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Background Insurance status may influence quality of opioid analgesic (OA) prescribing among patients seen by the same clinician. Objective To explore how high-risk OA prescribing varies by payer type among patients seeing the same prescriber and identify clinician characteristics associated with variable prescribing Design Retrospective cohort study using the 2016–2018 IQVIA Real World Data – Longitudinal Prescription Participants New OA treatment episodes for individuals ≥ 12 years, categorized by payer and prescriber. We created three dyads: prescribers with ≥ 10 commercial insurance episodes and ≥ 10 Medicaid episodes; ≥ 10 commercial insurance episodes and ≥ 10 self-pay episodes; and ≥ 10 Medicaid episodes and ≥ 10 self-pay episodes. Main Outcome(s) and Measure(s) Rates of high-risk episodes (initial opioid episodes with > 7-days’ supply or prescriptions with a morphine milliequivalent daily dose >90) and odds of being an unbalanced prescriber (prescribers with significantly higher percentage of high-risk episodes paid by one payer vs. the other payer) Key Results There were 88,352 prescribers in the Medicaid/self-pay dyad, 172,392 in the Medicaid/commercial dyad, and 122,748 in the self-pay/commercial dyad. In the Medicaid/self-pay and the commercial-self-pay dyads, self-pay episodes had higher high-risk episode rates than Medicaid (16.1% and 18.4%) or commercial (22.7% vs. 22.4%). In the Medicaid/commercial dyad, Medicaid had higher high-risk episode rates (21.1% vs. 20.4%). The proportion of unbalanced prescribers was 11–12% across dyads. In adjusted analyses, surgeons and pain specialists were more likely to be unbalanced prescribers than adult primary care physicians (PCPs) in the Medicaid/self-paydyad (aOR 1.2, 95% CI 1.16–1.34 and aOR 1.2, 95% CI 1.03–1.34). For Medicaid/commercial and self-pay/commercial dyads, surgeons had lower odds of being unbalanced compared to PCPs (aOR 0.6, 95% CI 0.57–0.66 and aOR 0.6, 95% CI 0.61–0.68). Conclusions Clinicians prescribe high-risk OAs differently based on insurance type. The relationship between insurance and opioid prescribing quality goes beyond where patients receive care.

We analyze how Medicaid automatic enrollment policies for children with special health care needs (CSHCN) who are enrolled in Supplemental Security Income (SSI) reduce disparities in health insurance coverage and caregiving burden. Using the 2009–2010 National Survey of Children with Special Health Care Needs, we implement a difference-in-differences regression model comparing insurance enrollment rates between CSHCN receiving SSI and CSHCN not receiving SSI, in states with and without automatic enrollment policies. We find that Medicaid automatic enrollment has a meaningful impact on insurance enrollment for low-income CSHCN who participate in SSI and can be an effective method for mitigating disparities in insurance coverage (reducing uninsurance by 38%). Medicaid automatic enrollment also reduces caregiver burden among socioeconomically disadvantaged families with CSHCN. The effects of these policies are largest families who might be on the margin of eligibility or who face high administrative burden.

Contains fulltext : 292919.pdf (Publisher’s version ) (Open Access) BACKGROUND: High myopia (HM), defined as a spherical equivalent refractive error (SER) ≤ -6.00 diopters (D), is a leading cause of sight impairment, through myopic macular degeneration (MMD). We aimed to derive an improved polygenic score (PGS) for predicting children at risk of HM and to test if a PGS is predictive of MMD after accounting for SER. METHODS: The PGS was derived from genome-wide association studies in participants of UK Biobank, CREAM Consortium, and Genetic Epidemiology Research on Adult Health and Aging. MMD severity was quantified by a deep learning algorithm. Prediction of HM was quantified as the area under the receiver operating curve (AUROC). Prediction of severe MMD was assessed by logistic regression. FINDINGS: In independent samples of European, African, South Asian and East Asian ancestry, the PGS explained 19% (95% confidence interval 17-21%), 2% (1-3%), 8% (7-10%) and 6% (3-9%) of the variation in SER, respectively. The AUROC for HM in these samples was 0.78 (0.75-0.81), 0.58 (0.53-0.64), 0.71 (0.69-0.74) and 0.67 (0.62-0.72), respectively. The PGS was not associated with the risk of MMD after accounting for SER: OR = 1.07 (0.92-1.24). INTERPRETATION: Performance of the PGS approached the level required for clinical utility in Europeans but not in other ancestries. A PGS for refractive error was not predictive of MMD risk once SER was accounted for. FUNDING: Supported by the Welsh Government and Fight for Sight (24WG201).

