Modernizing pediatric primary care to better manage children's behavioral health.
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Adolescent↗
Biomedical subjects
James P Guevara
Publications and source records attributed to James P Guevara.
Disparities in the reporting and treatment of health conditions in children: an analysis of the Medical Expenditure Panel Survey.
OBJECTIVES: To determine whether racial and ethnic disparities in health care use differ for physical and behavioral health conditions. DATA SOURCES: Secondary analysis of the 1996-1997 Medical Expenditure Panel Survey. STUDY DESIGN: Retrospective cohort study of children aged 2-18 years old who were members of participating households. Children were categorized as Hispanic, black, or white. Differences in caregiver-reported behavioral and physical health conditions and services use were compared, and estimates were weighted to reflect the complex sampling scheme. PRINCIPAL FINDINGS: Of eligible children weighted to represent over 44 million in each year, 13-15 percent were Hispanic, 14 percent black, and 68-70 percent white. After adjusting for potential confounding, Hispanic and black children were less likely to report externalizing behavioral conditions than white children. Black but not Hispanic children were more likely than white children to report asthma. In addition, Hispanic and black children were less likely to report ambulatory visits, and black children were less likely to report receiving a prescription medication than white children. There were no differences in reported emergency room visits or hospitalizations. Interactions between race and various health conditions, health status, insurance, and income were not significant. CONCLUSIONS: In this nationally representative sample, we identified racial and ethnic disparities in the reporting of health conditions and the use of discretionary health services. Disparities differed between those with behavioral conditions and those with physical conditions. These disparities were not explained by traditional measures including the presence of health conditions, health status, insurance, and family income, and suggest that national surveys such as Medical Expenditure Panel Survey may benefit from the inclusion of additional explanatory measures.
Adolescent↗
Fragmented care for inner-city minority children with attention-deficit/hyperactivity disorder.
OBJECTIVES: To identify systematic problems in coordinating care for inner-city minority youths with attention-deficit/hyperactivity disorder. METHODS: We recruited participants from inner-city minority communities in a single metropolitan area for a focus group study. We held separate meetings for pediatricians, mental health therapists, school staff, and parents (both black and Latino). We audiotaped and transcribed the meetings. We identified themes by consensus and used root cause analysis as a conceptual framework to guide our analysis. RESULTS: We held 13 focus group meetings. Participants uniformly perceived insufficient communication and coordination of care. Five themes representing system and human factors that contributed to this fragmentation in care emerged: (1) a lack of consensus about who should oversee care; (2) changes in health care providers or teachers; (3) uncertainty in the diagnosis, insufficient training, and few resources; (4) distrust and blame that emerged when relationships among people who care for the child were absent or otherwise inadequate; and (5) lack of support from employers, friends, and family to engage in collaborative care. CONCLUSIONS: Using a root cause analysis framework, we identified system- and human-level factors that were perceived to impede communication and coordination of care for this population of children with attention-deficit/hyperactivity disorder. These results suggest that better organizational policies that define provider responsibilities and accountability, support the coordination of care, bridge relationships between agencies, and provide additional education and resources may improve collaboration. Additional study is needed to assess the generalizability of these finding to other settings.
Attention Deficit Disorder with Hyperactivity↗
Meta-analytic methods for pooling rates when follow-up duration varies: a case study.
BACKGROUND: Meta-analysis can be used to pool rate measures across studies, but challenges arise when follow-up duration varies. Our objective was to compare different statistical approaches for pooling count data of varying follow-up times in terms of estimates of effect, precision, and clinical interpretability. METHODS: We examined data from a published Cochrane Review of asthma self-management education in children. We selected two rate measures with the largest number of contributing studies: school absences and emergency room (ER) visits. We estimated fixed- and random-effects standardized weighted mean differences (SMD), stratified incidence rate differences (IRD), and stratified incidence rate ratios (IRR). We also fit Poisson regression models, which allowed for further adjustment for clustering by study. RESULTS: For both outcomes, all methods gave qualitatively similar estimates of effect in favor of the intervention. For school absences, SMD showed modest results in favor of the intervention (SMD -0.14, 95% CI -0.23 to -0.04). IRD implied that the intervention reduced school absences by 1.8 days per year (IRD -0.15 days/child-month, 95% CI -0.19 to -0.11), while IRR suggested a 14% reduction in absences (IRR 0.86, 95% CI 0.83 to 0.90). For ER visits, SMD showed a modest benefit in favor of the intervention (SMD -0.27, 95% CI: -0.45 to -0.09). IRD implied that the intervention reduced ER visits by 1 visit every 2 years (IRD -0.04 visits/child-month, 95% CI: -0.05 to -0.03), while IRR suggested a 34% reduction in ER visits (IRR 0.66, 95% CI 0.59 to 0.74). In Poisson models, adjustment for clustering lowered the precision of the estimates relative to stratified IRR results. For ER visits but not school absences, failure to incorporate study indicators resulted in a different estimate of effect (unadjusted IRR 0.77, 95% CI 0.59 to 0.99). CONCLUSIONS: Choice of method among the ones presented had little effect on inference but affected the clinical interpretability of the findings. Incidence rate methods gave more clinically interpretable results than SMD. Poisson regression allowed for further adjustment for heterogeneity across studies. These data suggest that analysts who want to improve the clinical interpretability of their findings should consider incidence rate methods.
