Utility In Children Research Articles

The Effect of Point‐of‐care Ultrasonography on Emergency Department Length of Stay and Computed Tomography Utilization in Children With Suspected Appendicitis

The role of clinician-performed ultrasonography (US) for suspected appendicitis is unclear. Published data conclude that US has high specificity to rule in the diagnosis of appendicitis, with variable sensitivity to rule it out. Newer data suggest that point-of-care (POC) US may have similar test characteristics. Our objective was to evaluate the effect of POC US in children with suspected appendicitis and its effect on emergency department (ED) length of stay (LOS) and computed tomography (CT) utilization. This was a prospective observational convenience sample of children with suspected appendicitis requiring imaging evaluation that adhered to the Standards for the Reporting of Diagnostic accuracy studies (STARD) criteria. Outcomes were determined by operative or pathology report in those who had appendicitis, and 3-week phone follow-up in those patients who were nonoperative. Differences in ED LOS were analyzed by one-way analysis of variance (ANOVA) between patients who received dispositions after POC US, radiology US, or CT. Test performance characteristics were calculated for all imaging modalities. Among 150 enrolled patients, 50 had appendicitis (33.3%). There were no missed cases of appendicitis in discharged patients at 3-week phone follow-up, nor negative laparotomies in those who went to the operating room. Those who had dispositions after POC US (n=25) had a significantly decreased mean ED LOS (154minutes, 95% confidence interval [CI]=115 to 193minutes) compared with those requiring radiology US (288minutes, 95% CI=257 to 319minutes) or CT scan (487minutes; 95% CI=434 to 540minutes). Baseline CT rate was 44.2% (95% CI=30.7% to 57.7%) prior to study start and decreased to 27.3% (95% CI=20.17% to 34.43%) during the study. CTs were avoided in four patients with conclusive POC US results and inconclusive radiology US results. The sensitivity, specificity, positive likelihood ratio (LR+), and negative likelihood ratio (LR-) forPOC US were60% (95% CI=46% to 72%), 94% (95% CI=88% to 97%), 10 (95% CI=4 to 23), and 0.4 (95% CI=0.3 to 0.6). For radiology US they were 63% (95% CI=48% to 75%), 99% (95% CI=94% to 99%), 94 (95% CI=6 to 1,500), and 0.4 (95% CI=0.3 to 0.6); and for CT they were 83% (95% CI=58% to 95%), 98% (95% CI=85% to 99%), 45 (95% CI=3 to 707), and 0.2 (95% CI=0.05 to 0.5). It may be feasible to reduce ED LOS and avoid CT scan when using POC US to evaluate children with suspected appendicitis. Test characteristics for POC US have high specificity to rule in appendicitis, similar to radiology US. Addition of POC US prior to sequential radiology imaging was safe, without missed cases of appendicitis or negative laparotomies.

The impact of a home visiting program on children's utilization of dental services.

Child Health Investment Partnership (CHIP) of Roanoke Valley is a home visiting program that promotes children's health and family self-sufficiency. CHIP's Begin With a Grin program provides preventive dental services in the home (oral health anticipatory guidance and fluoride varnish) for children aged 0 to 6 years. The purpose of this study was to compare the dental utilization of Medicaid-enrolled children in CHIP versus Medicaid-enrolled children not in CHIP. Using the propensity score method, control subjects were selected from the statewide Medicaid database by using a caliper-matching algorithm. A vector of chosen covariates was used to match control subjects; these covariates included risk factors, estimated propensity score, age, race, gender, and days of Medicaid eligibility. Propensity scores were developed by using a logistic regression. Differences in dental utilization outcomes were tested: ≥1 dental claim (logistic regression) and number of dental claims (Poisson regression) for each subject within the test period. When CHIP children were compared with Medicaid-only children, the CHIP child was 3 times more likely to have at least 1 dental visit (odds ratio: 3.0 [95% confidence interval: 1.9-4.7]) and have a higher number of dental claims (ratio of estimated average number of dental claims [cases/control]: 8.60/3.05 = 2.82 [95% confidence interval: 2.56-3.12]). A home visiting model can introduce children and their families to dental prevention, improve dental health literacy, establish a dental home, and provide application of fluoride varnish.

