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To examine the relationship between measures of state economic, political, health services, and Title V capacity and individual level measures of the well-being of CSHCN. We selected five measures of Title V capacity from the Title V Information System and 13 state capacity measures from a variety of data sources, and eight indicators of intermediate health outcomes from the National Survey of Children with Special Health Care Needs. To assess the associations between Title V capacity and health services outcomes, we used stepwise regression to identify significant capacity measures while accounting for the survey design and clustering of observations by state. To assess the associations between economic, political and health systems capacity and health outcomes we fit weighted logistic regression models for each outcome, using a stepwise procedure to reduce the models. Using statistically significant capacity measures from the stepwise models, we fit reduced random effects logistic regression models to account for clustering of observations by state. Few measures of Title V and state capacity were associated with health services outcomes. For health systems measures, a higher percentage of uninsured children was associated with decreased odds of receipt of early intervention services, decreased odds of receipt of professional care coordination, and increased odds of delayed or missed care. Parents in states with higher per capita Medicaid expenditures on children were more likely to report receipt of special education services. Only two state capacity measures were associated explicitly with Title V: states with higher generalist physician to population ratios were associated with a greater likelihood of parent report of having heard of Title V and states with higher per capita gross state product were less likely to be associated with a report of using Title V services, conditional on having heard of Title V. The state level measure of family participation in Title V governance was negatively associated with receipt of care coordination and having used Title V services. The measures of state economic, political, health systems, and Title V capacity that we have analyzed are only weakly associated with the well-being of children with special health care needs. If Congress and other policymakers increase the expectations of the states in assuring that the needs of CSHCN and their families are addressed, it is essential to be cognizant of the capacities of the states to undertake that role.

OBJECTIVE: Although adverse health outcomes are increased among children with BMI above the 85th (overweight) and 95th (obese) percentiles, previous studies have not clearly defined the BMI percentile at which adverse health outcomes begin to increase. We examined whether the existing BMI percentile cutoffs are optimal for defining increased risk for dyslipidemia, dysglycemia, and hypertension. METHODS: This was a cross-sectional analysis of the National Health and Nutrition Examination Survey from 2001 to 2006. Studied were 8216 children aged 6 to 17 years, representative of the US population. BMI was calculated by using measured height and weight and converted to percentiles for age in months and gender. Outcome measures (dyslipidemia, dysglycemia, and hypertension) were based on laboratory and physical examination results; these were analyzed as both continuous and categorical outcomes. RESULTS: Significant increases for total cholesterol values and prevalence of abnormal cholesterol begin at the 80th percentile. Significant increases in glycohemoglobin values and prevalence of abnormal values begin at the 99th percentile. Consistent significant increases in the prevalence of high or borderline systolic blood pressure begin at the 90th percentile. CONCLUSIONS: Intervening for overweight children and their health requires clinical interventions that target the right children. On the basis of our data, a judicious approach to screening could include consideration of lipid screening for children beginning at the 80th percentile but for dysglycemia at the 99th percentile. Current definitions of overweight and obese may be more useful for general recognition of potential health problems and discussions with parents and children about the need to address childhood obesity.

Background The authors compared children with special health care needs (CSHCN) and children without special health care needs (SHCN) with respect to the odds, amount and determinants of having any dental care and dental care expenditures. Methods The authors assessed data from the 2004 Medical Expenditures Panel Survey, Agency for Healthcare Research and Quality, to identify a sample of 8,518 children aged 2 to 17 years. The authors used logistic regression to determine the effect of having SHCN on the probability of having any dental care expenditure, for total dental care expenditures and procedure-specific expenditures. They tested the modifying effect between CSHCN and other variables on the probability of having any dental care expenditure. Results Compared with children without SHCN, CSHCN did not differ in the probability (odds ratio = 0.91, 95 percent confidence interval [CI] = 0.76 to 1.09) or amount (β = 30.17, 95 percent CI = −162.93 to 223.27) of total dental care expenditures. Likewise, CSHCN did not differ in their likelihood of having undergone a preventive, restorative, diagnostic or other procedure. Known determinants of dental care utilization did not modify the relationships between having SCHN and any dental care expenditure. Conclusions Despite the reported difficulty in CSHCN's accessing dental care, the authors found that CSHCN had dental care utilization and expenditures that were comparable with those of children without SHCN. Furthermore, the association of CSHCN status and any dental care expenditure was not modified by known determinants of dental care utilization. Future research should focus on characterizing risk for dental disease among CSHCN more accurately and identifying factors that affect dental care utilization in CSHCN, including provider and parent characteristics. Practice Implications The study results highlight low rates of dental care utilization among all young children, including CSHCN. Efforts to increase dental care utilization among children are warranted and need to include broad-based provider and parent initiatives.

