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ObjectivesSchool 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.MethodsWe 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.ResultsAttending 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.ConclusionAmong 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.

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.

OBJECTIVE: Streptococcus pneumoniae is an important cause of otitis media in children. In this study we estimated the effect of routine childhood immunization with heptavalent pneumococcal conjugate vaccine on frequent otitis media (3 episodes in 6 months or 4 episodes in 1 year) and pressure-equalizing tube insertions. PATIENTS AND METHODS: The study population included all children who were enrolled at birth in TennCare or selected upstate New York commercial insurance plans as of July 1998 and continuously followed until 5 years old, loss of health plan enrollment, study outcome, or end of the study. We compared the risk of developing frequent otitis media or having pressure-equalizing tube insertion for 4 birth cohorts (1998-1999, 1999-2000, 2000-2001, and 2001-2002) by using Cox regression analysis. We used data from the National Immunization Survey to estimate the heptavalent pneumococcal conjugate vaccine uptake for children in these 4 birth cohorts in Tennessee and New York. RESULTS: The proportion of children in Tennessee and New York who received at least 3 doses of heptavalent pneumococcal conjugate vaccine by 2 years of age increased from < or = 1% for the 1998-1999 birth cohort to approximately 75% for the 2000-2001 birth cohort. By age 2 years, 29% of Tennessee and New York children born in 2000-2001 had developed frequent otitis media, and 6% of each of these birth cohorts had pressure-equalizing tubes inserted. Comparing the 2000-2001 birth cohort to the 1998-1999 birth cohort, frequent otitis media declined by 17% and 28%, and pressure-equalizing tube insertions declined by 16% and 23% for Tennessee and New York children, respectively. For the 2000-2001 to the 2001-2002 birth cohort, frequent otitis media and pressure-equalizing tubes remained stable in New York but increased in Tennessee. CONCLUSIONS: After heptavalent pneumococcal conjugate vaccine introduction, children were less likely to develop frequent otitis media or have pressure-equalizing tube insertions. [ABSTRACT FROM AUTHOR]

Background.-Although national guidelines recommend controller medications for children with persistent asthma, adherence is poor. Prior studies have begun to explore parental beliefs regarding controller asthma medications and their effect on adherence. Objective.-To describe parental beliefs about controller medications among a community-based sample of urban children with persistent asthma and to examine the relationship between parental beliefs and adherence. Design/Methods.-Parents of 150 children with asthma completed a telephone survey as part of a larger asthma intervention. Parents of children using controller asthma medications were included in this study. A previously validated Beliefs About Medications Questionnaire (BMQ) was used, which included two subscales: necessity and concern. The relationship between parental beliefs about medications and medication adherence was assessed using bivariate linear regression and multivariate statistics. Results.-This study included 67 children with parental report of controller medication (54% male, 61% African American, 69% Medicaid). Overall, 75% of parents strongly believed that their child's medications were necessary for their health and 34% had strong concerns about the medications. Only 22% of parents reported being completely adherent with medications. Parents with greater concern about medications were more likely to have poor adherence (P < .05). In a multivariate analysis, including both BMQ subscales and asthma severity, concern about medications significantly predicted poor medication adherence (P = .03). Conclusions.-Parental concerns about controller medications were associated with poor medication adherence for this population of urban children with asthma. These findings highlight the importance of addressing parental concerns at the time of medication prescription. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine emergency department (ED) utilization of children in foster care using nationally representative data. METHODS: Cross-sectional analysis of the National Survey of Child and Adolescent Well-Being, Wave 1, which provided data for children ages 1 to 14 years in foster care for 1 year between October 1999 and December 2000. We identified children as having used the ED based upon foster parent responses to the question, 'In the last 12 months, has your child gone to an emergency room or urgent care center (UCC) for an illness or injury?' We examined child and family demographic variables that were associated with having used the ED. RESULTS: The sample included 559 children in foster care. Thirty-one percent (95% confidence interval = 26%, 36%) of foster children had visited the ED or UCC in the past 12 months. Multivariate logistic regression analysis revealed that out of all children in foster care, children who had a chronic condition, children of younger age, and children with younger foster caregivers were significantly more likely to have used the ED. CONCLUSION: A sizeable proportion of children in foster care use the ED, and subgroups of these children have particularly high rates of ED use. An important component of providing a medical home for children in foster care should involve coordination of care around ED visits for this vulnerable group of children. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

