Children's Health Care Use Research Articles

Do parents who smoke underutilize health care services for their children? A cross sectional study within the longitudinal PIAMA study

BackgroundA higher prevalence of respiratory symptoms and an associated increase in health care utilization among children with parents who smoke is to be expected. From previous studies however, it appears that parents who smoke may underutilize health services for their children, especially with respect to respiratory care. This study explores the validity and generalizability of the previous assumption.MethodsData were obtained from a Dutch birth-cohort study; the Prevention and Incidence of Asthma and Mite Allergy (PIAMA) project. Information regarding parental smoking, the child's respiratory symptoms and health care use and potential confounders were obtained by postal questionnaires. Multivariate logistic models were used to relate parental smoking to the child's respiratory symptoms and health care use.ResultsThe study comprised 3,564, 4-year old children. In the crude analysis, respiratory symptoms were more frequent among children with a parent who smoked, while health care utilization for respiratory symptoms was not significantly different between children with or without a parent who smoked. In the multivariate analyses, maternal smoking had a larger impact on the child's respiratory symptoms and health care use as compared to paternal smoking. Maternal smoking was positively associated with mild respiratory symptoms of the child, adjusted odds ratio [AOR] 1.50 (1.19–1.91), but not with severe respiratory symptoms AOR 1.03 (0.75–1.40). Among children with mild respiratory symptoms, children with a mother who smoked were less likely to be taken to the general practitioner (GP) for respiratory symptoms, than children with mothers who did not smoke, AOR 0.58 (0.33–1.01). This finding was less pronounced among children with severe respiratory symptoms AOR 0.86 (0.49–1.52). Neither GP visits for non-respiratory symptoms nor specialized care for respiratory disease were significantly associated with parental smoking.ConclusionMothers who smoke appear to underutilize health care for their children with mild respiratory symptoms. Health care workers should be informed about this phenomenon. Inquiring after the respiratory health of the children during regular visits to healthy baby clinics may help to track potential underutilization of care.

Impact of Medicaid Disenrollment on Health Care Use and Cost

The objective of this study was to compare the health care use of children who are covered by public insurance and uninsured children who live in a large urban area and the potential impact of disenrollment on health care use and costs if these children become uninsured. The 2004 health care transactions for 43,313 uninsured children and 168,722 children who were insured by Medicaid/State Children's Health Insurance Program and living in the Phoenix metropolitan area were analyzed using a community-wide administrative health database (Arizona HealthQuery). Using a multivariate model of health care use by currently uninsured children, we examined the effect of 10% disenrollment of the children who were currently insured by Medicaid/State Children's Health Insurance Program. A 10% disenrollment would increase the costs of health care in the community by $3,460,398 annually, or $2121 for each child disenrolled. This increase in costs is attributed to a shift of care from ambulatory settings to more expensive emergency departments and an increase in hospital days. We determined that 69% of the change in emergency department visits, 58% of the change in hospital stays, and 74% of the change in ambulatory visits would be attributable to the change in insurance status. Programmatic changes that result in disenrollment from public insurance programs will increase the number of emergency department visits and hospital days as well as the total community costs of health care. These increases in health care use can be expected to aggravate community problems of emergency department overcrowding and inpatient bed shortages. The majority of the changes in use are attributable to changes in insurance status, which results in a shift of care from less expensive ambulatory settings to emergency departments and increases in hospital days when children lose Medicaid/State Children's Health Insurance Program coverage.

