Association between school racial/ethnic composition during adolescence and adult health.

OBJECTIVES: School racial/ethnic segregation in U.S. schoolsDifferences in school racial/ethnic composition may increase health disparities by concentrating educational opportunities that confer long-term health benefits in schools serving predominantly wwhite students. For racial minority students, high concentrations of white students may increase exposure to racismis also associated with psychologicstress, which may ultimately reduceing the long-term health benefits from educational opportunities. Meanwhile associations of racial/ethnic academic tacking within schools and health have been mixed. We sought to test whether: 1) differences in racial/ethnic composition between schools and, 2) racial/ethnic distribution of students in academic tracks within schools are associated with long-term health benefits or risks for white, Black and Latinx students. METHODS: We analyzed the National Longitudinal Study of Adolescent to Adult Health (12,438 participants, collected 1994-2008), to test whether the school-level segregation (percent of non-Latinx white students at participants' school during adolescence) was associated with adult health outcomes at ages 18-26 & 24-32, controlling for contextual factorscomparing Black, Latinx, and white students, and controlling for contextualf factors. A secondary analysis explored whether racial/ethnic cohorting across levels of English courses was associated with each health outcome. RESULTS: Attending a school with a higher percent of white students was associated with higher adult depression scores, substance abuse, and worse self-rated health for black Black students; lower depression scores, better self-rated health, and alcohol abuse for white students; and no health differences for Latinx students. Greater within school racial/ethnic cohorting across English courses was associated with increased odds of alcohol abuse for white students; decreased odds of alcohol abuse for Black and Latinx students; and decreased odds of drug abuse for Black students. CONCLUSION: Among Bblack youth, attending a school with a higher percentage of white students is associated with worse behavioral health in adulthood. Understanding the potential impacts of school racial/ethnic composition on health is critical to designing policies that maximize access to opportunity and health.Education policies should comprehensively address school quality and racism to maximize adult health.

Parental perception of a picture-based chronic asthma care management tool in an urban pediatric emergency department.

BACKGROUND: National asthma guidelines recommend use of an asthma action plan (AAP) as part of chronic asthma care. Unfortunately, AAPs have not been tailored for use in acute care settings, where many patients at risk for poor chronic asthma care are seen, including those who are non-English-speaking or have low literacy levels. We previously developed a picture-based medication plan (PBMP), a unique type of AAP for use in an ambulatory setting and designed to increase patient use and understanding. However, little is known about how parents seeking emergency department (ED) asthma care would perceive the PBMP. OBJECTIVE: To assess parental attitudes toward an asthma PBMP in the largest pediatric ED in Los Angeles County. METHODS: We surveyed a consecutive sample of English- or Spanish-speaking parents of children 2-17 years seeking ED asthma care. Parents used a 5-point Likert scale for various statements regarding their perceptions of the PBMP. Responses were analyzed by sociodemographics, asthma control, and health literacy using Chi-squared and t-tests. RESULTS: 90 parents provided feedback on the PBMP. The majority of parents endorsed the PBMP. Endorsement was 20%-30% higher among Spanish-speaking parents and those who did not complete high-school compared to English-speaking parents and parents with a high school education or higher (p < 0.05 for both comparisons). CONCLUSION: Spanish-speaking parents and parents with less than a high-school education overwhelmingly endorsed the PBMP. It may be useful to consider incorporating the PBMP as part of patient-centered chronic asthma care strategies for populations seen in ED settings.

Incidence and viral aetiologies of acute respiratory illnesses (ARIs) in the United States: a population-based study.

We conducted prospective, community-wide surveillance for acute respiratory illnesses (ARIs) in Rochester, NY and Marshfield, WI during a 3-month period in winter 2011. We estimated the incidence of ARIs in each community, tested for viruses, and determined the proportion of ARIs associated with healthcare visits. We used a rolling cross-sectional design to sample participants, conducted telephone interviews to assess ARI symptoms (defined as a current illness with feverishness or cough within the past 7 days), collected nasal/throat swabs to identify viruses, and extracted healthcare utilization from outpatient/inpatient records. Of 6492 individuals, 321 reported an ARI within 7 days (4·9% total, 5·7% in Rochester, 4·4% in Marshfield); swabs were collected from 208 subjects. The cumulative ARI incidence for the entire 3-month period was 52% in Rochester [95% confidence interval (CI) 42-63] and 35% in Marshfield (95% CI 28-42). A specific virus was identified in 39% of specimens: human coronavirus (13% of samples), rhinovirus (12%), RSV (7%), influenza virus (4%), human metapneumovirus (4%), and adenovirus (1%). Only 39/200 (20%) had a healthcare visit (2/9 individuals with influenza). ARI incidence was ~5% per week during winter.

