Care Enrollment Research Articles

The Benefits of Center-Based Care and Full-Day Kindergarten for School Attendance in the Early Grades

School absenteeism has been recognized as a growing issue in the United States, especially during the early elementary school years when it is most pervasive. Accordingly, there has been growing interest in understanding why children are absent and whether certain early educational experiences can reduce children’s rates of school absences. The objective of this investigation was to estimate the additive and multiplicative benefits of children’s early school experiences in preschool (center-based care) and kindergarten (center-based care and full day kindergarten enrollment) for patterns of school absenteeism in kindergarten and first grade. To address these objectives, data were drawn from the Early Childhood Longitudinal Study Kindergarten Class of 2010–2011 and included 12,835 children and families. Children who attended center-based care in preschool and kindergarten had fewer missed school days and were less likely to be chronically absent in kindergarten and first grade. Children in full-day kindergarten programs had more absences by the end of kindergarten, but fewer absences by the end of the following year. No specific combination of early school arrangements was most beneficial. Instead, children who experienced more early educational arrangements were generally absent less frequently and these benefits were larger in first grade than in kindergarten. When taken together, findings underscore the importance of formal early educational programs and opportunities on longer-term school attendance.

PDB74 - Association Between Insurance Type and Patient Activation Among Medicare Beneficiaries with Type 2 Diabetes

Patient activation has been increasingly recognized as a significant predictor of health behaviors, healthcare utilization, and costs. It’s important to know whether insurance types affect care delivery in a way that influences patient activation. This study assessed patient activation levels of Medicare beneficiaries with type 2 diabetes and assessed the association between insurance type and patient activation. Data from the 2011 and 2012 Medicare Current Beneficiary Survey (MCBS) was used for analysis. Patient activation levels were classified as “low,” scores less than the mean minus half of the standard deviation; as “high,” scores greater than the mean plus half of the standard deviation; or as “moderate,” scores between the cutoff points for “low” and “high.” Effects of managed care enrollment, Medicaid eligibility, and private insurance coverage were examined in bivariate and multivariate ordinal logistic regressions. SAS 9.4 for Linux and an alpha of 0.05 were used in all analyses. The sample included 3,255 patients, 26.4% with low activation, 38.3% with moderate activation, and 35.3% with high activation. Non-white patients (Odds Ratio, O.R. = 1.4, 95% C.I.: 1.2 to 1.6, p = 0.0001) and males (O.R. = 1.4, 95% C.I.: 1.2 to 1.6, p < 0.0001) were more likely to report low activation. In bivariate analyses, Medicaid eligibility (O.R. = 1.5, 95% C.I.: 1.3 to 1.7, p < 0.0001) and no private insurance (O.R. = 1.4, 95% C.I.: 1.2 to 1.6, p < 0.0001) were associated with low activation. However, there was no association between managed care enrollment and patient activation. In multivariate models adjusting for covariates, none of the insurance variables were associated with activation level. Managed care enrollment, Medicaid eligibility, and private insurance coverage were not associated with patient activation levels when other risk factors were accounted for.

Risks for upper respiratory infections in infants during their first months in day care included environmental and child-related factors.

We examined the frequency and potential risk factors for respiratory infections, diarrhoea and absences in infants during their first months in day care. This prospective cohort study comprised 269 Danish infants aged eight months to 14months and was part of a study that examined how probiotics affected absences from day care due to respiratory and gastrointestinal infections. The risk factors examined were the household, child characteristics and type of day care facility. Parents registered upper respiratory tract infections (URTIs), lower respiratory tract infections (LRTIs), diarrhoea and day care absences on web-based questionnaires. Over a mean of 5.6months in day care, 36% and 20% of the infants had at least one URTI or LRTI, and 60% had diarrhoeal episodes. The risk of at least one URTI was increased by previous respiratory infections, with an odds ratio (OR) of 2.65, but was inversely associated with having a pet (OR: 0.43), being cared for by registered child minders compared to day care centres (OR: 0.36), birthweight (OR 0.40) and age at day care enrolment (OR: 0.64). No significant risk factors for LRTIs and diarrhoea were found. Infection risks were associated with environmental factors and factors related to the child.

Association between pregnancy at enrollment into HIV care and loss to care among women in the Democratic Republic of Congo, 2006-2013.