State interventions during municipal financial emergencies can play a critical role in ensuring the continuation of public services and preventing municipal bankruptcy but have often been applied unevenly. Using a case study of municipal takeovers in Michigan, we examine their predictability based on financial stress indicators and effects on drinking water services. We find financial stress alone does not explain takeover decisions, and that a city’s reliance on state revenue and racial and economic context play a role. Cities that have been taken over are more likely to experience drinking water privatization and rate increases than similarly financially stressed cities. The malleable definition of financial distress and discretion in implementation allow takeover policies to be applied unevenly, creating additional challenges for already distressed communities. Decision makers should seek alternative approaches to municipal financial emergencies that address underlying causes while minimizing the potential for bias and significant changes to public services.

Inequities exist in nursing home (NH) quality of care for racial/ethnic minorities, but the extent of palliative care (PC) disparities in unknown. We used cross-sectional national survey data (2017-18) from 869 NHs to measure PC services (summative score: 0-100). Survey linked to Minimum Data Set and Area Health Resources Files. Descriptive statistics and NH-level, multivariable regressions examined regional differences in NH PC services by varying concentrations of Black and Latino residents. Substantial regional differences were recorded in mean PC score and by concentration. Mean PC services were highest in the Northeast and lowest in the South: Northeast (× ̅=50.45, SE=1.50); West (× ̅=49.96, SE=1.74); Midwest (× ̅=48.18, SE=1.17); South (× ̅=44.71, SE=1.30). After adjusting for urbanicity and county level poverty, NHs in the Northeast and West with increasing concentrations of Black and Hispanic residents offered significantly fewer PC services. Overall, NHs serving predominantly serving minority populations offer fewer PC services.

Background Juvenile idiopathic arthritis (JIA)-associated uveitis is a chronic paediatric ocular inflammatory condition that can result in visual impairment. Adalimumab, a tumour necrosis factor (TNF)-alpha inhibitor, effectively controls joint and eye inflammation; however, its long-term use may increase the risk of adverse health outcomes and place an undue financial burden on the patient and healthcare system given its high cost. There is great interest for patients to stop adalimumab following remission due to these reasons but there is a lack of information on the ability to maintain control after discontinuing adalimumab. Methods The Adalimumab in Juvenile Idiopathic Arthritis-associated Uveitis Trial (ADJUST) is a multicentred, international trial that will randomise 118 participants aged 2 years and older with controlled JIA-associated uveitis to either continue adalimumab or discontinue adalimumab and receive a placebo. The trial will compare the time to uveitis recurrence between the two groups over 12 months. All participants will receive the standard weight-based dose of adalimumab or placebo: 20 mg biweekly (if Discussion This is the first randomised controlled trial to assess the efficacy of discontinuing adalimumab after demonstrating control of JIA-associated uveitis for at least 12 months. The results of ADJUST will provide information on clinical outcomes to guide clinicians in their decision-making regarding discontinuation of adalimumab. Trial registration ClinicalTrials.gov NCT03816397. Registered on 25 January 2019. EudraCT 2019-000412-29. Registered on 17 January 2019

This paper is motivated by the growing use of state takeovers of local units of government and the growing financial precarity of many U.S. cities. Takeover policies have been shown broadly to disproportionately target low income and minority communities and to prioritize service reduction and cost cutting measures. Michigan's state takeover policy, Public Act 436, has come under particular scrutiny due to its role in the Flint water crisis. In this paper, we examine the implementation of PA 436 to determine if majority-black cities in financial distress have been more likely to trigger the provisions of Public Act 436. We then use case studies to determine the consequences of emergency management for drinking water services. Our findings have implications for the study of state takeovers and their local effects, and for the evaluation of Michigan’s Public Act 436, which remains in place despite significant controversy.