Association Between Parental Depression and Children's Health Care Use

The objective of this study was to determine the association between parental depression and pediatric health care use patterns. We selected all children who were 0 to 17 years of age, enrolled in Kaiser Permanente of Colorado during the study period July 1997 to December 2002, and linked to at least 1 parent/subscriber who was enrolled for at least 6 months during that period. Unexposed children were selected from a pool of children whose parents did not have a depression diagnosis. Outcome measures were derived from the child's payment files and electronic medical charts and included 5 categories of use: well-child-care visits, sick visits to primary care departments, specialty clinic visits, emergency department visits, and inpatient visits. We compared the rate of use per enrollment month for these 5 categories between exposed and unexposed children within each of the 5 age strata. Our study population had 24,391 exposed and 45,274 age-matched, unexposed children. For the outcome of well-child-care visits, teenagers showed decreased rates of visits among exposed children. The rate of specialty department visits was higher in exposed children in the 4 oldest age groups. The rates of both emergency department visits and sick visits to primary care departments were higher for exposed children across all 5 age categories. The rate of inpatient visits was higher among exposed children in 2 of the 5 age groups. Overall, having at least 1 depressed parent is associated with greater rate of emergency department and sick visits across all age groups, greater use of inpatient and specialty services in some age groups, and a lower rate of well-child-care visits among 13- to 17-year-olds. This pattern of increased use of expensive resources and decreased use of preventive services represents one of the hidden costs of adult depression.

Caregiver Health Literacy and the Use of Child Health Services

Eighty million US adults have low health literacy, a risk factor for increased health care use among adults. The purpose of this work was to assess the association between caregiver health literacy and the use and cost of child health services. We conducted a cross-sectional study of caregiver-child dyads from a sample of children aged 12 months to 12 years presenting to the pediatric emergency department of an urban, public hospital. Caregiver health literacy was measured by the Short Test of Functional Health Literacy in their preferred language (English or Spanish). Child health care use was measured by a 12-month retrospective review of the public hospital system's electronic database and of state Medicaid billing records for 4 types of visits: preventive care, urgent care, emergency care, and hospital care. Cost of child health care use was provided by Medicaid billing records. Multivariate analysis included caregiver education, age, and language proficiency, as well as child age, special health care needs, ethnicity, and health-insurance coverage. A total of 290 dyads were enrolled in the study. Twenty-two percent of caregivers had low (inadequate or marginal) health literacy. Caregivers with low health literacy were more likely to have less than a high school education, to have limited English proficiency, and to have been born outside the United States. There were no differences in health care use or cost between children of caregivers with low health literacy and children of caregivers with adequate health literacy. Three caregiver characteristics were associated with increased use of child health care services: born outside the United States, age at child's birth <24 years, and limited English proficiency. One in 5 caregivers of young children has low health literacy. Caregiver health literacy, however, was not associated with disparities in the use of child health services in this inner-city, ethnic minority population.

Elevated Morbidity and Health Care Use in Children with Obstructive Sleep Apnea Syndrome

Health care use, a reliable measure of morbidity, is noticeably higher 1 yr before obstructive sleep apnea syndrome (OSAS) diagnosis in preschool children. It is not clear at what age OSAS-related morbidity becomes expressed. To explore morbidity and health care use among children with OSAS starting from first year of life. Case-control study, starting from the first year of life to date of OSAS diagnosis, among 156 patients (age range, 3-5 yr) and their pair-matched healthy control subjects, by age, sex, primary care physician, and geographic location. Patients with OSAS underwent nocturnal polysomnography studies. Medical records during hospital visits were reviewed for diagnosis. Variables of health care use were obtained from computerized databases of Clalit Health Care Services, the largest health maintenance organization in Israel. From the first year of life to date of OSAS diagnosis, children with OSAS had 40% more (p = 0.048) hospital visits, 20% more repeated (two or more) visits (p < 0.0001), and higher consumption of antiinfective and respiratory system drugs (p < 0.0001). Referrals of children with OSAS to otolaryngology surgeons and pediatric pulmonologists were higher from Year 1 (p < 0.0001) to date of OSAS diagnosis, especially in Year 4 (odds ratio, 9.4; 95% confidence interval, 4.2-21.1). The 215% elevation (p < 0.0001) in health care use of the OSAS group was due mainly to higher occurrence of respiratory tract morbidity (p < 0.0001). Practitioners should be aware that starting in Year 1 until date of diagnosis, children with OSAS have higher health care use, mostly related to respiratory diseases.