Children's Utilization of the U.S. Military Dental Insurance

The objectives of this study were to determine the dental utilization of children enrolled in a military dental insurance program and to assess if utilization differs by socioeconomic status. Claims data for children enrolled in the Department of Defense TRICARE Dental Program for the period of February 1, 2010 through January 31, 2011 were used to identify children who had a dental visit during that benefit year. Of the 376,681 continuously enrolled children, 266,862 (71%) had at least one dental visit during the benefit year. 82.7% of children of officers had a dental visit, as compared to 66.4% of children from enlisted families. There was a difference in dental utilization based on the military rank of the sponsors (χ(2) = 8,939.39, df = 1, p < 0.0001). Children of officers were 2.5 times (95% confidence intervals = 2.44-2.61), and children of warrant officers were 1.6 times (95% confidence intervals = 1.51-1.74) more likely to have a dental visit than children from enlisted families. The results also show utilization trends within the enlisted and officer categories with higher utilization among more senior personnel. Socioeconomic status does play a role in dental care-seeking behavior of military families. Even when families voluntarily enroll in a program and there are no cost shares for services such as preventive services, there may be other barriers to accessing care that need to be addressed so that all groups can maximize their oral health.

Annual Report on Health Care for Children and Youth in the United States: Trends in Racial/Ethnic, Income, and Insurance Disparities Over Time, 2002–2009

ObjectiveTo examine trends in children's health access, utilization, and expenditures over time (2002–2009) by race/ethnicity, income, and insurance status/expected payer. MethodsData include a nationally representative random sample of children in the United States in 2002–2009 from the Medical Expenditure Panel Survey (MEPS) and a nationwide sample of pediatric hospitalizations in 2005 and 2009 from the Healthcare Cost and Utilization Project (HCUP). ResultsThe percentage of children with private insurance coverage declined from 65.3% in 2002 to 60.6% in 2009. At the same time, the percentage of publicly insured children increased from 27.0% in 2002 to 33.1% in 2009. Fewer children reported being uninsured in 2009 (6.3%) compared to 2002 (7.7%). The most significant progress was for Hispanic children, for whom the percentage of uninsured dropped from 15.0% in 2002 to 10.3% in 2009. The uninsured were consistently the least likely to have access to a usual source of care, and this disparity remained unchanged in 2009. Non-Hispanic whites were most likely to report a usual source of care in both 2002 and 2009. The percentage of children with a doctor visit improved for whites and Hispanics (2009 vs 2002). In contrast, black children saw no improvement during this time period. Between 2002 and 2009, children's average total health care expenditures increased from $1294 to $1914. Average total expenditures nearly doubled between 2002 and 2009 for white children with private health insurance. Among infants, hospitalizations for pneumonia decreased in absolute number (41,000 to 34,000) and as a share of discharges (0.8% to 0.7%). Fluid and electrolyte disorders also decreased over time. Influenza appeared only in 2009 in the list of top 15 diagnoses with 11,000 hospitalization cases. For children aged 1 to 17, asthma hospitalization increased in absolute number (from 119,000 to 134,000) and share of discharges (6.6% to 7.6%). Skin infections appeared in the top 15 categories in 2009, with 57,000 cases (3.3% of total). ConclusionsDespite significant improvement in insurance coverage, disparities by race/ethnicity and income persist in access to and use of care. Hispanic children experienced progress in a number of measures, while black children did not. Because racial/ethnic and socioeconomic disparities are often reported as single cross-sectional studies, our approach is innovative and improves on prior studies by examining population trends during the time period 2002–2009. Our study sheds light on children's disparities during the most recent economic crisis.