Evaluating the benefits of increasing measles immunization rates.

OBJECTIVE: To calculate the cost-effectiveness, expressed in dollars per quality-adjusted life years (QALY), of increasing measles immunization rates. DATA SOURCES/STUDY DESIGN: Published data were supplemented by expert opinion. We determined the cost savings and value of the health benefits from averting a single case of measles. Next we examined the U. S. data regarding the relationship between pre-school measles immunization and incidence rates. Finally, we calculated the cost-effectiveness of a program that would increase a locality's immunization rate to the point of disease elimination. PRINCIPAL FINDINGS: Averting a single case of measles, using "base case" assumptions, yields societal cost savings of $2,089 and an increase of 0.086 QALYs. Using a very low discount rate increases the total benefits to $2,251 in societal cost savings and 0.150 QALYs in health benefits. In general, programs to raise measles immunization rates are not cost-effective, except possibly during an outbreak of the disease or in areas with very low immunization rates. The extremely low measles incidence rates in the mid-1990s result in such programs having extremely high costs per QALY gained. CONCLUSIONS: Programs that are narrowly designed to increase immunization rates alone are not likely to be cost-effective. Yet these programs do have the potential to be cost-effective if the program design and evaluation also recognize the benefits associated with the primary and preventive care that can accompany immunizations. Such programs may also be cost-effective if they are components of a global eradication of measles.

Iron deficiency and cognitive achievement among school-aged children and adolescents in the United States.

CONTEXT: Iron deficiency anemia in infants can cause developmental problems. However, the relationship between iron status and cognitive achievement in older children is less clear. OBJECTIVE: To investigate the relationship between iron deficiency and cognitive test scores among a nationally representative sample of school-aged children and adolescents. DESIGN: The National Health and Nutrition Examination Survey III 1988-1994 provides cross-sectional data for children 6 to 16 years old and contains measures of iron status including transferrin saturation, free erythrocyte protoporphyrin, and serum ferritin. Children were considered iron-deficient if any 2 of these values were abnormal for age and gender, and standard hemoglobin values were used to detect anemia. Scores from standardized tests were compared for children with normal iron status, iron deficiency without anemia, and iron deficiency with anemia. Logistic regression was used to estimate the association of iron status and below average test scores, controlling for confounding factors. RESULTS: Among the 5398 children in the sample, 3% were iron-deficient. The prevalence of iron deficiency was highest among adolescent girls (8.7%). Average math scores were lower for children with iron deficiency with and without anemia, compared with children with normal iron status (86.4 and 87.4 vs 93.7). By logistic regression, children with iron deficiency had greater than twice the risk of scoring below average in math than did children with normal iron status (odds ratio: 2.3; 95% confidence interval: 1.1-4.4). This elevated risk was present even for iron-deficient children without anemia (odds ratio: 2.4; 95% confidence interval: 1.1-5.2). CONCLUSIONS: We demonstrated lower standardized math scores among iron-deficient school-aged children and adolescents, including those with iron deficiency without anemia. Screening for iron deficiency without anemia may be warranted for children at risk.

Adolescent immunization practices: a national survey of US physicians.

BACKGROUND: Adolescent immunization rates remain low. Hence, a better understanding of the factors that influence adolescent immunization is needed. OBJECTIVE: To assess the adolescent immunization practices of US physicians. DESIGN AND SETTING: A 24-item survey mailed in 1997 to a national sample of 1480 pediatricians and family physicians living in the United States, randomly selected from the American Medical Association's Master List of Physicians. PARTICIPANTS: Of 1110 physicians (75%) who responded, 761 met inclusion criteria. OUTCOME MEASURES: Immunization practices and policies, use of tracking and recall, opinions about school-based immunizations, and reasons for not providing particular immunizations to eligible adolescents. RESULTS: Seventy-nine percent of physicians reported using protocols for adolescent immunization, and 82% recommended hepatitis B immunization for all eligible adolescents. Those who did not routinely immunize adolescents often cited insufficient insurance coverage for immunizations. While 42% of physicians reported that they review the immunization status of adolescent patients at acute illness visits, only 24% immunized eligible adolescents during such visits. Twenty-one percent used immunization tracking and recall systems. Though 84% preferred that immunizations be administered at their practice, 71% of physicians considered schools, and 63% considered teen clinics to be acceptable alternative adolescent immunization sites. However, many had concerns about continuity of care for adolescents receiving immunizations in school. CONCLUSIONS: Most physicians supported adolescent immunization efforts. Barriers preventing adolescent immunization included financial barriers, record scattering, lack of tracking and recall, and missed opportunities. School-based immunization programs were acceptable to most physicians, despite concerns about continuity of care. Further research is needed to determine whether interventions that have successfully increased infant immunization rates are also effective for adolescents.