Absenteeism↗
Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis.
OBJECTIVE: To determine the effectiveness of educational programmes for the self management of asthma in children and adolescents. DATA SOURCES: Databases of the Cochrane Airways Group, PsychINFO, reference lists of review papers, and eligible studies. REVIEW METHODS: Eligible studies were published randomised controlled trials or controlled clinical trials of educational programmes for the self management of asthma in children and adolescents that reported lung function, morbidity, self perception of asthma control, or utilisation of healthcare services. Eligible studies were abstracted, assessed for methodological quality, and pooled with fixed effects and random effects models. RESULTS: 32 of 45 identified trials were eligible, totalling 3706 patients aged 2 to 18 years. Education in asthma was associated with improved lung function (standardised mean difference 0.50, 95% confidence interval 0.25 to 0.75) and self efficacy (0.36, 0.15 to 0.57) and reduced absenteeism from school (-0.14, -0.23 to -0.04), number of days of restricted activity (-0.29, -0.33 to -0.09), and number of visits to an emergency department (-0.21, -0.33 to -0.09). When pooled by the fixed effects model but not by the random effects model, education was also associated with a reduced number of nights disturbed by asthma. The effect on morbidity was greatest among programmes with strategies based on peak flow, interventions targeted at the individual, and participants with severe asthma. CONCLUSIONS: Educational programmes for the self management of asthma in children and adolescents improve lung function and feelings of self control, reduce absenteeism from school, number of days with restricted activity, number of visits to an emergency department, and possibly number of disturbed nights. Educational programmes should be considered a part of the routine care of young people with asthma.
Adolescent↗
Economic grand rounds: medical expenditures among children with psychiatric disorders in a Medicaid population.
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Adolescent↗
National estimates of health services expenditures for children with behavioral disorders: an analysis of the medical expenditure panel survey.
BACKGROUND: Children with attention-deficit/hyperactivity disorder and asthma incur similar health care costs that are greater than those of most children without these conditions. Preliminary findings suggest that children with emotional behavioral disorders, anxiety and depression, incur even greater costs. OBJECTIVE: To determine if children with behavioral disorders have similar health services expenditures as children with physical conditions and to assess whether children with emotional behavioral disorders incur greater expenditures than children with disruptive behavioral disorders. METHODS: Children 2 to 18 years old who were members of households participating in the 1996 Medical Expenditure Panel Survey were eligible for this retrospective cohort study. Children with common behavioral disorders selected a priori were identified by using truncated International Classification of Diseases (Ninth Revision) codes obtained from household interviews. Children with common physical conditions (asthma, epilepsy, and diabetes) and children without these conditions served as controls. Estimates were weighted to reflect the complex sampling scheme. Expenditures for health services were compared. RESULTS: Of 3955 eligible children weighted to represent >44 million, 7.1% were identified with a behavioral disorder: 4.5% with disruptive disorders; 2.1% with emotional disorders; and 0.5% with miscellaneous disorders. Children with behavioral disorders incurred overall expenditures similar to children with physical conditions (adjusted 1492 dollars vs 1245 dollars; P =.18) but greater than children without these conditions (adjusted 1492 dollars vs 834 dollars; P =.001). Children with behavioral disorders had greater expenditures for office-based visits (adjusted 410 dollars; 95% confidence interval: 146-672 dollars) and prescription medications (adjusted 361 dollars; 95% confidence interval: 72-648 dollars) than those of children in either control group. Among children with behavioral disorders, children with emotional disorders incurred substantially greater overall expenditures (adjusted 2152 dollars vs 1026 dollars; P =.003) than children with disruptive disorders. Children with emotional disorders incurred greater hospitalization expenditures (664 dollars vs 43 dollars; P =.01) but lower pharmacy expenditures (154 dollars vs 307 dollars; P =.001) than children with disruptive disorders. CONCLUSIONS: In this nationally representative sample, children with behavioral disorders incurred overall health care costs similar to children with physical conditions but greater than children without any of these conditions because of increased costs for office-based visits and prescription medications. However, costs were not uniform among children with behavioral disorders. Children with emotional disorders incurred twofold higher costs than children with disruptive disorders. Greater recognition of children with emotional disorders and efforts to address the high rate of hospitalizations in this population are warranted.
Adolescent↗
Self-management education of children with asthma: a meta-analysis.
Nearly one in every thirteen children has asthma, making it the most common chronic condition in childhood. For a variety of biological and environmental reasons, the prevalence of childhood asthma has risen dramatically in the past 20 years, with disproportionate effects on low-income populations, minorities, and children living in inner cities. Much of the morbidity associated with childhood asthma, such as activity restrictions, missed school days, and emergency doctor visits, are preventable through appropriate management strategies. This Issue Brief summarizes evidence on the effectiveness of educational programs to improve self-management in children with asthma, and bolsters existing guidelines to include self-management education in the routine care of these patients.
Adolescent↗