Between the years 1999-2008, a substantial increase in nursing home use occurred among Black and Latinx older adults, while white older adults’ use of nursing homes decreased. These disparate trends suggested potential racial and ethnic disparities in options for preferred long-term services and supports (LTSS) settings. Over the last decade, several initiatives have been put in place to support LTSS needs in the community. However, it is unclear whether Black and Latinx older adults are continuing to use nursing home services at disproportionate rates. We used LTCfocus data for 2011-2017 to explore current trends in nursing home use and access among Black and Latinx older adults in light of these current initiatives. Our findings reveal a continued rise in Black and Latinx older adults’ use of nursing homes while white older adults’ use continues to decline. More notably, there has been a decline in nursing homes servicing these minority groups.

The incidence of Severe Combined Immunodeficiency (SCID) in Manitoba, (1/15,000), is at least three to four times higher than the national average and that reported from other jurisdictions. It is overrepresented in two population groups: Mennonites (ZAP70 founder mutation) and First Nations of Northern Cree ancestry (IKBKB founder mutation). We have previously demonstrated that in these two populations the most widely utilized T-cell receptor excision circle (TREC) assay is an ineffective newborn screening test to detect SCID as these patients have normal numbers of mature T-cells. We have developed a semi-automated, closed tube, high resolution DNA melting procedure to simultaneously genotype both of these mutations from the same newborn blood spot DNA extract used for the TREC assay. Parallel analysis of all newborn screening specimens utilizing both TREC analysis and the high-resolution DNA procedure should provide as complete ascertainment as possible of SCID in the Manitoba population.

The incidence of Severe Combined Immunodeficiency (SCID) in Manitoba, (1/15,000), is at least three to four times higher than the national average and that reported from other jurisdictions. It is overrepresented in two population groups: Mennonites (ZAP70 founder mutation) and First Nations of Northern Cree ancestry (IKBKB founder mutation). We have previously demonstrated that in these two populations the most widely utilized T-cell receptor excision circle (TREC) assay is an ineffective newborn screening test to detect SCID as these patients have normal numbers of mature T-cells. We have developed a semi-automated, closed tube, high resolution DNA melting procedure to simultaneously genotype both of these mutations from the same newborn blood spot DNA extract used for the TREC assay. Parallel analysis of all newborn screening specimens utilizing both TREC analysis and the high resolution DNA procedure should provide as complete ascertainment as possible of SCID in the Manitoba population.

The morphometric characteristics of the retinal vascular network have been associated with risk markers of many systemic and vascular diseases. However, analysis of data from large population based studies is needed to help resolve uncertainties in these associations. QUARTZ (QUantitative Analysis of Retinal vessel Topology and siZe) is a fully automated retinal image analysis system that has been designed to process large numbers of retinal images and obtains quantitative measures of vessel morphology to be used in epidemiological studies. QUARTZ has been used to process retinal images from UK Biobank which is a large population-based cohort study. In this paper, we address issues of robustness with respect to processing large datasets and validate QUARTZ using a subset of 4,692 UK Biobank retinal images. Ground truth data produced by human observers for validation have been made available online. Following validation, 135,867 retinal images (68,549 participants) from the UK Biobank study were processed by QUARTZ. 71.53% of these images were classified as being of adequate quality, which equated to 80.90% participants with at least one image of adequate quality. The vessel morphometric data are currently being used in epidemiological studies. The intention of the UK Biobank Eye and Vision Consortium is to include these derived measures in the UK Biobank data archive.