Little is known about the specific roles of pediatric subspecialists and other physician providers, such as general specialists, internist subspecialists, and general pediatricians, in the care of children in the United States.1–4 The involvement of various types of providers in the care of children with chronic or serious acute conditions raises concerns about interspecialty differences in quality. Many studies of adult populations have demonstrated interspecialty differences in care for various conditions.5–7 These studies generally found that specialists are more knowledgeable than generalists for specific conditions, adhere more closely to current recommendations and guidelines, and have better condition-specific outcomes. Others found that generalists have better knowledge of immunization recommendations,8 similar outcomes and patient satisfaction levels,6,9 and lower costs.10 Systematic reviews have identified persistent interspecialty differences in knowledge, patterns of care, costs, and outcomes for a wide variety of chronic conditions affecting adult patients.11,12 To explore these issues, we conducted a review to determine what is currently known about interspecialty differences in the care of children and the quality of the existing literature.

Research has shown that access to an asthma specialist improves asthma outcomes. We hypothesized that we could improve access to expert asthma care through a telemedicine link between an asthma specialist and a school-based asthma program. We conducted a prospective cohort study in 3 urban schools to ascertain the feasibility of using an asthma-focused telemedicine solution. Each subject was seen by an asthma expert at 0, 8, and 32 weeks. The assessment and recommendations for care were sent to the primary care physician (PCP) and parents were told to contact their physician for follow-up care. Eighty three subjects participated in the study. Subjects experienced improvement (P<.05) in family social activities and the number of asthma attacks. Ninety four percent of subjects rated the program as good or excellent. This study demonstrates the feasibility and acceptance of a school-based asthma program using a telemedicine link to an asthma specialist.

Purpose: To identify correlates of geographic access to pediatric medical subspecialists in the United States and identify characteristics of populations at risk for poor geographic access. Methods: Geographic access was operationalized as distance to care. Using data from the American Board of Pediatrics and the Claritas’ Pop-Facts Database, the straight-line distance between each zip code in the United States and the nearest subspecialist was calculated for each pediatric subspecialty using zip code centroids. Using 16 specialty-specific, random-effects multiple regression models, zip code characteristics associated with being farther from a subspecialty provider were identified. Results: Under-18 population, metropolitan status, and presence of a nearby teaching facility were associated with shorter distances to care across pediatric subspecialties. The proportion of the population below the federal poverty level was positively associated with greater distances to care. Zip codes in the Mountain and West North Central regions, likewise, were significantly farther from pediatric subspecialists, even when statistically controlling for other factors. Conclusions: Pediatric populations at risk for poor geographic access to pediatric subspecialty care include those who reside in zip codes with high concentrations of poverty, in rural and small metropolitan areas, and in the Mountain and West North Central regions. The extent to which these distances create barriers to receipt of care is not established.

Objective To characterize the availability of pediatric rheumatology training in general pediatric residencies. Methods We surveyed 195 pediatric residency program directors in the US using a combined Web-based and paper-based survey format. The survey asked directors about the availability of an on-site pediatric rheumatologist in their institution, the availability of formal pediatric rheumatology rotations, and the types of physicians involved in teaching curriculum components related to pediatric rheumatology. Survey responses were analyzed using descriptive and bivariate statistics. Results Of the 195 program directors surveyed, 127 (65%) responded. More than 40% of responding programs did not have a pediatric rheumatologist on site. Programs with on-site pediatric rheumatologists were significantly more likely than those without on-site pediatric rheumatologists to have an on-site pediatric rheumatology rotation available (94% versus 9%; P < 0.001). Although pediatric rheumatologists' involvement in 4 curriculum areas relevant to pediatric rheumatology is nearly universal in programs with on-site pediatric rheumatologists, nearly two-thirds of programs without on-site pediatric rheumatologists rely on internist rheumatologists, general pediatricians, or other physicians to cover these areas. Conclusion Programs without pediatric rheumatologists on site are less likely to have pediatric rheumatology rotations and are more likely to rely on internist rheumatologists and nonrheumatologists to address rheumatology-related curriculum components. Lack of exposure to pediatric rheumatology during residency may impede general pediatricians' ability to identify and treat children with rheumatic diseases, undermine resident interest in this field, and perpetuate low levels of supply.