School readiness among urban children with asthma.

BACKGROUND: Children with chronic illnesses, including asthma, are at risk for school problems. Developmental problems, however, may begin before school entry, and the developmental status of preschool children with asthma has not been evaluated. OBJECTIVE: To test the hypothesis that urban preschool children with asthma have lower parent-reported developmental scores compared with children without asthma. METHODS: A comprehensive survey of children beginning kindergarten in 1998 in the urban school system in Rochester, NY, collected parent reports of demographic, medical, and developmental data. We compared children with asthma with and without limitation of activity to children without asthma for motor, language, socioemotional, and school readiness skills and the need for extra help with learning. Linear and logistic regression were used to determine associations between asthma and developmental outcomes. RESULTS: Among the 1058 children in this sample, 9% had asthma, including 5% with asthma with limitation of activity. After adjustment for multiple potential confounding variables, the children with asthma with limitation had lower scores on school readiness skills compared with children without asthma (2.0 vs 2.5, P <.001). Further, the parents of children with asthma with limitation were substantially more likely (P <.05) to describe them as needing extra help with learning (74% vs 56%; odds ratio, 3.2; 95% confidence interval, 1.5--7.8). CONCLUSIONS: Urban preschool children with significant asthma had poorer parent-reported school readiness skills and a greater need for extra help with learning compared with children without asthma. This finding suggests that developmental problems for children with asthma may begin before school entry.

National, state and urban-area vaccination-coverage levels among children aged 19-35 months, United States, 1999.

BACKGROUND: Assessment of vaccination coverage is an important component of the U.S. vaccination program and is primarily measured by the National Immunization Survey (NIS). METHODS: The 1999 NIS is a nationally representative sample of children aged 19 to 35 months, verified by provider records, that is conducted to obtain estimates of vaccination coverage rates. Coverage estimates are calculated for the nation, states, and selected urban areas for recommended vaccines and selected vaccine series. RESULTS: Coverage estimates are presented by a variety of demographic and healthcare-related factors: overall, by poverty status, race/ethnicity, selected milestone ages, participation in WIC, level of urbanicity, provider participation in VFC, and by provider facility type. In 1999, national coverage estimates were high for most vaccines and among most demographic groups. State and urban-area level estimates varied.

Effect of patient reminder/recall interventions on immunization rates: A review.

CONTEXT: Immunization rates for children and adults remain below national goals. While experts recommend that health care professionals remind patients of needed immunizations, few practitioners actually use reminders. Little is known about the effectiveness of reminders in different settings or patient populations. OBJECTIVES: To assess the effectiveness of patient reminder systems in improving immunization rates, and to compare the effectiveness of different types of reminders for a variety of patient populations. DATA SOURCES: A search was performed using MEDLINE, EMBASE, PsychINFO, Sociological Abstracts, and CAB Health Abstracts. Relevant articles, as well as published abstracts, conference proceedings, and files of study collaborators, were searched for relevant references. STUDY SELECTION AND DATA EXTRACTION: English-language studies involving patient reminder/recall interventions (using criteria established by the Cochrane Collaboration) were eligible for review if they involved randomized controlled trials, controlled before-after studies, or interrupted time series, and measured immunization rates. Of 109 studies identified, 41 met eligibility criteria. Studies were reviewed independently by 2 reviewers using a standardized checklist. Results of studies are expressed as absolute percentage-point changes in immunization rates and as odds ratios (ORs). Studies with similar characteristics of patients or interventions were pooled (random effects model). DATA SYNTHESIS: Patient reminder systems were effective in improving immunization rates in 33 (80%) of the 41 studies, irrespective of baseline immunization rates, patient age, setting, or vaccination type. Increases in immunization rates due to reminders ranged from 5 to 20 percentage points. Reminders were effective for childhood vaccinations (OR, 2.02; 95% confidence interval [CI], 1.49-2.72), childhood influenza vaccinations (OR, 4. 25; 95% CI, 2.10-8.60), adult pneumococcus or tetanus vaccinations (OR, 5.14; 95% CI, 1.21-21.78), and adult influenza vaccinations (OR, 2.29; 95% CI, 1.69-3.10). While reminders were most effective in academic settings (OR, 3.33; 95% CI, 1.98-5.58), they were also highly effective in private practice settings (OR, 1.79; 95% CI, 1. 45-2.22) and public health clinics (OR, 2.09; 95% CI, 1.42-3.07). All types of reminders were effective (postcards, letters, and telephone or autodialer calls), with telephone reminders being most effective but costliest. CONCLUSIONS: Patient reminder systems in primary care settings are effective in improving immunization rates. Primary care physicians should use patient reminders to improve immunization delivery. JAMA. 2000;284:1820-1827.