Peroxynitrite, the reaction product of nitric oxide and superoxide, contributes to the pathogenesis of chronic pulmonary hypertension in immature animals by stimulating proliferation of pulmonary arterial smooth muscle cells (PASMCs). Pulmonary vasoconstriction, secondary to hypoxia and other stimuli, leads to enhanced pulsatile stretch of cells in the vascular wall, particularly in smooth muscle, which we hypothesized would cause increased peroxynitrite generation. Our objectives in this study were to determine whether cyclic mechanical stretch, at supraphysiologic levels, would cause increased production of reactive oxygen species (ROS), nitric oxide, and peroxynitrite in vitro. Early passage neonatal rat PASMCs were seeded and grown to subconfluence on collagen-coated elastomer-bottom plates and subjected to cyclic mechanical stretch (10% (“physiologic”) or 20% (“supraphysiologic”) at 0.5 Hz) for up to 24 h. Compared to nonstretched controls and to cells subjected to 10% stretch, 20% stretch increased H 2 O 2 (stable marker of ROS) and nitrate/nitrite (stable marker of nitric oxide) in conditioned medium. These effects were accompanied by increased peroxynitrite, as evidenced by increased in situ dihydroethidium fluorescence and immunoreactive nitrotyrosine and by increased expression of nitric oxide synthase (NOS)-1 and NADPH oxidase 4 (NOX4), but not NOS-2. Stretch-induced H 2 O 2 release and increased dihydroethidium fluorescence were prevented by pretreatment with a superoxide scavenger, nonspecific inhibitors of NADPH oxidase or NOS, or a peroxynitrite decomposition catalyst. Short-interfering RNA-mediated knockdown of NOS-1 or NOX4 attenuated increased nitric oxide and H 2 O 2 content, respectively, in stretched-cell-conditioned medium. Knockdown of NOS-1 also attenuated increased immunoreactive nitrotyrosine content and stretch-induced proliferation, whereas knockdown of NOS-2 had no effect. We conclude that increased peroxynitrite generation by neonatal rat PASMCs subjected to supraphysiologic levels of cyclic stretch is NOS-1-dependent and that increased ROS production is predominantly mediated by NADPH oxidase, specifically NOX4.

Purple acid phosphatases (PAPs) are a group of metallohydrolases that contain a dinuclear Fe(III)M(II) center (M(II) = Fe, Mn, Zn) in the active site and are able to catalyze the hydrolysis of a variety of phosphoric acid esters. The dinuclear complex [(H(2)O)Fe(III)(μ-OH)Zn(II)(L-H)](ClO(4))(2) (2) with the ligand 2-[N-bis(2-pyridylmethyl)aminomethyl]-4-methyl-6-[N'-(2-pyridylmethyl)(2-hydroxybenzyl) aminomethyl]phenol (H(2)L-H) has recently been prepared and is found to closely mimic the coordination environment of the Fe(III)Zn(II) active site found in red kidney bean PAP (Neves et al. J. Am. Chem. Soc. 2007, 129, 7486). The biomimetic shows significant catalytic activity in hydrolytic reactions. By using a variety of structural, spectroscopic, and computational techniques the electronic structure of the Fe(III) center of this biomimetic complex was determined. In the solid state the electronic ground state reflects the rhombically distorted Fe(III)N(2)O(4) octahedron with a dominant tetragonal compression aligned along the μ-OH-Fe-O(phenolate) direction. To probe the role of the Fe-O(phenolate) bond, the phenolate moiety was modified to contain electron-donating or -withdrawing groups (-CH(3), -H, -Br, -NO(2)) in the 5-position. The effects of the substituents on the electronic properties of the biomimetic complexes were studied with a range of experimental and computational techniques. This study establishes benchmarks against accurate crystallographic structural information using spectroscopic techniques that are not restricted to single crystals. Kinetic studies on the hydrolysis reaction revealed that the phosphodiesterase activity increases in the order -NO(2) ←Br ←H ←CH(3) when 2,4-bis(dinitrophenyl)phosphate (2,4-bdnpp) was used as substrate, and a linear free energy relationship is found when log(k(cat)/k(0)) is plotted against the Hammett parameter σ. However, nuclease activity measurements in the cleavage of double stranded DNA showed that the complexes containing the electron-withdrawing -NO(2) and electron-donating -CH(3) groups are the most active while the cytotoxic activity of the biomimetics on leukemia and lung tumoral cells is highest for complexes with electron-donating groups.