Background: Unmet need for dental care is the most prevalent unmet health care need among children with special health care needs (CSHCN), even though these children are at a greater risk for dental problems. The combination of rural residence and special health care needs may leave rural CSHCN particularly vulnerable to high levels of unmet dental needs. Objective: To examine the effects of rural residence on unmet dental need for CSHCN. Methods: We use the nationally representative National Survey of CSHCN Needs. We performed logistic regression to estimate the independent effects of rural residence on the likelihood of having an unmet dental need, using a measure of unmet need based on professional society recommendations and a measure based on parental report. Results: Using either of the measures, a substantial percentage of CSHCN do not receive all needed dental care. Rural CSHCN are more likely to forgo needed dental care than their urban counterparts. Our results suggest that rural CSHCN have unmet needs for dental care due to both difficulty accessing care and because their parents do not recognize a need. Conclusion: Traditional access barriers for rural children, such as inadequate provider supply and lack of insurance, may increase unmet needs both directly and indirectly, through their effects on parents’ perceptions of need. Reducing unmet needs for dental care in rural children with special needs will require addressing both access issues and parents’ understanding of dental care need.

Objective. To quantify and describe the role of internist and pediatric rheumatologists in the care of children with rheumatic diseases and identify factors associated with internist rheumatologists’ willingness to treat children. Methods. We surveyed physician members of the American College of Rheumatology who currently practice in California (n = 589). Bivariate and logit analyses were used to examine the effects of training, provider, practice, and distance to the nearest pediatric rheumatologist on the likelihood that an internist rheumatologist treated children. Results. Our effective response rate was 51%. More than one third of internist rheumatologists who practice in California reported treating pediatric patients. On average, internist rheumatologists who treated children saw 3.1 patients younger than 18 years weekly; half of these patients were 16 and 17 years of age. In logistic regression analysis, internist rheumatologists who treat pediatric patients were significantly more likely to practice in a multispecialty clinic (adjusted odds ratio: 3.5; 95% confidence interval: 1.9–9.7) and to live >50 miles from a pediatric rheumatologists (adjusted odds ratio: 6.8; 95% confidence interval: 2.1–22.7). In aggregate, we estimate that pediatric rheumatologists and internist rheumatologists provide care to 550 and 419 patients younger than 18 years per week, respectively. Conclusions. A substantial number of California internist rheumatologists are involved in the care of children, especially adolescents. The heavy involvement of internist rheumatologists in the care of children suggests that additional pediatric rheumatologists may be needed in select areas. Our findings have important implications for the size and distribution of the pediatric rheumatology workforce, the content of fellowship training for internist rheumatologists, and future studies of the relative quality of pediatric rheumatology care offered by internist rheumatologists. Furthermore, the role of internist subspecialists in caring for children with other chronic illness should be assessed.

Background. Because no validated “gold standard” for measuring asthma outcomes exists, asthma interventions are often evaluated using a large number of disease status measures. Some of these measures may be redundant, whereas others may be complementary. Use of multiple outcomes may lead to ambiguous results, increased type I error rates, and be an inefficient use of resources including caregiver and patient/participant time and effort. Understanding the relationship between these measures may facilitate more parsimonious and valid evaluation strategies without loss of information.Objective. To assess the relationships between multiple measures of asthma disease status over time.Design/Methods.We used data from a randomized, controlled trial of a comprehensive disease management program involving 119 disadvantaged inner-city children aged 5 to 12 years with moderate to severe asthma. Spearman correlations were calculated between the following asthma disease status measures: parent-reported disease symptoms, parent-reported health care utilization, functional health status using the American Academy of Pediatrics’ validated Child Health Survey for Asthma (CHSA), diary data (symptom scores, night wakings, and bronchodilator use), and pulmonary function tests at baseline, 32 weeks, 52 weeks, and changes from baseline to 52 weeks.Results. Ninety-four (79%) of randomized patients participated at baseline and 52 weeks. Completion rates for outcome measures ranged from 79% (CHSA, spirometry data) to 64% (diary data). At baseline, asthma symptoms, health care utilization, and individual domains from the CHSA were significantly correlated (r = 0.21–0.53). These correlations were stable over the 52-week follow-up. Forced expiratory volume in 1 second and diary data did not correlate to any other measures at baseline, and these measures correlated only inconsistently with other measures at 32 weeks and 52 weeks. Baseline to 52-week changes in asthma symptoms, utilization, and the CHSA domains were significantly correlated (0.22–0.56), as were baseline to 52-week changes in symptom days, night wakings, and the CHSA domains (r = 0.24–0.64). Baseline to 52-week changes in forced expiratory volume in 1 second and diary data did not correlate with other measures.Conclusions. These results suggest that asthma status and change in asthma status over time after introduction of a disease management intervention are best characterized by parent-reported symptoms, parent-reported utilization, and functional health status measures. Asthma diaries and pulmonary function tests did not seem to provide additional benefit, although they may play an important role in individual patient management. Our findings suggest a parsimonious evaluation strategy would include collection of key data elements regarding symptoms, utilization, and functional health status only, without loss of vital response information.