BACKGROUND. The State Child 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 became a model for SCHIP. OBJECTIVE. To examine changes in access to care, utilization of services, and quality of care among children enrolled in CHPlus. DESIGN. A pre-post design was used to evaluate the health care experiences of children in the year before enrollment in CHPlus and during the year after CHPlus enrollment. SETTING. New York State, stratified into 4 regions: New York City, urban counties around New York City, upstate urban counties, and upstate rural counties. PARTICIPANTS. A total of 2126 children (0-12.99 years of age) who enrolled in CHPlus in 1992-1993. DATA COLLECTION. Parents were interviewed by telephone, and primary care medical charts were reviewed for 694 children (0-3. 99 years of age). ANALYSIS. Access, utilization, and quality of care measures for each child were compared for the year before and the year after CHPlus enrollment, controlling for age, geographic region, previous insurance coverage, and CHPlus plan type (indemnity or managed care). RESULTS. Enrollment in CHPlus was associated with fewer children lacking a medical home (5% before CHPlus vs 1% during CHPlus), with the greatest change occurring in New York City (11% vs 1%), where access before CHPlus was lowest. CHPlus was also associated with increased primary care visits: by 25% for preventive visits, by 52% for acute visits, and by 42% for total visits. The number of specialists seen during CHPlus was more than twice as high than before CHPlus. CHPlus was not associated with changes in emergency department utilization, although hospitalizations, which were not covered by CHPlus, were 36% lower during CHPlus coverage. Use of public health departments for immunizations declined by 64%, with more immunizations delivered in the medical home during CHPlus coverage. One third of parents reported improved quality of health care for their child as a result of CHPlus, and virtually none noted worse quality of care. CONCLUSIONS. This statewide health insurance program for low-income children was associated with improved access, utilization, and quality of care, suggesting that SCHIP has the potential to improve health care for low-income American children. [ABSTRACT FROM AUTHOR]

OBJECTIVE. To assess current practices and attitudes among pediatricians and family physicians across the United States regarding immunizations. DESIGN. Survey of a random sample of pediatricians and family physicians. SUBJECTS. Fellows of the American Academy of Pediatrics (N = 746) and American Academy of Family Medicine (N = 429). SURVEY TOPICS. General immunization practices (eg, types of visits during which vaccinations are provided, mechanisms to identify undervaccinated children); and opinions about perceived barriers to immunizations, acceptance of alternative sites for immunizations, and possible immunization requirements for Medicaid and The Special Supplemental Food Program for Women, Infants, and Children (WIC). RESULTS. Pediatricians and family physicians (combined) reported the following: immunizing children during acute illness visits (28%), follow-up visits (90%), and chronic illness visits (77%); using computer or reminder files to identify undervaccinated children (13%); and simultaneously administering four vaccines (diphtheria-tetanus-pertussis, oral poliovaccine, measles, mumps, and rubella and Haemophilus influenzae type b) to an eligible 18-month-old child (66%). Physicians perceived the following as barriers to immunizations: missed preventive visits (40%), vaccine costs (24%), lack of insurance coverage (24%), inability to track undervaccinated patients (22%), incomplete immunization records (12%), and missed vaccination opportunities (12%). Physicians agreed with offering vaccinations during hospitalizations (51%) or emergency department visits (30%), and with immunization requirements for continued eligibility for Medicaid (66%) or WIC (64%). Pediatricians were more likely to vaccinate during chronic illness and follow-up visits, and were more likely to use systems to track undervaccinated children (P < .05); however, most immunization practices and attitudes of pediatricians and family physicians were similar. Physicians who graduated from medical school more recently and those in high-risk urban practices were more likely to vaccinate during acute illness visits, provide simultaneous vaccinations, and favor vaccinations in hospital settings. CONCLUSIONS. Vaccination rates might be improved by closer adherence to current immunization guidelines regarding vaccinations during all encounters and simultaneous vaccinations, by developing systems to identify undervaccinated children, and by reducing patient costs for vaccinations. Current immunization practices fall short of the immunization guidelines; changes in individual practice styles will be required to conform with these standards. [ABSTRACT FROM AUTHOR]