A consideration of the economic viability of hydrogen fuel production is important in the STEP (Solar Thermal Electrochemical Photo) production of hydrogen fuel. STEP is an innovative way to decrease costs and increase the efficiency of hydrogen fuel production, which is a synergistic process that can use concentrating photovoltaics (CPV) and solar thermal energy to drive a high temperature, low voltage, electrolysis (water-splitting), resulting in H 2 at decreased energy and higher solar efficiency. This study provides evidence that the STEP system is an economically viable solution for the production of hydrogen. STEP occurs at both higher electrolysis and solar conversion efficiencies than conventional room temperature photovoltaic (PV) generation of hydrogen. This paper probes the economic viability of this process, by comparing four different systems: (1) 10% or (2) 14% flat plate PV driven aqueous alkaline electrolysis H 2 production, (3) 25% CPV driven molten electrolysis H 2 production, and (4) 35% CPV driven solid oxide electrolysis H 2 production. The molten and solid oxide electrolysers are high temperature systems that can make use of light, normally discarded, for heating. This significantly increases system efficiency. Using levelized cost analysis, this study shows significant cost reduction using the STEP system. The total price per kg of hydrogen is shown to decrease from $5.74 to $4.96 to $3.01 to $2.61 with the four alternative systems. The advanced STEP plant requires less than one seventh of the land area of the 10% flat cell plant. To generate the 216 million kg H 2 /year required by 1 million fuel cell vehicles, the 35% CPV driven solid oxide electrolysis requires a plant only 9.6 mi 2 in area. While PV and electrolysis components dominate the cost of conventional PV generated hydrogen, they do not dominate the cost of the STEP-generated hydrogen. The lower cost of STEP hydrogen is driven by residual distribution and gate costs.

The Cu(II) doped MgO system is known to display features indicating behavior intermediate between static and dynamic Jahn−Teller effects at low temperature. The system is interesting as there is a low barrier between equivalent Jahn−Teller distortions in the cubic host lattice. In order to study the geometry of the Cu(II) ion in this system, we have recorded the low temperature magnetic circular dichroism (MCD) and X-ray absorption fine structure (XAFS) spectra. The spectra have been interpreted in terms of the Cu(II) centers distorting the host lattice such that the CuO6 center is a tetragonally elongated octahedron.

Morphological changes in the retinal vascular network are associated with future risk of many systemic and vascular diseases. However, uncertainty over the presence and nature of some of these associations exists. Analysis of data from large population based studies will help to resolve these uncertainties. The QUARTZ (QUantitative Analysis of Retinal vessel Topology and siZe) retinal image analysis system allows automated processing of large numbers of retinal images. However, an image quality assessment module is needed to achieve full automation. In this paper, we propose such an algorithm, which uses the segmented vessel map to determine the suitability of retinal images for use in the creation of vessel morphometric data suitable for epidemiological studies. This includes an effective 3-dimensional feature set and support vector machine classification. A random subset of 800 retinal images from UK Biobank (a large prospective study of 500,000 middle aged adults; where 68,151 underwent retinal imaging) was used to examine the performance of the image quality algorithm. The algorithm achieved a sensitivity of 95.33% and a specificity of 91.13% for the detection of inadequate images. The strong performance of this image quality algorithm will make rapid automated analysis of vascular morphometry feasible on the entire UK Biobank dataset (and other large retinal datasets), with minimal operator involvement, and at low cost. Changes in retinal vasculature prospectively associated with disease outcomes.Large population based studies help to resolve uncertainties in these associations.QUARTZ software extracts morphometric data from large numbers of retinal images.Automated image quality assessment is required to achieve full automation.This addition into QUARTZ makes processing the entire UK Biobank dataset feasible.