This analysis questions the appropriateness of inflation adjustment in analyses of provider behavior by comparing results from estimations using adjusted financial variables with those from estimations using unadjusted financial variables. Using Medicaid claims from 1984-1991, we explored the effects of Medicaid reimbursement increases on dentists' participation. Using results from inflation adjusted analyses, we would conclude that a 23% nominal increase in Medicaid reimbursement rates yields no increase in the number of Medicaid children seen by dentists. In contrast, estimations based on unadjusted reimbursement rates suggest that this same 23% nominal increase in reimbursement leads to an expected 16-person (15.4%) increase in the number of Medicaid patients seen per provider per year. These analyses demonstrate that results are sensitive to adjustment for inflation. While adjusting for inflation is a generally accepted practice in health services research, doing so without evidence that providers respond to adjusted reimbursement may be unjustified. More research is needed to determine the appropriateness of inflation adjustment in analyses of provider behavior, and the circumstances under which it should or should not be done.

We describe barriers to care reported by racial/ethnic groups and explore the extent to which barriers vary between persons enrolled in managed care and those in non-managed care plans, using data from the 1996 Medical Expenditure Panel Survey (MEPS). Most respondents expressed satisfaction with their care; however, a substantial percentage reported experiencing barriers. Minorities, particularly Hispanics and Asian Americans, were more likely than non-Hispanic whites were to report barriers. Managed care enrollees across racial/ethnic groups faced different types of barriers than non-managed care enrollees did. Although managed care enrollees were more likely to report having a usual source of care and greater continuity of care, they also reported more difficulties obtaining care and less satisfaction with their care.

OBJECTIVES: This study assessed the influence of public policies on the immunization status of 2-year old children in the United States. METHODS: Up-to-dateness for the primary immunization series was assessed in a national sample of 8100 children from the 1988 National Maternal and Infant Health Survey and its 1991 Longitudinal Follow-Up. RESULTS: Documented immunization rates of this sample were 33% for poor children and 44% for others. More widespread Medicated coverage was associated with greater likelihood of up-to-dateness among poor children. Up-to-dateness was more likely for poor children with public rather than private sources of routine pediatric care, but all children living in states where most immunizations were delivered in the public sector were less likely to be up to date. Poor children in state with partial vaccine replacement programs were less likely to be up to date than those in free-market purchase states. CONCLUSIONS: While state policies can enhance immunization delivery for poor children, heavy reliance on public sector immunization does not ensure timely receipt of vaccines. Public- and private-sector collaboration is necessary to protect children from vaccine-preventable diseases.

Objectives To examine whether recently certified pediatric subspecialists enter markets that previously lacked subspecialists and to determine whether changes in overall supply are associated with changes in geographic availability of care. Design Multiple cross-sectional analyses. Setting United States. Participants Physician data for 2003 and 2006 from the American Board of Pediatrics. Main Exposure New entrants, defined as subspecialists who first obtained certification after 2003. Main Outcome Measures We examined the following: (1) whether new entrants were more likely to practice in locations lacking certified subspecialists; (2) changes in the percentage of hospital referral regions (HRRs) with at least 1 subspecialist; and (3) changes in the number of subspecialists per HRR. Results Ten pediatric subspecialties experienced increases in supply and 5 experienced decreases. For 8 of the 15 pediatric subspecialties studied, new entrants were more likely than previously certified physicians to locate in an HRR that lacked a subspecialist in 2003. The percentage of HRRs with a subspecialist increased significantly for 3 of the 10 pediatric subspecialties with increases in supply. Among HRRs with a subspecialist in 2003, the average number of subspecialists per HRR increased between 2003 and 2006 for 6 of the 10 pediatric subspecialties with total supply increases and decreased for 4 of the 5 subspecialties with decreases in supply. Conclusions Increases in the number of pediatric subspecialists generally did not lead to improvements in distribution and may actually reinforce the existing distribution for certain pediatric subspecialties. However, because newly certified subspecialists are more likely to enter an HRR that previously lacked a subspecialist, long-term increases in supply may lead to improvements in distribution.