BackgroundLoss to care is high among asymptomatic HIV-infected women initiated on antiretroviral therapy (ART) during pregnancy or in the postpartum period. However, whether pregnancy itself plays a role in the high loss to care rate is uncertain. We compared loss to care over seven years between pregnant and non-pregnant women at enrollment into HIV care in the Democratic Republic of Congo (DRC).MethodsWe conducted a retrospective analysis of all ART-naive women aged 15–45 initiating HIV care at two large clinics in Kinshasa, DRC, from 2007–2013. Pregnancy status was recorded at care enrollment. Patients were classified as having no follow-up if they did not return to care after the initial enrollment visit. Among those with at least one follow-up visit after enrollment, we classified patients as lost to care if more than 365 days had passed since their last clinic visit. We used logistic regression to model the association between pregnancy status and no follow-up, and Cox proportional hazards regression to model the association between pregnancy status and time to loss to care.ResultsOf 2175 women included in the analysis, 1497 (68.8%) were pregnant at enrollment. Compared to non-pregnant women, pregnant women were less likely to be over 35 years of age (19.1% vs. 31.9%, p<0.0001) and less likely to be in WHO stage III or IV (9.0% vs. 26.3%, p<0.0001). Among pregnant women, 106 (7.1%) were not seen after enrollment, versus 25 (3.7%) non-pregnant women (adjusted odds ratio 2.01, 95% CI 1.24–3.24). Of the 2,044 women with at least one follow-up visit, 46.5% of pregnant women and 46.7% of non-pregnant women were lost to care by 5 years; hazards of loss to care were similar for pregnant and non-pregnant women (adjusted hazard ratio 1.08, 95% CI 0.93–1.26).ConclusionsIn this large cohort of HIV-infected women, patients pregnant at care enrollment were more likely to never return for follow-up. Among those who attended at least one follow-up visit, loss to care was not different between pregnant and non-pregnant women, suggesting that pregnancy itself may not be the main driver of the high attrition observed in this cohort.

Monitoring progress towards the first UNAIDS target: understanding the impact of people living with HIV who re-test during HIV-testing campaigns in rural Mozambique.

IntroductionAwareness of HIV‐infection goes beyond diagnosis, and encompasses understanding, acceptance, disclosure and initiation of the HIV‐care. We aimed to characterize the HIV‐positive population that underwent repeat HIV‐testing without disclosing their serostatus and the impact on estimates of the first UNAIDS 90 target.MethodsThis analysis was nested in a prospective cohort established in southern Mozambique which conducted three HIV‐testing modalities: voluntary counselling and testing (VCT), provider‐initiated counselling and testing (PICT) and home‐based testing (HBT). Participants were given the opportunity to self‐report their status to lay counsellors and HIV‐positive diagnoses were verified for previous enrolment in care. This study included 1955 individuals diagnosed with HIV through VCT/PICT and 11,746 participants of a HBT campaign. Those who did not report their serostatus prior to testing, and were found to have a previous HIV‐diagnosis, were defined as non‐disclosures. Venue‐stratified descriptive analyses were performed and factors associated with non‐disclosure were estimated through log‐binomial regression.ResultsIn the first round of 2500 adults randomized for HBT, 1725 were eligible for testing and 18.7% self‐reported their HIV‐positivity. Of those tested with a positive result, 38.9% were found to be non‐disclosures. Similar prevalence of non‐disclosures was found in clinical‐testing modalities, 29.4% (95% CI 26.7 to 32.3) for PICT strategy and 13.0% (95% CI 10.9 to 15.3) for VCT. Prior history of missed visits (adjusted prevalence ratio (APR) 4.2, 95% CI 2.6 to 6.8), younger age (APR 2.5, 95% CI 1.4 to 4.4) and no prior history of treatment ((APR) 1.4, 95% CI 1.0 to 2.1) were significantly associated with non‐disclosure as compared to patients who self‐reported. When considering non‐disclosures as people living with HIV (PLWHIV) aware of their HIV‐status, the proportion of PLWHIV aware increased from 78.3% (95% CI 74.2 to 81.6) to 86.8% (95% CI 83.4 to 89.6).ConclusionMore than one‐third of individuals testing HIV‐positive did not disclose their previous positive HIV‐diagnosis to counsellors. This proportion varied according to testing modality and age. In the absence of an efficient and non‐anonymous tracking system for HIV‐testers, repeat testing of non‐disclosures leads to wasted resources and may distort programmatic indicators. Developing interventions that ensure appropriate psychosocial support are needed to encourage this population to disclose their status and optimize scarce resources.