Uninsured children with psychosocial problems: primary care management.

OBJECTIVE: Nearly 14% of children in the United States are uninsured. We compared the prevalence of psychosocial problems and mental health services received by insured and uninsured children in primary care practices. METHODS: The Child Behavior Study was a cohort study conducted by Pediatric Research in Office Settings and the Ambulatory Sentinel Practice Network. Four hundred one primary care clinicians enrolled an average sample of 55 consecutive children (4-15 years old) per clinician. RESULTS: Of the 13 401 visits to clinicians with 3 or more uninsured patients, 12 518 were by insured children (93.4%) and 883 were by uninsured children (6. 6%). A higher percentage of adolescents, Hispanic children, those with unmarried parents, and those with less educated parents were uninsured. According to clinicians, uninsured children and insured children had similar rates of psychosocial problems (19%) and severe psychosocial problems (2%). For children with a clinician-identified psychosocial problem, we found no differences in clinician-reported counseling, medication use, or referral to mental health professionals. CONCLUSIONS: Among children served in primary care practices, uninsured children have similar prevalence of clinician-identified psychosocial and mental health problems compared with insured children. Within their practices, clinicians managed uninsured children much the same way as insured children. psychosocial problems, uninsured children, pediatrics, family medicine, primary care.

Decline in physician referrals to health department clinics for immunizations: the role of vaccine financing.

BACKGROUND: Physicians frequently refer children to health department clinics (HDCs) for immunizations because of high out-of-pocket costs to parents and poor reimbursement for providers. Referrals for immunizations can lead to scattered care. In 1994, two vaccine financing reforms began in New York State that reduced patient costs and improved provider reimbursement: the Vaccines for Children Program (VFC, mostly for those on Medicaid and uninsured) and a law requiring indemnity insurers to cover childhood immunizations and preventive services. OBJECTIVE: To measure reported changes in physician referrals to HDCs for immunizations before and after the vaccine financing reforms. DESIGN: In 1993, a self-administered survey measured immunization referral practices of primary care physicians. In 1997, we resurveyed respondents of the 1993 survey to evaluate changes in referrals. SETTING/ PARTICIPANTS: Three hundred twenty-eight eligible New York State primary care physicians (65% pediatricians and 35% family physicians) who responded to the 1997 follow-up immunization survey (response rate of 82%). RESULTS: The proportion of physicians reporting that they referred some or all children out for immunizations decreased from 51% in 1993 to 18% in 1997 (p<0.001). In 1997, physicians were more likely to refer if they were family physicians (28% vs. 13%,p<0.01), or did not obtain VFC vaccines (29% vs. 13%,p<0.001). According to physicians who referred in 1993, decreased referrals in 1997 were due to the new insurance laws (noted by 61%), VFC (60%), Child Health Plus (a statewide insurance program for poor children, 28%), growth in commercial managed care (23%), Medicaid managed care (19%), and higher Medicaid reimbursement for immunizations that is due to VFC (18%). For physicians noting a decline in referrals, the magnitude of the decline was substantial-60% fewer referrals for VFC-eligible patients and 50% fewer for patients eligible under the new insurance law. CONCLUSIONS: Vaccine financing reforms decreased the proportion of physicians who referred children to HDCs for immunizations, and may have reduced scattering of pediatric care.

The effect of audit and feedback on immunization delivery: a systematic review.