Health Care for Children and Youth in the United States: Annual Report on Patterns of Coverage, Utilization, Quality, and Expenditures by a County Level of Urban Influence

To examine child and hospital demographics and children's health care coverage, use, expenditures, and quality by a county-level measure of urban influence. Two national health care databases serve as the sources of data for this report: the 2002 Medical Expenditure Panel Survey (MEPS) and the 2002 Nationwide Inpatient Sample (NIS) and State Inpatient Databases (SID) from the Healthcare Cost and Utilization Project (HCUP). In both data sets, county urbanicity is defined by use of a collapsed version of the 2003 Urban Influence Codes, to distinguish among children residing in and hospitals located in large metropolitan (metro) counties, small metro counties, micropolitan counties, and noncore counties. Demographics. In large metro counties, greater percentages of the child population are Hispanic or black non-Hispanic than in small metro, micropolitan, and noncore counties; in micropolitan and noncore counties, higher proportions of children are below 200% of the federal poverty level than in large metro and small metro counties. Noncore areas have a greater percentage of children in fair or poor health compared with those in small metro and micropolitan counties. Most hospitals are located in large and small metro areas, and large metro areas have a higher proportion of teaching hospitals compared with other areas. Health care. In general, there were no overall differences by place of residence in the proportion of children with and without insurance, although differences emerged in subpopulations within Urban Influence Code types. Hispanic children residing in large metro counties were more likely to be uninsured than those in small metro counties. Overall, the proportion of children with at least one dental visit was larger in small metro areas compared with both large metro and noncore areas. The proportion of children with medicines prescribed was generally lower in large metro areas compared with all other areas both overall and among subpopulations of children. Children in noncore areas were more likely to have a hospital inpatient stay and any emergency department use compared with children in large metro areas. Children in large metro counties had longer average inpatient stays and a higher hospital inpatient charge per day compared with children in all other counties. Although most hospitalizations for children from large metro areas occurred in large metro areas, over half of hospitalizations for noncore children occurred outside of noncore counties. Further, children from noncore counties appear to be hospitalized for ambulatory sensitive conditions more than children from all other areas. County-level data analyses performed using a collapsed version of the Urban Influence Codes with MEPS and HCUP data shed additional light on the health care patterns for children that were not previously evident when only the dichotomous metropolitan/nonmetropolitan geographic schema was used.

Somatic complaints and health care use in children: Mood, emotion awareness and sense of coherence

In this study, we compared several aspects of the emotional functioning of schoolchildren reporting very few somatic complaints ( n = 59 ), schoolchildren reporting many somatic complaints ( n = 61 ), and a clinical group of children with functional abdominal complaints who visited the outpatient clinical of the VU University Medical Centre in Amsterdam ( n = 33 ). The children had an average age of 10.6 years. We studied whether general moods (happiness, anger, fear, and sadness), symptoms of depressiveness, emotion awareness, and sense of coherence contributed to group classification. Eighty-three percent of the schoolchildren reporting very few somatic complaints were identified correctly on the basis of better emotional functioning. However, there was little difference in the emotional functioning of schoolchildren with many somatic complaints and that of the clinical group. We concluded that the variables studied are valuable for differentiating children who are troubled by somatic complaints from children experiencing few somatic complaints. The results stress the existence of emotional problems in children reporting many somatic complaints.