Associations of the type of childcare with reported preventive medical and dental care utilization for 1‐ to 5‐year‐old children in the United States

Despite that the majority of US children use nonparental childcare (NPC), research examining its effects on children's preventive healthcare utilization is lacking. Our aim was to contrast NPC against parental childcare in terms of preventive medical and dental care utilization. Associations of childcare and healthcare utilization were evaluated using the 2007 National Survey of Children's Health, a telephone interview of parent-reported children's health (22,773 children ages 1- to 5-year old). The type of childcare was categorized as parental care, center-based care (CBC), nonrelative home care (NRHC), relative care (RCC), and mixed care (MCC). The outcome measures were preventive medical care (≥ 1 physical examination/well child check-up visit) and preventive dental care (≥ 1 check-ups/dental cleanings visit) during the past 12 months. Overall, 94.7% of 1- to 5-year-old children received preventive medical care, while only 53.6% received preventive dental care. The highest odds for preventive medical care was for 1- to 2-year-old children utilizing CBC [Odds Ratio (OR) = 2.85, 95% CI = 1.11-7.30] and for 3- to 5-year-old children utilizing MCC (OR = 2.00, 95% CI = 1.23-3.26) followed by CBC (OR = 1.66, 95% CI = 1.13-2.42). Considering preventive dental care, a statistically significant increase occurred for 1- to 2-year-old children with CBC (OR = 1.93, 95% CI = 1.62-2.30), and none occurred for any NPC above the parental childcare rates for 3- to 5-year-old children. Childcare use, particularly center-based care, may provide a means to raise preventive healthcare utilization for young children. Future regulations, as well as policy and program development, should consider promoting childcare settings as a means to improve preventive health care utilization.

Child–adult differences in the kinetics of torque development

Children have lower size-normalised maximal voluntary force, speed, and power than adults. It has been hypothesised that these and other age-related performance differences are due to lesser type-II motor-unit utilisation in children. This should be manifested as slower force kinetics in explosive muscle contractions. The purpose of this study was to investigate the nature of child–adult force-kinetics differences and whether the latter could support that hypothesis. Untrained boys (n = 20) and men (n = 20) (10.1 ± 1.3 and 22.9 ± 4.4 years, respectively), performed maximal, explosive, isometric elbow flexions and knee extensions on a Biodex dynamometer. Peak torque (MVC), times to 10–100% MVC, and other kinetics parameters were determined. The boys’ body-mass-normalised knee extension MVC, peak rate of torque development, and %MVC at 100 ms were 26, 17 and 23% lower compared with the men and their times to 30% and 80% MVC were 24 and 48% longer, respectively. Elbow flexion kinetics showed similar or greater differences. The findings illuminate boys’ inherent disadvantage in tasks requiring speed or explosive force. It is demonstrated that the extent of the boys–men kinetics disparity cannot be explained by muscle-composition and/or musculo-tendinous-stiffness differences. We suggest therefore that the findings indirectly support children's lower utilisation of type-II motor units.

Increased Health Care Utilization in Children of Deployed Parents

Increased Health Care Utilization in Children of Deployed Parents

Mortality and Resource Utilization in Children with De Novo Acute Myeloid Leukemia Treated with Chemotherapy and Gemtuzumab Ozogamicin in the United States