OBJECTIVES. Among adults, having a usual source of care has been associated with lower health care expenditures primarily through decreased emergency department and inpatient expenditures. The extent of this effect among children is unknown. We hypothesized that children with a usual source of care would have greater odds of having any outpatient expenditures, lower odds of emergency department and inpatient expenditures, and lower expenditures overall.PATIENTS AND METHODS. Using a 2-part model, we studied expenditures among children ≤17 years of age in the 2004 Medical Expenditure Panel Survey (N = 8810). Logistic regression was used to assess the relationship between having a usual source of care and the odds of having any outpatient, emergency department, and inpatient expenditures, and ordinary least-squares regression was used to compare the amount of total, outpatient, emergency department, and inpatient expenditures among children with and without a usual source of care, controlling for confounders.RESULTS. The odds of having any expenditures overall and any outpatient expenditures were 2.42 and 2.91 times higher among children with a usual source of care than among those without a usual source of care. The odds of having any emergency department or inpatient visits did not differ between groups. Having a usual source of care was associated with higher total expenditures and lower inpatient expenditures.CONCLUSIONS. Having a usual source of care is associated with increased odds of having any expenditures overall and any outpatient expenditures, higher total expenditures, and lower inpatient expenditures. Because emergency department and inpatient visits are less common among children than among adults, reductions in receipt of such care do not offset the associated increase in total expenditures and may not be appropriate indicators of the benefit of having a usual source of care among children. Intermediate indicators such as receipt of age-appropriate preventive services should be assessed.

Background/Purpose The aim of this study is to describe geographic proximity to and quantify relative supply of 7 pediatric surgical specialties in the United States. Methods Data from the 2005 American Medical Association Physician Masterfile and the Claritas Pop-Facts Database were used to calculate subspecialty-specific, population-weighted, straight-line distances between each zip code centroid and the nearest provider. These same data sources were used to calculate the percentage of hospital referral regions with a provider, the percentage of the younger than 18 years population living within selected distances of providers, and provider-to-population ratios for each of the pediatric surgical subspecialties. Further, we calculated the correlation between practice locations and children's hospitals offering pediatric surgical services. Results Across pediatric surgical specialties, average distances to the nearest provider ranged from 27.1 miles for pediatric surgery to 100.9 miles for pediatric cardiothoracic surgery. The average population-weighted distance to a provider was less than 30 miles for pediatric surgery and pediatric ophthalmology only. For 5 of the 7 pediatric surgical specialties studied, approximately one quarter of the younger than 18 years population lives more than 1-hour drive from a provider. Provider–to–younger than 18 years population ratios range across hospital referral region from 0.04 per 100,000 for pediatric cardiothoracic surgery to 0.97 per 100,000 for pediatric surgery. The correlation between pediatric surgeons and children's hospitals offering services was 0.72. Conclusions Although the practice locations of pediatric surgical subspecialties parallel the geographic distribution of children in the United States, large percentages of the younger than 18 years population must travel long distance to receive care from these providers. Large coefficients of variation reveal substantial maldistribution. These findings lay the groundwork for workforce assessments of the pediatric surgical subspecialties and underscore the need for future studies that assess access barriers for children in need of surgical care.

OBJECTIVE. Childhood overweight is epidemic in the United States. Although limited, previous studies suggest that overweight children have chronic health problems. A more complete understanding of the effect of overweight on children's health requires a nationally representative, population-based sample. Our objective was to examine whether overweight children have (1) more chronic conditions, (2) poorer health, and (3) greater health care expenditures than healthy-weight children.PATIENTS AND METHODS. This was a cross-sectional study of children aged 6 to 17 years participating in 1 of 2 nationally representative surveys of civilian, noninstitutionalized Americans, the 2001–2002 National Health and Nutrition Examination Survey and 2002 Medical Expenditure Panel Survey. The main outcome measures were prevalence of dyslipidemia, hyperglycemia, and hypertension; self-reported health status; and health care expenditures.RESULTS. Overweight children, compared with healthy-weight children, have significantly increased risk for high total cholesterol levels (15.7% vs 7.2%), high low-density lipoprotein (11.4% vs 7.7%) or borderline low-density lipoprotein cholesterol levels (20.2% vs 12.5%), low high-density lipoprotein cholesterol levels (15.5% vs 3.0%), high triglyceride levels (6.7% vs 2.1%), high fasting glucose levels (2.9% vs 0.0%), high glycohemoglobin levels (3.7% vs 0.5%), and high systolic blood pressure (9.0% vs 1.6%). Overweight children, compared with healthy-weight children, demonstrate significantly lower prevalence of excellent health (National Health and Nutrition Examination Survey: 36.5% vs 53.3%; Medical Expenditure Panel Survey: 42.8% vs 55.6%). These differences persist in multiple regression models that control for potential confounders. In adjusted analyses, expenditures were comparable between overweight and healthy-weight children.CONCLUSIONS. Our data demonstrate that overweight children have more chronic conditions and poorer health but have health care expenditures that are no greater than those for healthy-weight children. Addressing the health care needs of overweight children may prevent the development of chronic conditions and improve health status. These findings demonstrate the need to more thoroughly consider whether (1) overweight children have appropriate access to care, (2) physicians fully recognize the impact of overweight, and (3) physicians have resources to address overweight.

