CHPlus between 1993 and 1994 in the 6-county upstate New York study area, and to estimate the participation rate in CHPlus. Methods. A parent interview was conducted to obtain information about children, 0 to 6.9 years old, who enrolled in CHPlus in the study area. Two school-based surveys and the Current Population Survey were used to estimate health insurance coverage. Enrollment data from New York State's Department of Health, together with estimates of the uninsured, were used to estimate participation rates in CHPlus. RESULTS: Most children enrolled in CHPlus in the study area were white. Although 17% of all children in the study area who were <13 years old and living in families with incomes below 160% of the federal poverty level were black, only 9% of CHPlus-enrolled children were black. Twenty-one percent of enrolled children were uninsured during the entire year before enrollment and 61% of children had a gap in coverage lasting >1 month. Children were generally healthy; only 4% had fair or poor health. Eighty-eight percent of parents of enrolled children had completed high school or a higher level of education. Parents reported that loss of a job was the main reason for loss of prior health insurance for their child. Most families learned about CHPlus from a friend (30%) or from their doctor (26%). The uninsured rate among children in the study area was approximately 4.1%. By 1993, the participation rate in CHPlus was about 36%. CONCLUSION: Blacks were underrepresented in CHPlus. Because the underlying uninsured rate was relatively low and parental education and family income were relatively high, the effects of CHPlus observed in this evaluation may be conservative in comparison to the potential effects of CHPlus for other populations of children. Participation rates during the early years of the program were modest.