AbstractAbstract 4283 BackgroundThe role of Gemtuzumab ozogamicin (GO) for acute myeloid leukemia (AML) remains controversial. GO was removed from the U.S. market in 2010 due to concerns of increased induction mortality in adults. Other studies have shown a survival benefit without increased treatment related mortality. Moreover, no data are available on the resources required to deliver GO based chemotherapy. Since pediatric data are limited, we evaluated in-hospital mortality and resource utilization in pediatric AML patients treated with GO and standard chemotherapy. MethodsWe used the Pediatric Information Health System (PHIS) to establish a cohort of children < 19 years old treated for de novo AML with GO and standard cytarabine, daunorubicin, and etoposide (ADE) induction. Cohort assembly was validated by local chart review and used ICD-9 diagnosis codes and manual review of chemotherapy. Case fatality was determined after induction (defined from the start of therapy to the initiation course 3), at 6 months and at 12 months. Resource utilization was determined for each patient based on daily billing data. Each resource variable was dichotomized (exposure or no exposure) for each inpatient day and then summarized during each study period to determine resource utilization days per 1,000 hospital days. ResultsIn total, 253 children who had billing data for GO during the first course of ADE induction were identified. Median age was 9.6 years; a slight male predominance was observed (54%) and most patients were white (69%). In-hospital case-fatality rates were 2.4% during induction, 6.7% at 6 months, and 13.0% at 12 months from start of therapy. PHIS billing data demonstrated that patients received opioids almost on one in four hospital days, that during induction period 12% of patients received vasopressors on at least two consecutive days, and 12% needed assisted ventilation. Mean inpatient stay and resource utilization rates are presented in Table 1. DiscussionIn-hospital mortality rates at the three time points were low and concordant with published data on pediatric AML trials using an ADE induction (Gibson, BJH 2011) and ADE Induction + GO (Cooper, Cancer 2012) and lower than trials using intensively timed DCTER regimens (Woods, Blood 2001; Lange, Blood 2008). Resource utilization data demonstrated an extensive use of resources needed to manage infections (blood cultures, imaging, antimicrobials). While infections are the leading cause of non-relapse morbidity and mortality in pediatric AML, such extensive use of resources has not been previously quantified. In addition, PHIS billing data describe toxicities such as pain (opioid use), hypotension (vasopressor support), and respiratory failure (assisted ventilation) at rates higher than those previously reported in clinical trials. In conclusion, the in-hospital mortality of children treated with GO at PHIS centers appears comparable to previously published studies of ADE and ADE + GO. The resource utilization data provide a more comprehensive description of resources needed to treat pediatric AML than previously reported. In addition, the resource utilization data suggest that toxicities reported on clinical trials may underestimate the resources needed to administer AML induction therapy safely.Table 1Resource utilization days per 1000 hospital daysResourceInduction6 months12 monthsInpatient days56.6117.3139.5Complete blood counts898.0873.6874.0Blood cultures205.1222.4228.6AntibioticsTotal1079.41039.71073.0Gram-positive coverage289.4285.9298.8Beta lactams (Anti-Pseudomonal)488.1436.8434.5Carbapenems (Anti-Pseudomonal)110.2117.6120.5Quinolones14.723.534.7Aminoglycosides169.2166.2169.3Anti-fungalsTotal770.3774.3790.8Amphotericins104.496.6100.0Echinocandins89.596.1110.3Azoles576.4581.6580.6Anti-virals128.7168.4203.9Blood productsPacked red blood cells114.3116.5118.1Platelets202.5206.6215.5Fresh frozen plasma11.08.78.2AnalgesicsNon-opioid261.2270.5279.1Opioid (all routes)243.2221.9240.3PCA18.019.322.0Parenteral nutrition136.5130.2141.4Anti-hypertensives57.470.392.5Diuretics59.563.276.8VasopressorsDopamine7.27.69.3Other12.413.516.5Supplemental oxygen20.320.323.5Assisted ventilation17.616.817.8ECMO0.10.070.06Dialysis2.23.25.5ImagingChest X-ray75.674.580.5Head CT8.68.38.9Chest CT17.418.018.5 Disclosures:No relevant conflicts of interest to declare.

The Effect of Central Executive Load on Adult’s Strategy Using in Computational Estimation