BackgroundThe current climate of rising health care costs has led many health insurance programs to limit benefits, which may be problematic for children needing specialty care. Findings from pediatric primary care may not transfer to pediatric specialty care because pediatric specialists are often located in academic medical centers where institutional rules determine accepted insurance. Furthermore, coverage for pediatric specialty care may vary more widely due to systematic differences in inclusion on preferred provider lists, lack of availability in staff model HMOs, and requirements for referral. Our objective was to review the literature on the effects of insurance status on children's access to specialty care.MethodsWe conducted a systematic review of original research published between January 1, 1992 and July 31, 2006. Searches were performed using Pubmed.ResultsOf 30 articles identified, the majority use number of specialty visits or referrals to measure access. Uninsured children have poorer access to specialty care than insured children. Children with public coverage have better access to specialty care than uninsured children, but poorer access compared to privately insured children. Findings on the effects of managed care are mixed.ConclusionInsurance coverage is clearly an important factor in children's access to specialty care. However, we cannot determine the structure of insurance that leads to the best use of appropriate, quality care by children. Research about specific characteristics of health plans and effects on health outcomes is needed to determine a structure of insurance coverage that provides optimal access to specialty care for children.

Objectives To examine the association between state economic, political and health services capacity and state allocations for Title V capacity for Children and Youth with Special Health Care Needs (CSHCN). Methods Numerous datasets were reviewed to select 13 state capacity measures: per capita Gross State Product (economic); governor’s institutional powers and legislative professionalism (political); percent of Children with Special Health Care Needs, percent of uninsured children, percent of children enrolled in Medicaid, state health funds as a percent of Gross State Product, ratio of Medicaid to Medicare fees, percent of children in Medicaid enrolled in managed care, per capita Medicaid expenditures for children, ratios of pediatricians/family practitioners and pediatric subspecialists per 10,000 children, and categorical versus functional state definition of CSHCN (health). Five measures of Title V capacity were selected from the Title V Information System, four that reflect allocation decisions by states and the fifth a state assessment of the role of families in Title V decision-making: ratio of state/federal Title V spending; per capita state Title V spending; percent of state Title V spending on CSHCN; state per child spending on CSHCN; and, state Title V Family Participation Score. OLS regression was used to model the association between state and Title V capacity measures. Results The percentage of the state’s gross state product (GSP) accounted for by state health funds and the per capita GSP were positively associated with the per capita expenditures on all children. The percentage of CSHCN in the state was negatively associated with the ratio of state to federal support for Title V and the per child expenditures on CSHCN. Lower family participation scores were associated with having a hybrid legislature; however, higher family participation scores were found in states using a functional definition of special needs. Conclusions Measures of state economic, political and health services capacity do not demonstrate consistent and significant associations with the Title V capacity measures that we explored. States with greater economic capacity appear to devote more financial resources to Title V. Our finding that per capita CSHCN expenditures are negatively associated with the percentage of CSHCN in the state suggests that there is an upper limit on what states devote to CSHCN. Our current understanding of what state factors influence Title V capacity remains limited.

OBJECTIVE. The objective of this study was to describe geographic proximity, quantify variation in supply, and estimate pediatric population increments that are needed to support providers across pediatric subspecialties. METHODS. Data from the American Board of Pediatrics and the Claritas Pop-Facts Database were used to calculate subspecialty-specific straight-line distances between each zip code and the nearest board-certified subspecialist. These data sources also were used to estimate the percentage of hospital referral regions with providers and calculate physician-to-population ratios for each of 16 pediatric medical subspecialties. Coefficients of variation for the ratios were used to assess intraspecialty variation in supply across markets. Estimates of the pediatric population that is needed to support an initial or additional physician in a market were generated using subspecialty-specific ordered logit analyses. RESULTS. The population-weighted average distance to a subspecialist ranged from 15 miles for neonatology to 78 miles for pediatric sports medicine. For most pediatric subspecialties, more than two thirds of children live within 40 miles of a certified physician. For 7 of 16 of pediatric subspecialties, fewer than one half of hospital referral regions have a provider. Coefficients of variation vary across subspecialties and are lowest for neonatology at 76% and greatest for pediatric sports medicine at 287%. Pediatric population thresholds likewise vary with a tendency toward lower thresholds for procedural specialties, such as cardiology and critical care medicine. CONCLUSIONS. The practice locations of pediatric subspecialists parallel the geographic distribution of children in the United States, yet many hospital referral regions lack pediatric subspecialists and coefficients of variation vary widely across subspecialties. These findings suggest that either the supply of pediatric subspecialists is inadequate, pediatric subspecialists are distributed inequitably, or the market for pediatric subspecialists is larger than the hospital referral regions. Furthermore, population thresholds for many cognitive pediatric subspecialties are high; the extent to which high thresholds reflect low disease prevalence versus other factors, such as inadequate reimbursement, is not established.