Detection of Maternal Alcohol Use Problems in the Pediatric Emergency Department

Maternal alcohol use problems may impact the health and well-being of children, but often remain unrecognized. Mothers of young children seldom seek outpatient care for themselves; thus, pediatric settings may present an opportunity for the detection of maternal alcohol use problems. This study examines the feasibility of screening for and prevalence of alcohol use problems in mothers of young children in the context of seeking pediatric emergency care. We also examined the relationship of maternal alcohol use problems with use of pediatric emergency care. A total of 361 English-speaking mothers of children aged 7 and younger completed screening measures during their child's emergency care visit. TWEAK was used to screen for alcohol use problems. The screening survey also included information on children's health status and health care use, demographics, and the Center for Epidemiological Studies Depression Scale. Of the women approached, 90% agreed to complete the screening measure. On the basis of cutoff score of 2 or more, 7% of women had elevated TWEAK scores. Those women with a TWEAK score > 2 reported greater use of the pediatric emergency department (PED) than women scoring below the cutoff. On the basis of multivariate analyses, significant predictors of recent PED use included the presence of child chronic illness, younger maternal age, and TWEAK score. Screening for alcohol use problems among mothers of young children using the TWEAK appears to be feasible in a busy PED setting. The PED setting is promising for identifying risk drinking among women who may be less likely to be otherwise detected and for whom alcohol use may be impacting child outcomes.

Health Status and Health Service Access and Use Among Children in U.S. Immigrant Families

We examined the health status and patterns of health care use of children in US immigrant families. Data from the 1999 National Survey of America's Families were used to create 3 subgroups of immigrant children: US-born children with noncitizen parents, foreign-born children who were naturalized US citizens, and foreign-born children with noncitizen parents. Chi-square and logistic regression analyses were used to examine relationships between immigrant status and health access variables. Subgroup analyses were conducted with low-income families. Foreign-born noncitizen children were 4 times more likely than children from native families to lack health insurance coverage and to have not visited a mental health specialist in the preceding year. They were 40% and 80% more likely to have not visited a doctor or dentist in the previous year and twice as likely to lack a usual source of care. US-born children with noncitizen parents were also at a disadvantage in many of these aspects of care. We found that, overall, children from immigrant families were in worse physical health than children from non-immigrant families and used health care services at a significantly lower frequency.

Validity of Maternal Report of Acute Health Care Use for Children Younger Than 3 Years

National household surveys often rely on parents' recall to assess children's use of health care services. However, little is known about the accuracy of parental reporting of hospitalizations and emergency department (ED) use. To assess the agreement between maternal reported and medical record acute health care data for children younger than 3 years and to determine if agreement between the 2 varies by maternal characteristics. Data were obtained from the national evaluation of the Healthy Steps for Young Children for 2937 families who completed parent interviews at 2 to 4 and 30 to 33 months and whose children's medical records were abstracted. Services assessed included hospitalizations and ED visits since birth (2-4 and 30-33 months) and in the last 12 months (30-33 months). Absolute and beyond chance agreements were calculated. Results were stratified by maternal age (<20, 20-29, or > or =30 years), parity (first-time, second-time, or greater mother), income (<20,000 dollars, 20,000 dollars-49,999 dollars, or > or =50,000 dollars), and the presence or absence of maternal depressive symptoms. Absolute agreement was high for hospitalizations (> or =90%) at both time points. It was high for ED use (>90%) only at 2 to 4 months. Beyond chance agreement was higher for hospitalizations than for ED use at 2 to 4 and 30 to 33 months. Beyond chance agreement declined with increased duration of recall and younger maternal age. No differences were found by other maternal characteristics. Mothers have good recall for acute health care events during the first 3 years of their children's lives. This finding suggests that mothers are a good source of information regarding children's acute health care use.

Rates of maternal depression in pediatric emergency department and relationship to child service utilization

This cross-sectional study aimed to (a) identify rates and correlates of untreated elevated depression in mothers of young children in a pediatric emergency department (ED) setting and (b) examine the association of depression and other key variables to child healthcare use. Mothers ( n=176) bringing their child (<age 7) to the pediatric ED completed a screening survey assessing depression, demographic information, and select child healthcare information. Up to 31% of mothers screened evidenced elevated depression, and most were not being treated (78%). Elevated depression was related to both missed pediatric outpatient visits and greater use of pediatric ED services. Thus, the pediatric ED setting may provide the opportunity to identify mothers whose depressive symptoms have been obstacles to seeking routine primary care for their children. Detection of maternal depression in pediatric settings using a screening tool accompanied by appropriate follow through may be a reasonable strategy to improve health outcomes for both the mother and her child.