BACKGROUND: Two vaccines to prevent disease from rotavirus among young children were recently approved in the United States. Although previous studies of the burden of rotaviral disease have focused on hospitalizations, the assessment of baseline disease burden in ambulatory settings is useful for evaluating the overall impact of the vaccine. METHODS: Outpatient and emergency department (ED) data for 1994-2006 were analyzed from 2 nationally representative databases: the National Ambulatory Medical Care Survey and the National Hospital Medical Care Survey. Visits by children (younger than 5 years) with acute gastroenteritis (AGE) were identified by using a defined set of International Classification of Diseases, Ninth Revision, Clinical Modification codes. Two previously described methods (the winter-residual-excess [WRE] and Brandt methods) were used to estimate the proportion of AGE attributable to rotavirus and to determine the annual number of visits, annual average visits, and annual visit rates in each setting. RESULTS: The estimated average annual number of rotavirus-associated visits over the 13-year period was 782 453 outpatient visits and 164 261 ED visits from the WRE method and 665 773 outpatient visits and 205 206 ED visits from the Brandt method. This resulted in an average of 39.1 and 33.3 outpatient visits per 1000 children and 8.2 and 10.3 ED visits per 1000 children for both the WRE and Brandt methods, respectively. The average annual proportion of visits for AGE attributed to rotavirus was 34.2% (29.1% from the Brandt method) in the outpatient setting and 21.8% (27.1% from the Brandt method) in the ED, with wide variations in individual years. CONCLUSIONS: Before the rotavirus vaccine, rotavirus seemed to be associated with a large number of outpatient and ED visits among young children. Rotavirus vaccine has the potential to reduce many outpatient and ED visits. [ABSTRACT FROM AUTHOR]

BACKGROUND: Medical homes are health care settings that offer continuous, comprehensive, accessible primary care; these settings generally involve pediatric and family physician practices or community health centers but can also involve gynecologists or internists. OBJECTIVES: In this article, we review available evidence on the role of the medical home in optimizing adolescent immunization delivery, particularly with respect to health care utilization patterns and barriers to vaccinations in medical homes, and solutions. METHODS: We conducted a systematic review of the existing immunization and adolescent literature and used a Delphi process to solicit opinions from content experts across the United States. RESULTS: Most adolescents across the United States do have a medical home, and many pay a health care visit to their medical home within any given year. Barriers exist in regards to the receipt of adolescent immunizations, and they are related to the adolescent/family, health care provider, and health care system. Although few studies have evaluated adolescent vaccination delivery, many strategies recommended for childhood or adult vaccinations should be effective for adolescent vaccination delivery as well. These strategies include education of health care providers and adolescents/parents; having appropriate health insurance coverage; tracking and reminder/recall of adolescents who need vaccination; practice-level interventions to ensure that needed vaccinations are provided to eligible adolescents at the time of any health care visit; practice-level audits to measure vaccination coverage; and linkages across health care sites to exchange information about needed vaccinations. Medical homes should perform a quality improvement project to improve their delivery of adolescent vaccinations. Because many adolescents use a variety of health care sites, it is critical to effectively transfer vaccination information across health care settings to identify adolescents who are eligible for vaccinations and to encourage receipt of comprehensive preventive. CONCLUSIONS: Medical homes are integral to both the delivery of adolescent immunizations and comprehensive adolescent preventive health care. Many strategies recommended for childhood and adult vaccinations should work for adolescent vaccinations and should be evaluated and implemented if they are successful. By incorporating evidence-based strategies and coordinating effectively with other health care sites used by adolescents, medical homes will be the pivotal settings for the delivery of adolescent vaccinations. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although many studies have noted that uninsured children have poorer access and quality of health care than do insured children, few studies have been able to demonstrate the direct benefits of providing health insurance to previously uninsured children. The State Children's Health Insurance Program (SCHIP), enacted as Title XXI of the Social Security Act, was intended to improve insurance coverage and access to health care for low-income, uninsured children. With limited state and federal resources for health care, continued funding of SCHIP requires demonstration of success of the program. As yet, little is known about the effectiveness of SCHIP on improving access and quality of care to enrollees. OBJECTIVES: To measure the impact of the New York State (NYS) SCHIP on access, utilization, and quality of health services for enrolled children. DESIGN SETTING: NYS, stratified into 4 regions. The NYS SCHIP is modeled on commercial insurance (32 managed care plans) and at the time of the study had 18% of SCHIP enrollees nationwide. STUDY DESIGN: For the study group, the design used pre/poststudy telephone interviews of parents of children enrolling in the NYS SCHIP, with baseline interviews soon after enrollment and follow-up interviews 1 year after enrollment. Baseline interviews reflected the child's experience during the 1-year period before enrollment in SCHIP. The follow-up interviews reflected the 1-year period after enrollment in SCHIP. For the comparison group, the design used baseline interviews of a comparison group enrolled 1 year after the study group to test for secular trends; these interviews reflected the 1-year period before enrollment in SCHIP. SUBJECTS: Children (n = 2644) 0 to 18 years of age who enrolled in the NYS SCHIP for the first time (November 2000 to March 2001), stratified by age (0-5, 6-11, and 12-18 years), race/ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic; others excluded), and region of NYS. The comparison group consisted of 400 children. Telephone interviews were conducted in English or Spanish throughout the day and evening, 7 days per week, to obtain measures. MAIN OUTCOME MEASURES: Demographic and health measures (child and family characteristics, health status, presence of a special health care need, and prior health insurance), access (usual source of care [USC] and unmet needs for health care), utilization (visits for specific health services), and quality (continuity with USC and measures of primary care interactions). Analyses included bivariate tests, comparing the pre-SCHIP period to the 1-year period after enrollment in SCHIP. Multivariate models were computed to generate standardized populations comprised of key characteristics of the sample to test for differences in measures (after SCHIP versus before SCHIP), controlling for demographic characteristics. RESULTS: Of the 2644 study-group children who completed the initial interview, 2290 (87%) completed the follow-up interview. Key measures for the pre-SCHIP period and short-term 'postenrollment' measures for the study group were not statistically different from measures for the comparison group, suggesting no major secular trends. Participants were non-Hispanic white (25%), non-Hispanic black (31%), and Hispanic (45%). Fifty-one percent of the parents were single, and 61% had a high school education or less; 81% of families had income <160% of the federal poverty level. Sixty-two percent of the children were uninsured > or = 12 months before the NYS SCHIP; of those insured, 43% previously had Medicaid. The proportion of children who had a USC increased after enrollment in the NYS SCHIP (86% to 97%). Two measures of accessibility (difficulty getting a medical person by telephone and difficulty getting an appointment) improved after enrollment in SCHIP. The proportion of children with any unmet health care needs decreased (31% to 19%). Specific types of unmet need also were reduced after enrollment; for example, among SCHIP enrollees who had a need for specific type of care, unmet needs wds were significantly lower postenrollment versus pre-SCHIP for specialty care (-15.5% in unmet need), acute care (-10.1%), preventive care (-9.6%), dental care (-13.0%%), and vision care (-13.2%). Emergency and total ambulatory visits did not change, but the proportion of children with a preventive care visit increased (74% to 82%). The proportion of children who used their USC for most or all visits increased (47% to 89%), demonstrating increased continuity of care. Several indicators of health care quality improved, including an overall rating of quality, the 4 indicators of physician-patient interaction used by the Consumer Assessment of Health Plans Survey, and a measure of parental worry about their child's health. Improvements were noted among major subgroups of children, with the greatest improvements for those with the lowest baseline levels. For example, at baseline, a lower percentage of children living at <160% of the federal poverty level had a presence of a USC or continuity with their USC than children living in families at >160% of the federal poverty level, and these poorer children experienced the greatest gains in having a USC or having continuity with their USC after enrollment in SCHIP. CONCLUSIONS: Enrollment in the NYS SCHIP was associated with 1) improved access, continuity, and quality of care and 2) a change in the pattern of health care, with a greater proportion of care taking place within the usual source of primary care. [ABSTRACT FROM AUTHOR]