BACKGROUND. Previous studies documented considerable variability in the treatment of febrile infants, despite the existence of practice guidelines for this condition. None of those studies documented the extent to which this variability is accounted for by differences in clinical severity.OBJECTIVE. To quantify the individual effects of the patient's clinical presentation, demographic, provider, and practice characteristics, and regional variables on practice variability in the evaluation and treatment of febrile infants.METHODS. With data collected through the Pediatric Research in Office Settings network, we analyzed data on the treatment of 2712 febrile infants examined by 484 pediatricians located in 194 practices. We analyzed hospitalization, lumbar puncture, urinalysis and/or urine culture, blood work, and initial antibiotic administration. We obtained a summary score for evaluation and treatment intensity (ranging from no tests or treatments to comprehensive testing, hospitalization, and antibiotic therapy) by performing principal-components analysis with these 5 variables. This summary score was regressed with respect to patients' clinical presentation, demographic and practice/practitioner features, and geographic region. Provider fixed effects were also included in the model.RESULTS. Although the overall model explained 46.5% of the variance, the clinical characteristics of the patient alone explained 29.7% of the overall variance. Practice site fixed effects explained nearly 15% of the overall variance. Provider and practitioner characteristics and geographic region had minimal explanatory power.CONCLUSIONS. Our results show that measures of the patient's clinical presentation account for nearly one third of the variability that our model explains. This suggests that differences in clinical presentation and severity of illness underlie much of the observed practice variability among pediatricians evaluating and treating febrile infants. These findings demonstrate that the management of this common and potentially serious condition depends more on the clinical presentation of the patient than on the characteristics of the provider/practice and the residential region.

To determine whether self-reports of unmet need are biased measures of access to health care, the authors examine the relationship between rural residence and perceived need for physician services. They perform logistic regression analyses to examine the likelihood of reporting a need for routine preventive care and/or specialty care using data from the National Survey of Children with Special Health Care Needs. Even after controlling for factors known to be associated with evaluated need, parents of rural children were less likely to report a need for routine or specialty services. Poor children, those whose mothers had less education, and those who were uninsured in the previous year were also less likely to perceive a need for physician services. Findings suggest that rural residence and other social vulnerabilities are associated with decreased perception of need, which may bias subjective measurements of unmet need for these populations.

Objective.—To estimate the prevalence of unmet needs for therapy services, vision and hearing care or aids, mobility aids, and communication aids and to investigate the association between predisposing, enabling, need, and environmental factors and unmet needs. Methods.—Using the National Survey of Children with Special Health Care Needs, we generated national prevalence estimates and performed bivariate and logistic analyses, accounting for the complex survey design. Results.—Nationally, the prevalence of unmet needs ranged from 5.8% among children with special health care needs (CSHCN) with a reported need for vision care or glasses to 24.7% among CSHCN with a reported need for communication aids. In logit analyses, CSHCN without insurance coverage were significantly more likely to have a reported unmet need for therapy services (adjusted odds ratio [OR]: 2.08, confidence interval [CI]: 1.39–3.12), vision care or glasses (OR: 3.94, CI: 2.64–5.86), and mobility aids (OR: 5.17, CI: 1.86–14.37). Children in families at or below 100% of the federal poverty level were significantly more likely to have a reported unmet need for vision care or glasses (OR: 4.51, CI: 2.86–7.12) and hearing aids or hearing care (OR: 3.61, CI: 1.70–7.65). For each of the services studied, more-severely limited children were significantly more likely to have an unmet need reported. Conclusion.—Our findings demonstrate that a minority of CSHCN have unmet needs for therapy services, assistive devices, and related services. Parents of children with more-severe ability limitations were more likely to report having unmet needs. Our findings highlight the importance of insurance coverage in ensuring access to therapy services, assistive devices, and related services.