Managed care organizational characteristics and health care use among children with special health care needs.

To examine the relationship between features of managed care organizations (MCOs) and health care use patterns by children. Telephone survey data from 2,223 parents of children with special health care needs, MCO-administrator interview data, and health care claims data. Cross-sectional survey data from families about the number of consequences of their children's conditions and from MCO administrators about their plans' organizational features were used. Indices reflecting the MCO characteristics were developed using data reduction techniques. Hierarchical models were developed to examine the relationship between child sociodemographic and health characteristics and the MCO indices labeled: Pediatrician Focused (PF) Index, Specialist Focused (SF) Index, and Fee for Service (FFS) Index, and outpatient use rates and charges, inpatient admissions, emergency room (ER) visits, and specialty consultations. The telephone and MCO-administrator survey data were linked to the enrollment and claims files. The child's age, gender, and condition consequences were consistent predictor variables related to health care use and charges. The PF Index was associated with decreased outpatient use rates and charges and decreased inpatient admissions. The SF Index was associated with increased ER visits and decreased specialty consultations, while the FFS Index was associated with increased outpatient use rates and charges. After controlling for sociodemographic and health characteristics, the PF, SF, and FFS indices were significantly associated with children's health care use patterns.

Children's primary health care services: social-cognitive factors related to utilization.

To test social-cognitive influences on parent decision-making processes related to children's health care use. Eighty-seven primary caretakers of children ages 4 to 9 years completed measures of child health and behavior, parent functioning, and social-cognitive factors related to parenting and health care use. Primary care use was obtained from the children's primary care physician(s) for the 2 years prior to recruitment. Social-cognitive variables accounted for 13.2% of the variance in primary health care use, above and beyond the influence of child health status and psychosocial variables. The best predictive model, accounting for 29.8% of the variance in primary care use, included the interaction between parental stress and self-efficacy to cope with parenting demands, child behavior problems, self-efficacy for accessing physician assistance, medication use, and parent health care use. Results documented the relationship between self-efficacy and parent stress in decision making about pediatric primary care use. Social-cognitive theory provides a new perspective for evaluating factors that influence health care use.

Children's health care use: a prospective investigation of factors related to care-seeking.

To determine the best predictors of the amount of children's health care use. Child health, psychosocial, and family status variables were collected. Families were then followed prospectively for 2 years to gather health care use data. Multivariate regression analysis was used to determine factors related to volume of child health care use. 367 mothers and children ages 5 to 11 years continuously enrolled in a staff model HMO. Child health care visits obtained from a computerized database comprised the dependent variable. Independent variables were organized into a 5-component framework including: Demographic Characteristics; Family Characteristics; Child Health and Prior Health Care Use; Child Behavior and Mental Health; and Mothers' Mental Health and Health Care Use. The volume of a child's past health care use was the best predictor of future health care use, with the presence of past acute recurring illnesses, child pain and mother's retrospective health care use also serving as significant predictors in the model. Analysis of a second model was conducted omitting children's past use of health care. In this model the mother's worry about child health was the best predictor of use, with child health and child and maternal psychosocial variables significantly contributing to explained variance in the model. This study supports prior research indicating past use is the best predictor of future health care use. In addition, the study suggests that maternal perceptions of child health and maternal emotional functioning influence the decision-making process involved in seeking health care on behalf of children. Effective management of pediatric health care use needs to address broader needs of the child and family beyond solely the child's health, most notably maternal functioning.

Health care and hospitalizations of young children born to cocaine-using women.