BACKGROUND: Children with special health care needs (CSHCN) often require more extensive services than children without special needs. The State Children's Health Insurance Program (SCHIP) in many states typically provides less extensive benefits and services than do state Medicaid programs. To design SCHIP to address the needs of CSHCN adequately, it is important to measure the degree to which children who enroll in SCHIP have special health care needs and to assess their health status and unmet health care needs. Little is known about the characteristics or preenrollment experience of CSHCN who enroll in SCHIP. OBJECTIVES: To use data from the Child Health Insurance Research Initiative to measure the prevalence of CSHCN in SCHIP in 4 states, describe their demographic and health care features at enrollment, and compare their sociodemographic characteristics, health status, prior health care experiences, and unmet needs versus children without special health care needs. METHODS: Children (0-18 years old) newly enrolled in SCHIP in 4 states were eligible for the study: New York, Florida (adolescents only), Kansas, and Indiana (CSHCN only). Telephone interviews were conducted shortly after enrollment and identified CSHCN by using the Child and Adolescent Health Measurement Initiative CSHCN screener. A common set of core questions assessed demographic characteristics, health status, special health care need status, insurance experience, access, use, quality of health care, and unmet needs during the year before enrollment. Bivariate and multivariate analyses were used to compare characteristics of CSHCN with characteristics of children without special needs. RESULTS: Interviews were completed for parents of 5296 children enrolled in SCHIP in the 4 states. By using the Child and Adolescent Health Measurement Initiative CSHCN screener, the prevalence of CSHCN among SCHIP enrollees was 17% (New York), 18% (Florida), and 25% (Kansas), higher than the prevalence of CSHCN reported in the general population in those states. More than half of CSHCN reported the use of a chronic medication. Demographic characteristics of CSHCN were similar to those of children without special needs, although CSHCN were more likely to reside in single-parent households. Although CSHCN had poorer health status than children without special needs, many CSHCN were reported to be in good health, suggesting a wide spectrum of severity of illnesses within the CSHCN group. Although CSHCN were more likely than children without special needs to have been insured before SCHIP, a large proportion of CSHCN were nevertheless uninsured for at least 12 months before SCHIP (New York, 56%; Florida, 68%; Kansas, 24%; Indiana, 25%). Although most SCHIP enrollees had a usual source of care (USC) before SCHIP and there was some variation across states, between 4% and 13% of CSHCN lacked a USC on enrollment, and 23% to 38% of CSHCN changed their USC after enrollment in SCHIP. The majority of all SCHIP enrollees (including CSHCN) had used some health care during the year before SCHIP including preventive, acute, or specialty care. A high proportion of all SCHIP enrollees, including >30% to 40% of CSHCN, were reported to have unmet health care needs at enrollment in SCHIP. A variety of unmet needs were reported by CSHCN including specialty care, mental health care, dental care, and prescription medications. Nevertheless, the vast majority of CSHCN as well as children without special needs rated the quality of their medical care before SCHIP highly on several specific quality measures. Findings from multivariate analyses were similar to bivariate results with CSHCN in several states having higher use of care and more unmet health care needs before enrollment. CONCLUSIONS: SCHIP is enrolling many CSHCN, with the prevalence of these children occurring at least as high as the prevalence of CSHCN in the general population. CSHCN enrolled in SCHIP represent a heterogeneous population with a wide range of health status and health care needs. Although most CSHCN were already already connected to the health care system with a USC and prior health care visits, many had unmet health care needs before enrolling in SCHIP. IMPLICATIONS FOR MONITORING AND IMPROVING SCHIP FOR CSHCN ENROLLEES: 1) SCHIP benefit packages need to adequately cover services required by CSHCN such as prescription medications and specialty, mental health, developmental, and home services; 2) because utilization of care will be high among this large group of children, alternative methods of financing and managing care should be considered such as risk adjustment and special programs that involve case management and care coordination; 3) coordination of care across programs (such as between SCHIP and the state Title V Maternal and Child Health Services program, a component of which serves CSHCN) and ensuring adequate access to primary care and specialty providers might improve access to services for CSHCN; and 4) it is critical to monitor the quality of care for CSHCN enrolled in SCHIP, because these children are among the most vulnerable children covered by public health insurance programs and many of them are enrolling in SCHIP. [ABSTRACT FROM AUTHOR]