Background Improving asthma knowledge and self-management is a common focus of asthma educational programs, but most programs have had little influence on morbidity outcomes. We developed a novel multiple-component intervention that included the use of an asthma education video game intended to promote adoption of asthma self-management behaviors and appropriate asthma care. Objective To determine the effectiveness of an asthma education video game in reducing morbidity among highrisk, school-aged children with asthma. Methods We enrolled 119 children aged 5 to 12 years from low-income, urban areas in and around San Francisco, CA, and San Jose, CA. Children with moderate-to-severe asthma and parental reports of significant asthma health care utilization were randomized to participate in the disease management intervention or to receive their usual care (control group). Patients were evaluated for clinical and quality-of-life outcomes at weeks 8, 32, and 52 of the study. Results Compared with controls, the intervention group had significant improvements in the physical domain ( P = .04 and P = .01 at 32 and 52 weeks, respectively) and social activity domain ( P = .02 and P = .05 at 32 and 52 weeks, respectively) of asthma quality of life on the Child Health Survey for Asthma and child ( P = .02 at 8 weeks) and parent ( P = .04 and .004 at 32 and 52 weeks, respectively) asthma self-management knowledge. There were no significant differences between groups on clinical outcome variables. Conclusions A multicomponent educational, behavioral, and medical intervention targeted at highrisk, innercity children with asthma can improve asthma knowledge and quality of life.

Objective To describe rheumatology providers, depict their availability, and determine the extent to which internist rheumatologists may expand access to care for children with rheumatic diseases. Methods Using data from the American College of Rheumatology and the Bureau of Health Professions Area Resource File, we generated a national map of providers' practice locations and calculated distances between each county and the nearest rheumatologist. We also performed a logit analysis to identify provider and county characteristics that were associated with internist rheumatologists' willingness to treat children. Results Approximately 50% of the under 18 population in the United States live within 50 miles of a pediatric rheumatologist and nearly 90% live within 50 miles of a pediatric rheumatologist or an internist rheumatologist who treats children. Internist rheumatologists in private practice were 3 times as likely as those in medical schools to treat children (P < 0.001). Likewise, internist rheumatologists who live 200 or more miles from a pediatric rheumatologist were more than twice as likely to treat children as those who lived within 10 miles of a pediatric rheumatologist (P < 0.001). Conclusions Our analysis suggests that internist rheumatologists are more geographically diffuse than pediatric rheumatologists and act as substitutes for pediatric rheumatologists in those regions that lack such providers. Research is needed to understand the role of internist rheumatologists in caring for children with rheumatic diseases and the quality of the care that they provide to this population.

In the United States, sickle cell disease primarily affects African Americans and carries a high risk of disability, making its sufferers particularly vulnerable. Sickle cell patients often experience unexpected, intermittent, and life-threatening complications leading to high levels of emergency room use and frequent hospitalizations. Using national discharge data from not-for-profit hospitals, this study explores the relationship between patient and hospital characteristics and hospital resource use by sickle cell patients. A random-effects least squares regression analysis was used to examine relationships between patient and hospital characteristics and hospital charges and length of stay. Patient characteristics, especially severity measures, related significantly to total hospital charges, length of stay, and average daily charges, but few hospital characteristics were associated significantly with these outcomes.

To determine the effect of implementing an evidence-based hand washing policy on between-patient hand washing compliance and on blood and cerebrospinal fluid (CSF) culture rates in a level III neonatal intensive care unit (NICU).An evidence-based hand washing policy, supported by an intensive education program, was introduced in a regional NICU. A total of 2009 preintervention neonates (16,168 patient days) over 17 months were compared to 676 postintervention neonates (5779 patient days) over 6 months. Hand washing compliance and rates of blood and CSF cultures yielding coagulase negative staphylococci (CONS) were compared before and after intervention.Compliance with appropriate between-patient hand washing improved (from 47.4% to 85.4%, p=0.001) after the hand washing policy was introduced. The rate of cultures positive for CONS declined from 6.1+/-2.3 to 3.2+/-1.6 per 1000 patient days (p=0.005). Most of this reduction was attributable to a reduction in false-positive cultures, from 4.2+/-2.4 to 1.9+/-1.8 per 1000 patient days (p=0.042), but there was a trend toward decreased true-positive cultures (from 2.1+/-1.2 to 1.2+/-1.0 per 1000 patient days, p=0.074) as well. Potential confounders and demographics factors were similar between the control and intervention subjects.Implementation of an evidence-based hand washing policy resulted in a significant increase in hand washing compliance and a significant decrease in false-positive coagulase negative staphylococcal blood and CSF culture rates. Exploratory data analysis revealed a possible effect on true-positive coagulase negative staphylococcal blood and CSF culture rates, but these results need to be confirmed in future studies.