To examine the health care and hospitalizations of young children (birth to age 2 years) born to cocaine-using women and to assess the extent to which premature births account for differences between these children and comparison children. A retrospective cohort design using a repeat-matching method: comparison children were matched to subjects with exposure to cocaine on 6 sociodemographic variables, first, without attention to gestational age and then using the gestational age as additional matching variable. City hospitals and primary care clinics. Children of women giving birth at a single hospital. Hospital admission and indexes of health care use for children from birth to age 2 years. Of the 139 subjects with exposure to cocaine, 23% were born prematurely compared with only 6% in the first comparison ( P < .001). At birth, children with exposure to cocaine remained in the hospital longer (P < .01), but this difference was explained by the increased prevalence of prematurity. By age 2 years, these children had significantly fewer visits for health care maintenance (P < .001), were less likely to have completed immunizations (P < .05), and spend more days in the hospital than comparison children. These differences were not related to prematurity, but were explained by differences in sociodemographic characteristics. Although prematurity is the major reason for lengthier hospital stays at birth of children with exposure to cocaine, adverse social factors contribute most to inadequate preventive health care and increased stays in the hospital in subsequent years.

Children's health care use in the Healthy Kids Program.

In 1990, the Florida Legislature established the Florida Healthy Kids Corporation to implement the concept of school enrollment-based health insurance coverage for children. The county school districts are used as a grouping mechanism to negotiate health insurance policies. The Florida Healthy Kids Corporation negotiates contracts with health maintenance organizations (HMOs) to assume financial risk and to provide health care services at each program site. In 1994, there were five sites with four different participating HMOs. Assessing quality of care is particularly important when contracting with HMOs because of the perception that financial and utilization review arrangements may restrict the enrollees' access to needed health care. One essential component of health care quality is the extent to which health care services are used in a manner consistent with the expected pattern of use for the population of enrolled children. The purpose of this study is to compare children's health care use across five different Florida Healthy Kids Program sites. Specifically, we compare the enrollees' actual health care use across HMO settings and program sites to the expected health care use based on the enrollees' case-mix. Each HMO provided child-specific health care use data including Physician's Current Procedural Terminology codes and International Classification of Diseases, 9th Revision codes. We used the Ambulatory Care Groups (ACGs) software to compare the children's actual health care use to the expected health care use at each site adjusted for case-mix. Several steps were then taken to determine if the children were receiving the anticipated number of health care visits based on their diagnoses. First, we divided the average number of encounters at each site by the group average across all of the sites, without adjusting for the case-mix of the enrollees. We then divided the average number of visits at each site by the expected number of visits based on the case-mix adjustment. A value of 1.00 means that the actual use and the expected use are identical. Values below 1 indicate underuse and values over 1 indicate overuse of health care services. Statistical comparisons of the actual versus expected average health care use across the five sites were performed by deriving the appropriate chi2 statistics. A census of all children (N = 14 688) enrolled in the Florida Healthy Kids Program at each of the sites for 6 months or longer were included in the analysis. The average number of health care encounters across all sites for a 12-month time period was 2.98 +/- 4.6 visits. After adjusting for the case-mix of the enrollees in each site using the ACG software, several of the five sites differed from one in a statistically significant way. However, these statistical assessments must be tempered with assessing the practical magnitude of the observed differences. The number of public and private efforts to insure children who are not eligible for Medicaid and whose parents cannot purchase private insurance has grown dramatically. These programs are vital for ensuring financial access to care for uninsured children. However, it is essential that such programs are not viewed as merely cost containment efforts. Assessing the degree to which children receive the health care services they need across multiple delivery settings is an essential yet challenging component of quality assurance. Generally, our analysis indicates that children in the Florida Healthy Kids Program are receiving the amount of health care expected based on their health care needs; which is one component of a high-quality health care program.

The School Enrollment-Based Health Insurance program: socioeconomic factors in enrollees' use of health services.