Many models on strategy choosing in arithmetic cognition have been proposed,however,the role of central executive load in strategy utilization is still far from clear.A previous research with the Choice Reaction Time task(CRT) found that working memory load didn't affect children's strategy utilization(Imbo Vandierendonck,2007).In another study,Logie,Gilhooly and Wynn(1994) reported that different sub-tasks affected mental arithmetic.More recent studies also revealed that the inhibition and shifting capacities mediated age-related differences in strategy selection(Lemaire Lecacheur,2011;Hodzik Lemaire,2011).Dual-task paradigm is commonly utilized in exploring working memory load in arithmetic performance,and the choice/no-choice is a standard method to obtain unbiased data about strategy utilization.In this study,we employed the dual-task paradigm and choice/no-choice method to investigate the influence of central executive load upon individual strategy utilization during arithmetic processing.128 college students were tested by the dual-task paradigm and choice/no-choice method.They were asked to finish a two-digit addition computational estimate and a secondary task at the same time.The experimental design was as following:5(consistent-high load,consistent-low load,inconsistent-high load,inconsistent-low load,no load) × 4(free-choice condition,best-strategy choice condition,no-choice/rounding-up condition,no-choice/rounding-down condition).The main task was to finish 30 two-digit addition questions,and the secondary task was Han and Kim's(2004) design with some modifications.Results showed that:1) Central executive load did not affect adult's strategy distribution.But comparing with free-choice condition,adults used less rounding-down strategy under the best-strategy choice condition(F(4,123) = 0.58,p 0.05);2) Central executive load affected how participants selected(F(4,123) = 11.10,p 0.05) and executed(F(4,123) = 23.36,p 0.05) arithmetic strategies.Under consistent situation,the impact of central executive load on reaction time of strategy execution increased with the strength of central executive load,while central executive load on the correct rate of strategy execution had little effect;Under inconsistent situation,low-central executive load almost did not affect the reaction time and correct rate of strategy execution;Central executive load strength played an important role on reaction time of strategy choice,interference became significant only when central executive load of the secondary task was high;3) Adult's adaptivity of strategy choice was affected by the strength of central executive load,F(4,123) = 2.46,p 0.05.They showed a better adaptivity of strategy choice under no central executive load condition.The results of strategy utilization in this study confirm the SCADS model.Adults can select strategies according to external requirements,but their adaptivity was still vulnerable.Secondary task type significantly affected strategy utilization of adult.The larger similarity between the sub-task and the main task leaded to larger interference to main task.

Perceived Barriers to Help-Seeking Among Parents of At-Risk Kindergarteners in Rural Communities

This study examined help-seeking and perceived barriers to children's mental health service utilization in a large sample of parents living in rural communities who are at various stages in the help-seeking process. The goals were to (a) obtain a demographic profile of at-risk kindergarteners and their parents, (b) examine parent-reported help-seeking behaviors, and (c) assess barriers to mental health service use. Parent and teacher report of the Behavior Assessment System for Children, Second Edition, were used to screen children (N = 597) at kindergarten entry and to identify their risk status. Parents also completed the Barriers to Participation Scale and reported the frequency of help-seeking behaviors related to their child's problems. Using a cutoff score of 1.5 standard deviations above the mean, nearly half (51%) of children were identified as at-risk (76% low risk, 24% high risk) for emotional, behavioral, social, and adaptive problems. Barriers and help-seeking did not differ across parents of low and high risk children. Among parents of at-risk children, only 33% believed their child had a problem. Parents sought informal help more often than professional help; however, medical doctors and school staff were sought most among professionals. The majority of parents (61%) endorsed at least one barrier that would interfere with mental health service use. Results highlight the importance of early school mental health screening and the need for interventions to increase parent problem recognition and engagement in mental health service utilization.

A Parent-Child Dyad Approach to the Assessment of Health Status and Health-Related Quality of Life in Children with Asthma

Assessment of health state and health-related quality of life (HR-QOL) are limited by a child's age and cognitive ability. Parent-proxy reports are known to differ from children's reports. Simultaneous assessment using a parent-child dyad is an alternative approach. Our objective was to assess the validity, reliability and responsiveness of a parent-child dyad approach to utility and HR-QOL assessment of paediatric asthma health states. The setting was specialist care in a hospital-based asthma clinic. Participants were 91 girls and boys with asthma aged 8 to 17 years and 91 parents. The intervention employed was parent-child dyad administration of the Health Utilities Index (HUI) 2 and 3, the Pediatric Quality of Life Inventory™ (PedsQL™) Core and Asthma modules, and the Pediatric Asthma Quality of Life Questionnaire (PAQLQ). Questionnaires were administered by interview to children and parents separately and then together as a dyad to assess the child's health state. The dyad interview was repeated at the next clinic visit. Dyad-child agreement was measured by intra-class correlation (ICC) coefficient; Spearman correlations were used to assess convergent validity. Test-retest reliability was assessed in 28 children who remained clinically stable between visits with a two-way ICC coefficient. Responsiveness to change from baseline was assessed with Spearman coefficients in 30 children who demonstrated clinical change between visits. There was no significant agreement between parent and child for the HUI2 or HUI3 whereas agreement between dyad and child was 0.55 (95% confidence interval [CI] 0.36, 0.69) for the HUI2 and 0.74 (95% CI 0.61, 0.82) for the HUI3 overall. With respect to dyad performance characteristics, both HUI2 and HUI3 overall scores demonstrated moderate convergent validity with the generic PedsQL™ Core domains (range r = 0.30-0.52; p < 0.01). Dyad HUI2 attributes demonstrated moderate convergent validity with the generic PedsQL™ Core domains of similar constructs (range r = 0.35-0.43; p < 0.001) and weaker convergent validity with disease-specific domains (range r = 0.13-0.32). Dyad HUI3 attributes demonstrated weaker convergent validity compared with the HUI2. For the assessment of test-retest reliability, significant agreement between baseline and follow-up was observed for dyad HUI2 total (r = 0.53), dyad PedsQL™ Core summary (r = 0.70) and select dyad disease-specific domains. Significant responsiveness (r > 0.4; p < 0.05) was observed for dyad HUI2 total score change over time as correlated with dyad HUI3, dyad PedsQL™ Core summary and select disease-specific domains. The parent-child dyad approach demonstrated moderate to strong performance characteristics in generic and disease-specific questionnaires suggesting it may be a valuable alternative to relying on parent proxies for assessing children's utility and HR-QOL. Future research in additional paediatric populations, younger children and a population-based sample would be useful.