OBJECTIVES: Pneumococcal conjugate vaccine (PCV) was first licensed for routine administration to young children in February 2000. The objective of this study was to assess physician perspectives about the use of PCV, to ascertain which children were being given the vaccine soon after licensure, and to determine how the addition of PCV to the schedule of recommended childhood vaccines may affect the timing of other vaccinations. METHODS: A 30-item survey containing questions about the use of PCV was sent to all pediatricians and family physicians who provide primary care to young children in Monroe County (Rochester, NY) and Davidson County (Nashville, TN) in October 2000. As many as 3 subsequent mailings were sent to nonresponders. Descriptive and chi(2) statistical analyses and logistic regression were used to evaluate the responses. RESULTS: Response rates were 82% in Rochester and 78% in Nashville. Eighty-two percent of responding physicians, including 92% of pediatricians and 55% of family physicians, indicated that they were giving PCV to their patients at the time of the survey. Sixty percent noted that an initial lack of insurance reimbursement for the cost of the vaccine caused them to delay introducing PCV. Fifty-one percent delayed initially offering the vaccine to any of their patients because the Vaccines for Children (VFC) program did not begin to offer PCV until several months later. The vast majority routinely vaccinated healthy children who are younger than 2 years as well as older children who had defined chronic medical conditions that put them at high risk of invasive pneumococcal disease. Fewer than 15% were recalling patients for PCV, with most recall efforts focused on patients who had chronic medical conditions. When discussing PCV with parents, 78% of physicians primarily emphasized the vaccine's potential to decrease the risk of sepsis and/or meningitis, whereas smaller percentages primarily emphasized the vaccine's potential to decrease the risk of pneumonia or ear infections. Approximately 20% of physicians who gave PCV delayed other vaccinations (primarily varicella vaccine, hepatitis B vaccine, or polio vaccine) because of concern about administering 4 or more vaccines simultaneously. Similarly, 40% of physicians indicated that they considered PCV to be more important than varicella vaccine or hepatitis B vaccine, whereas 26% percent considered PCV to be more important than polio vaccine. CONCLUSIONS: PCV has been widely accepted by physicians in both Rochester and Nashville. However, many physicians delayed introducing the vaccine for reasons that were ultimately related to financial considerations. For privately insured patients, delays were related to when coverage for PCV was added to benefit packages. For patients who receive publicly purchased vaccine via the VFC program, delays were related to availability of the vaccine through the VFC program. In addition, after the introduction of PCV, some physicians began delaying the administration of other vaccines because of the need to give multiple vaccinations simultaneously. Although lack of insurance or VFC coverage and concerns about multiple simultaneous injections may somewhat delay the initial use of newly recommended vaccines, physicians rapidly begin to provide new vaccines that they believe to be beneficial once those vaccines are incorporated into existing payment mechanisms. [Abstract for this article also available on page 1239-40 of printed version. Full article available at www.pediatrics.org/cgi/content/full/110/6/e68] [ABSTRACT FROM AUTHOR]

CONTEXT: An overarching national health goal of Healthy People 2010 is to eliminate disparities in leading health care indicators including immunizations. Disparities in US childhood immunization rates persist, with inner-city, black, and Hispanic children having lower rates. Although practice or clinic-based interventions, such as patient reminder/recall systems, have been found to improve immunization rates in specific settings, there is little evidence that those site-based interventions can reduce disparities in immunization rates at the community level. OBJECTIVE: To assess the effect of a community-wide reminder, recall, and outreach (RRO) system for childhood immunizations on known disparities in immunization rates between inner-city versus suburban populations and among white, black, and Hispanic children within an entire county. SETTING: Monroe County, New York (birth cohort: 10 000, total population: 750 000), which includes the city of Rochester. Three geographic regions within the county were compared: the inner city of Rochester, which contains the greatest concentration of poverty (among 2-year-old children, 64% have Medicaid); the rest of the city of Rochester (38% have Medicaid); and the suburbs of the county (8% have Medicaid). INTERVENTIONS: An RRO system was implemented in 8 city practices in 1995 (covering 64% of inner-city children) and was expanded to 10 city practices by 1999 (covering 74% of inner-city children, 61% of rest-of-city children, and 9% of suburban children). The RRO intervention involved lay community-based outreach workers who were assigned to city practices to track immunization rates of all 0- to 2-year-olds, and to provide a staged intervention with increasing intensity depending on the degree to which children were behind in immunizations (tracking for all