OBJECTIVE: To assess the effective of audit and feedback (A&F) on immunization delivery by health care professionals. DESIGN: Systematic review of published literature. MAIN OUTCOME MEASURES: Changes in immunization rates. METHODS: We searched Medline between 1966 and 1997. We obtained additional studies from back-searching reference lists and the files of study collaborators. We included studies that were written in English, that included audit and feedback in at least one arm of the study, that studied universally recommended childhood or adult vaccines, and that provided immunization coverage data. Two reviewers read studies independently and abstracted using a validated checklist. Study quality was assessed using criteria standardized by the Cochrane Collaboration. Differences between reviewers were resolved by consensus. RESULTS: The search process resulted in 60 citations; 44 were fully reviewed and 15 met eligibility criteria. Five were randomized trials. Twelve of the fifteen studies found that A&F, alone or in combination with other interventions, were associated with improvements in immunization rates. The magnitude of the effect varied from -17% to +49% change. Study design heterogeneity precluded statistical pooling of study results. CONCLUSIONS: The evidence available from published studies suggests that A&F alone may be an effective strategy for improving immunization rates. The number of well-conducted studies is small, and the effect is variable. Additional well-designed studies are needed to identify the independent effects of A&F, optimal format and frequency of A&F, and to examine its long-term effect on provider immunization practices and costs.

Impact of vaccine financing on vaccinations delivered by health department clinics.

OBJECTIVES: This study measured the number of childhood vaccinations delivered at health department clinics (HDCs) before and after changes in vaccine financing in 1994, and it assessed the impact of changes in financing on HDC operations. METHODS: We measured the number of vaccination doses administered annually at all 57 HDCs in New York State between 1991 and 1996, before and after the financing changes. Interviews of HDC personnel assessed the impact of financing changes. A secondary study measured trends in Pennsylvania and California. RESULTS: HDC vaccinations for preschool children in New York State declined slightly prior to the financing changes (6%-8% between 1991 and 1993) but declined markedly thereafter (53%-56% between 1993 and 1996). According to nearly two thirds of New York State's HDCs, the primary cause for this decline was the vaccine-financing changes. HDC vaccinations for preschool children in Pennsylvania declined by 12% between 1991 and 1993 and by 56% between 1993 and 1997. HDC vaccinations for polio-containing vaccines in California declined by 31% between 1993 and 1997. CONCLUSIONS: Substantially fewer vaccinations have been administered at HDCs since changes in vaccine financing, thereby keeping preschool children in their primary care medical homes.

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.

Evaluation of New York State's Child Health Plus: access, utilization, quality of health care, and health status.

BACKGROUND: The recently enacted State Children's Health Insurance Program (SCHIP) is modeled after New York State's Child Health Plus (CHPlus) program. Since 1991, CHPlus has provided health insurance to children 0 to 13 years old whose annual family income was below 222% of the federal poverty level and who were ineligible for Medicaid or did not have equivalent health insurance coverage. CHPlus covered the costs for ambulatory, emergency, and specialty care, and prescriptions, but not inpatient services. OBJECTIVES: To assess the change associated with CHPlus regarding 1) access to health care; 2) utilization of ambulatory, inpatient, and emergency services; 3) quality of health care; and 4) health status. SETTING: Six western New York State counties (including the city of Rochester). SUBJECTS: Children (0-6.99 years old) enrolled for at least 9 consecutive months in CHPlus. METHODS: The design was a before-and-after study, comparing individual-level outcomes for the 12 months immediately before CHPlus enrollment and the 12 months immediately after enrollment in CHPlus. Parent telephone interviews and medical chart reviews conducted 12 months after enrollment to gather information. Subjects' primary care charts were located by using interview information; emergency department (ED) charts were identified by searching patient records at all 12 EDs serving children in the study; and health department charts were identified by searching patient records at the 6 county health department clinics. 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. RESULTS: Complete data were obtained for 1730 children. Coverage by CHPlus was associated with a significant improvement in access to care as measured by the proportion of children reported as having a usual source of care (preventive care: +1.9% improvement during CHPlus and sick care: +2. 7%). CHPlus was associated, among children 1 to 5 years old, with a significant increase in utilization of preventive care (+.23 visits/child/year) and sick care (+.91 visits/child/year) but no measurable change in utilization of specialty, emergency, or inpatient care. CHPlus was also associated, among children 1 to 5 years old, with significantly higher immunization rates (up-to-date for immunizations: 76% vs 71%), and screening rates for anemia (+11% increased proportion screened/year), lead (+9%), vision (+11%), and hearing (+7%). For 25% of the children, a parent reported that their child's health was improved as a result of having CHPlus. CONCLUSION: After enrollment in CHPlus, access to and utilization of primary care increased, continuity of care improved, and many quality of care measures were improved while utilization of emergency and specialty care did not change. Many parents reported improved health status of their child as a result of enrollment in CHPlus. Implication. This evaluation suggests that SCHIP programs are likely to improve access to, quality of, and participation in primary care significantly and may not be associated with significant changes in specialty or emergency care.