Resource Utilization in Children With Tuberous Sclerosis Complex and Associated Seizures

Seizures are a hallmark manifestation of tuberous sclerosis complex, yet data characterizing resource utilization are lacking. This retrospective chart review was performed to assess the economic burden of tuberous sclerosis complex with neurologic manifestations. Demographic and resource utilization data were collected for 95 patients for up to 5 years after tuberous sclerosis complex diagnosis. Mean age at diagnosis was 3.1 years, with complex partial and infantile spasms as the most common seizure types. In the first 5 years post-diagnosis, 83.2% required hospitalization, 30.5% underwent surgery, and the majority of patients (90.5%) underwent ≥3 testing procedures. In 79 patients with a full 5 years of data, hospitalizations, intensive care unit stays, diagnostic testing, and rehabilitation services decreased over the 5-year period. Resource utilization is cost-intensive in children with tuberous sclerosis complex and associated seizures during the first few years following diagnosis. Improving seizure control and reducing health care costs in this population remain unmet needs.

Factors that Predict Frequency of Emergency Department Utilization in Children With Diabetes-Related Complaints

The primary purpose of the study was to determine the factors that are associated with repeat emergency department (ED) visits in children with diabetes. Emergency department charts and billing data for children up to 18 years of age presenting to the ED with diabetic diagnoses over a 4-year period were reviewed. The overall rate of repeat visits to the ED was 0.24 visits per person-year of follow-up time. In univariate analyses, there were statistically significant effects of age, insurance category, sex, type of practice, and income. In a multivariate analysis, there was a significant interaction of insurance category and age. Revisit rate ratios for children older than 6 years were higher for those with Medicaid compared with those with commercial insurance. Diabetic boys were less likely to revisit the ED than were girls. Type of insurance was associated with repeated visits to the ED in children with diabetes. Other contributing factors included age group and sex.

A Review of Pediatric Palliative Care Service Utilization in Children With a Progressive Neuromuscular Disease Who Died on a Palliative Care Program

Recent studies and consensus statements have expressed the need to involve palliative care services in the care of children with progressive neuromuscular diseases (PMD), yet there have been no reviews of the utilization of palliative care services by children who died on a palliative care program. We conducted a retrospective chart review of all children who had a PMD who died on a single-center palliative care program. Twenty cases were identified. Services utilized by these patients included respite care, transition services, pain and symptom management, and end-of-life care. Prominent symptoms in the last 24 hours of life included respiratory distress, pain, nausea/vomiting, and anxiety; however, symptom management was very good. Utilization of services differed depending on the disease trajectory, with respite playing a critical role in the care of children with PMD. Good symptom management can be achieved.