children, mail, or telephone reminders for most children, assistance with transportation or scheduling for some children, and home visits for 5% of children who were most behind in immunizations and who faced complex barriers). STUDY PARTICIPANTS: Three separate cohorts of 0- to 2-year-old children were assessed-those residing in the county in 1993, 1996, and 1999. STUDY DESIGN: Immunization rates were measured for each geographic region in Monroe County at 3 time periods: before the implementation of a systematic RRO system (1993), during early phases of implementation of the RRO system (1996), and after implementation of the RRO system in 10 city practices (1999). Immunization rates were compared for children living in the 3 geographic regions, and for white, black, and Hispanic children. Immunization rates were measured by the same methodology in each of the 3 time periods. A denominator of children was obtained by merging patient lists from the practice files of most pediatric and family medicine practices in the county (covering 85% to 89% of county children). A random sample of children (>500 from the suburbs and >1200 from the city for each sampling period) was then selected for medical chart review at practices to determine demographic characteristics (including race and ethnicity) and immunization rates. City children were oversampled to allow detection of effects by geographic region and race. Rates for the 3 geographic regions and for the entire county were determined using Stata to adjust for the clustered sampling. MAIN OUTCOME MEASURES: Immunization rates at 12 and 24 months for recommended vaccines (4 diphtheria-tetanus-pertussis:3 polio:1 measles-mumps-rubella: > or =1 Haemophilus influenzae type b on or after 12 months of age). RESULTS: DISPARITIES BY GEOGRAPHIC REGION: Baseline immunization rates (1993) for 24-month-olds were as follows: inner city (55%), rest of city (64%), and suburbs (73%), with an 18% difference in rates between the inner city and suburbs. By 1996, immunization rates rose faster in the inner city (+21% points) than in the suburbs (+14% points) so that the difference in rates between the inner city and suburbs had narrowed to 11%. In 1999, rates were similar across geographic regions: inner city (84%), rest of city (81%), and suburbs (88%), with a 4% difference between the inner city and suburbs. DISPARITIES BY RACE AND ETHNICITY: Immunization rates were available in 1996 and 1999 by race and ethnicity. Twenty-four-month immunization rates in 1996 showed disparities: white (89%), black (76%), and Hispanic (74%), with a 13% difference between rates for white and black children and a 15% difference between white and Hispanic children. In 1999, rates were similar across the groups: white (88%), black (81%), and Hispanic (87%), with a 7% difference between rates for white and black children, and a 1% difference between white and Hispanic children. CONCLUSIONS: A community-wide intervention of patient RRO raised childhood immunization rates in the inner city of Rochester and was associated with marked reductions in disparities in immunization rates between inner-city and suburban children and among racial and ethnic minority populations. By targeting a relatively manageable number of primary care practices that serve city children and using an effective strategy to increase immunization rates in each practice, it is possible to eliminate disparities in immunizations for vulnerable children. [Abstract for this article also available on page XXXX of printed version. Full article available at http://www.pediatrics.org/cgi/content/full/110/5/e58] [ABSTRACT FROM AUTHOR]

OBJECTIVE: Assess health care providers' attitudes and practices regarding adolescent immunizations, including factors that either impede or facilitate vaccination. METHODS: Focus groups-In 2005, 3 focus groups were conducted in Monroe County, NY for (1) urban primary care physicians (PCPs); (2) suburban PCPs; and (3) nurses from practices represented in PCP groups. Audiotaped discussions were transcribed and analyzed using Atlas.ti. Key informant interviews-We recruited knowledgeable informants (18 physicians, 6 nurses) from across the US. The authors conducted in-depth telephone interviews with the participants, typed their interview notes, and sent them to the participant for verification. Separately for nurses, urban physicians, and suburban physicians results for each question were listed and reviewed by the authors. Themes were added to those from the focus groups. RESULTS: Three overarching themes were identified: professional buy-in (e.g., reimbursement, professional organization recommendations, disease and vaccine characteristics, office consensus); parent/adolescent buy-in (e.g., school requirements, perception of MD recommendations, cost and insurance coverage, media reports, disease and vaccine characteristics, 'vaccine fatigue'), and delivery factors (e.g., vaccine supply, ordering, timing and scheduling, consent). CONCLUSIONS: Providers identified intertwined system issues that color their attitudes about adolescent immunization. PRACTICE IMPLICATIONS: Buy-in and delivery factors must be addressed before high immunization rates will be achieved. [ABSTRACT FROM AUTHOR]