The School Enrollment-Based Health Insurance program is designed to reduce financial barriers to children's health care use. This study sought to determine if any socioeconomic measures differed between enrollees with at least one health care encounter and those with no encounters. Logistic regression was used to assess the impact of various predictors on the odds that a child would use health care services. Children receiving free insurance premiums were less likely to use health care than those receiving partial subsidy. African-American and Hispanic children were less likely than Whites to use health care. Age, sex, and months enrolled also influenced the likelihood of health care use. Financial and non-financial factors must be considered when developing children's health care programs.

Maternal factors and child's health care use

There is inadequate data about the association between specific psychosocial factors and pediatric health care use. We hypothesized that maternal substance abuse, depression, and low social support would be associated with increased medical visits, emergency room (ER) use, visits for injuries and delays in immunization. We conducted a prospective study of 202 U.S. families with preschool children in a clinic serving the inner city poor. Psychosocial factors were assessed from standardized screening questionnaires for substance abuse, depression and low social support. Research assistants blind to the study hypothesis reviewed medical records for health care over the year following completion of the questionnaire: number of clinic visits, use of emergency room, visits to the ER or clinic for injuries, and delays in immunizations of two months or more. Among the 202 mothers, the mean age was 24.4 years, 47% were African American, 32% Caucasian, and 14% Asian; 55% were high school graduates. The average household income was $7620 per year; the mean age of children was 12.2 months. Thirty-seven percent of mothers screened positively for substance abuse, 34% for depression, and 60% for low social support. Children had an average of 8.6 clinic visits per year; 41% had an ER visit, 21% had an injury resulting in an ER or clinic visit, and 43% of children under 2 years of age had a delay of 2 months or more in recommended immunizations. After controlling for maternal and child age in a regression equation, none of the psychosocial factors were significant predictors of health care use outcomes. In this low-income, urban population, substance abuse, depression, and low social support may not provide additional risk for use of pediatric health care.

Determinants of Children??s Health Care Use

Factors related to the amount of health care used by 5- to 11-year-old children in a health maintenance organization (HMO) were investigated using a comprehensive multivariate model that assessed the contribution of child health need, mental health, and social functioning; maternal mental health, social support and health care utilization; and family functioning and life events. Mothers reported on the 450 participating children. Health care visits for a two-year retrospective period were obtained from the computerized encounter system. Child health need and maternal patterns of health care use were powerful predictors of the overall amount of health care used, and these factors discriminated high users from low users of care. Family conflict was associated with a higher volume of care, while children's depressive symptoms and non-white race were related to lower use. Maternal social support, mental health, and life events were not predictive of use in either full multivariate model. Enabling factors were held relatively constant by participation of all families in a prepaid HMO. The multiple regression model explained 33% of the variance in use, slightly more than in previous studies of children's health care use. When included in a comprehensive analysis, child and family psychosocial characteristics help to explain children's health care use beyond what is possible using simple health and illness variables. The implications of these findings in the development of further research and to the practice of routine pediatric care are discussed.

Families on the Move and Children's Health Care

To evaluate the relationship of family moves to children's health care use. Analyses of data from the 1988 National Health Interview Survey of Child Health (NHIS-CH). This survey uses a multisite probability cluster technique to achieve nationally representative estimates of health and demographic characteristics of the US civilian population. 17,110 US children and their families who took part in the 1988 NHIS-CH. The 1988 NHIS-CH collected health and demographic data including family mobility information on 17,110 US children and their families. This study analyzed the relationship of number of family moves to reporting a regular site for preventive pediatric health care services, a regular site for pediatric sick care, and routine use of emergency departments when a child was sick. Overall, 8% of US children were reported to lack a regular site for preventive care services, 7% a site for sick care, and 3% routinely used an emergency department for sick care. However, 14% of children who had moved three or more times lacked a regular site for preventive care and 10% lacked a regular site for sick care, compared to only 3% of children who had never moved. Children who had moved more than twice were three times as likely to lack a regular site for preventive or sick care and 1.6 times as likely to use an emergency department for sick care, as were children who had never moved. Families with increased mobility are more likely to lack a regular site for both preventive and sick care and to use emergency departments when their children become ill.