Purple acid phosphatases (PAPs) are a group of heterovalent binuclear metalloenzymes that catalyze the hydrolysis of phosphomonoesters at acidic to neutral pH. While the metal ions are essential for catalysis, their precise roles are not fully understood. Here, the Fe(III)Ni(II) derivative of pig PAP (uteroferrin) was generated and its properties were compared with those of the native Fe(III)Fe(II) enzyme. The kcat of the Fe(III)Ni(II) derivative (approximately 60 s(-1)) is approximately 20% of that of native uteroferrin, and the Ni(II) uptake is considerably faster than the reconstitution of full enzymatic activity, suggesting a slow conformational change is required to attain optimal reactivity. An analysis of the pH dependence of the catalytic properties of Fe(III)Ni(II) uteroferrin indicates that the mu-hydroxide is the likely nucleophile. Thus, the Ni(II) derivative employs a mechanism similar to that proposed for the Ga(III)Zn(II) derivative of uteroferrin, but different from that of the native enzyme, which uses a terminal Fe(III)-bound nucleophile to initiate catalysis. Binuclear Fe(III)Ni(II) biomimetics with coordination environments similar to the coordination environment of uteroferrin were generated to provide both experimental benchmarks (structural and spectroscopic) and further insight into the catalytic mechanism of hydrolysis. The data are consistent with a reaction mechanism employing an Fe(III)-bound terminal hydroxide as a nucleophile, similar to that proposed for native uteroferrin and various related isostructural biomimetics. Thus, only in the uteroferrin-catalyzed reaction are the precise details of the catalytic mechanism sensitive to the metal ion composition, illustrating the significance of the dynamic ligand environment in the protein active site for the optimization of the catalytic efficiency.

Writing programs for parallel and distributed computing environments can be significantly more complex than writing programs for their sequential counterparts. These complexities mainly arise from the additional synchronization and communication requirements imposed by such environments. These requirements also make debugging and maintaining such programs significantly more complicated. The problem of debugging and maintenance is further exacerbated by the lack of good debuggers and the lack of proper I/O support for such environments.

● PURPOSE: To begin a process of standardizing the methods for reporting clinical data in the field of uveitis. ● DESIGN: Consensus workshop. ● METHODS: Members of an international working group were surveyed about diagnostic terminology, inflammation grading schema, and outcome measures, and the results used to develop a series of proposals to better standardize the use of these entities. Small groups employed nominal group techniques to achieve consensus on several of these issues. ● RESULTS: The group affirmed that an anatomic classification of uveitis should be used as a framework for subsequent work on diagnostic criteria for specific uveitic syndromes and that the classification of uveitis entities should be on the basis of the location of the inflammation and not on the presence of structural complications. Issues regarding the use of the terms “intermediate uveitis,” “pars planitis,” “panuveitis,” and descriptors of the onset and course of the uveitis were addressed. The following were adopted: standardized grading schema for anterior chamber cells, anterior chamber flare, and for vitreous haze; standardized methods of recording structural complications of uveitis; standardized definitions of outcomes, including “inactive” inflammation, “improvement” and “worsening” of the inflammation, and “corticosteroid sparing,” and standardized guidelines for reporting visual acuity outcomes. ● CONCLUSIONS: A process of standardizing the approach to reporting clinical data in uveitis research has begun, and several terms have been standardized.

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.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.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.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, including30% 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.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.