Postpartum Depression and Intimate Partner Violence in Urban Mothers: Co-Occurrence and Child Healthcare Utilization

To assess the prevalence, timing, and co-occurrence of positive screens for maternal postpartum depression and intimate partner violence and examine their relationships with children's healthcare utilization from birth to 2 years. Between February and March 2008, mothers bringing newborn, 2-, 4-, or 6-month-old children to an urban primary care clinic were screened for postpartum depression and intimate partner violence. A retrospective chart review abstracted demographic data, maternal responses on the postpartum depression/intimate partner violence screen at the initial and subsequent visits, and, from the child's birth to second birthday, adherence with well-child care and use of pediatric acute care and emergency department visits. Descriptive, bivariate, and multivariate analyses were conducted. A total of 173 mothers completed at least one postpartum depression/intimate partner violence screening survey. Overall, 26% screened positive for postpartum depression and 7% screened positive for intimate partner violence; most positive screens occurred at the initial visit. About 60% of mothers with a positive intimate partner violence screen also had a positive postpartum depression screen. Well-child care adherence and acute care visit utilization were not associated with maternal postpartum depression/intimate partner violence screening. Children of women with a positive screen for postpartum depression had greater emergency department utilization. The co-occurrence of postpartum depression and intimate partner violence is high in urban mothers. Primary care providers should routinely screen for both problems in this population and recognize the importance of screening for one problem if the other problem is identified.

A Comparison of Two Approaches to Increasing Access to Care: Expanding Coverage versus Increasing Physician Fees

To compare the effects of a coverage expansion versus a Medicaid physician fee increase on children's utilization of physician services. PRIMARY DATA SOURCE: National Health Interview Survey (1997-2009). We use the Children's Health Insurance Program, enacted in 1997, as a natural experiment, and we performed a panel data regression analysis using the state-year as the unit of observation. Outcomes include physician visits per child per year and the following indicators of access to primary care: whether the child saw a physician, pediatrician, or visited an ER in the last year, and whether the parents reported experiencing a non-cost-related access problem. We analyzed these outcomes among all children, and separately among socioeconomic status (SES) quartiles defined based on family income and parents' education. Children's Health Insurance Program had a major impact on the extent and nature of children's insurance coverage. However, it is not associated with any change in the aggregate quantity of physician services, and its associations with indicators of access are mixed. Increases in physician fees are associated with broad-based improvements in indicators of access. The findings suggest that (1) coverage expansions, even if they substantially reduce patient cost sharing, do not necessarily increase physician utilization, and (2) increasing the generosity of provider payments in public programs can improve access among low-SES children, and, through spillover effects, increase higher-SES children as well.

Factors Affecting Health Care Utilization for Children in Japan

Factors Affecting Health Care Utilization for Children in Japan

Possible supports for children's utilization of the structure strategy

Possible supports for children's utilization of the structure strategy

Computerized Tomography Utilization in Children with Appendicitis—Differences in Referring and Children's Hospitals

Increasingly, physicians rely on computerized tomography (CT) to aid in the workup of acute appendicitis (AA) in children despite the potential negative effects of CT-associated radiation exposure. Few studies have investigated the context or location in which the decision to perform CT for AA is made. We sought to determine where the decision to use CT was made during the initial workup of pediatric patients who later underwent an appendectomy. We reviewed the medical record of all patients at a children's hospital (CH) receiving appendectomy over 10.5 years. We abstracted clinical variables using an established clinical AA scoring system, demographics and outcome variables. Patients who underwent CT were compared with those who did not. Additionally, we identified the location where the CT was performed. Our children's hospital was compared with referring hospitals (RHs) with regard to utilization of CT imaging. Five hundred and forty-six patients underwent appendectomy for AA at CH. Of these, 50 per cent underwent CT. Patients who initially presented at the RHs underwent CT at a significantly higher rate than those first presenting to CH (P < 0.0001). Moreover, we found that unlike at the RHs, patients with a higher AA score underwent CT at CH less often (P < 0.0002). RHs used CT more often than CH to diagnose AA in our cohort. CH avoided CT for patients with higher Alvarado scores. Further research is needed to elucidate factors that lead healthcare providers to use CT for children with suspected AA to eliminate unnecessary CT-associated radiation exposure.

The Effect of Observation on Cranial Computed Tomography Utilization for Children After Blunt Head Trauma

The Effect of Observation on Cranial Computed Tomography Utilization for Children After Blunt Head Trauma