Out of Sight, Out of Mind? Measuring the Relationship between Privatization and Medicaid Self-Reporting.

Privatization has grown exponentially, both in salience and in form, over the past several decades. This shifting of administrative authority away from the state can make it difficult for program recipients to link their use of a federal program back to government, a disconnect known as "submerging" the state. However, privatization is a process that occurs in degrees, and not all privatization initiatives look alike. This study leverages variation in the implementation of Medicaid managed care, which is the most widespread form of Medicaid privatization, to examine how privatization maps onto state submersion and affects state visibility. This analysis shows that, although Medicaid managed care enrollment, at large, does not relate to recipients' self-reported Medicaid enrollment, when privatized Medicaid plans introduce administrative designs that obscure the role of government, Medicaid self-reporting declines. These findings demonstrate that policy recipients are less able to recognize both the personal relevance of a specific public program and the public nature of this interaction when privatized programs utilize design features that attenuate signals of government involvement. In highlighting this disconnect, this article shows how privatization makes it more difficult for policy recipients to engage in the civic sphere as informed advocates for their self-interest.

HIV treatment eligibility expansion and timely antiretroviral treatment initiation following enrollment in HIV care: A metaregression analysis of programmatic data from 22 countries.

BackgroundThe effect of antiretroviral treatment (ART) eligibility expansions on patient outcomes, including rates of timely ART initiation among those enrolling in care, has not been assessed on a large scale. In addition, it is not known whether ART eligibility expansions may lead to “crowding out” of sicker patients.Methods and findingsWe examined changes in timely ART initiation (within 6 months) at the original site of HIV care enrollment after ART eligibility expansions among 284,740 adult ART-naïve patients at 171 International Epidemiology Databases to Evaluate AIDS (IeDEA) network sites in 22 countries where national policies expanding ART eligibility were introduced between 2007 and 2015. Half of the sites included in this analysis were from Southern Africa, one-third were from East Africa, and the remainder were from the Asia-Pacific, Central Africa, North America, and South and Central America regions. The median age of patients enrolling in care at contributing sites was 33.5 years, and the median percentage of female patients at these clinics was 62.5%. We assessed the 6-month cumulative incidence of timely ART initiation (CI-ART) before and after major expansions of ART eligibility (i.e., expansion to treat persons with CD4 ≤ 350 cells/μL [145 sites in 22 countries] and CD4 ≤ 500 cells/μL [152 sites in 15 countries]). Random effects metaregression models were used to estimate absolute changes in CI-ART at each site before and after guideline expansion. The crude pooled estimate of change in CI-ART was 4.3 percentage points (95% confidence interval [CI] 2.6 to 6.1) after ART eligibility expansion to CD4 ≤ 350, from a baseline median CI-ART of 53%; and 15.9 percentage points (pp) (95% CI 14.3 to 17.4) after ART eligibility expansion to CD4 ≤ 500, from a baseline median CI-ART of 57%. The largest increases in CI-ART were observed among those newly eligible for treatment (18.2 pp after expansion to CD4 ≤ 350 and 47.4 pp after expansion to CD4 ≤ 500), with no change or small increases among those eligible under prior guidelines (CD4 ≤ 350: −0.6 pp, 95% CI −2.0 to 0.7 pp; CD4 ≤ 500: 4.9 pp, 95% CI 3.3 to 6.5 pp). For ART eligibility expansion to CD4 ≤ 500, changes in CI-ART were largest among younger patients (16–24 years: 21.5 pp, 95% CI 18.9 to 24.2 pp). Key limitations include the lack of a counterfactual and difficulty accounting for secular outcome trends, due to universal exposure to guideline changes in each country.ConclusionsThese findings underscore the potential of ART eligibility expansion to improve the timeliness of ART initiation globally, particularly for young adults.

Predictors of non-adherence to colorectal cancer screening among immigrants to Ontario, Canada: a population-based study

Though colorectal cancer (CRC) screening rates have increased over time in Ontario, Canada, immigrants continue to have lower rates of screening. This study examines the association between non-adherence to CRC screening and immigration, socio-demographic, healthcare utilization, and primary care physician characteristics among immigrants to Ontario. This is a population-based retrospective cross-sectional study that uses healthcare administrative databases housed at the Institute for Clinical Evaluative Sciences. Our cohort comprised immigrants aged 60 to 74 years who lived in Ontario on March 31, 2015 and who had been eligible for the Ontario Health Insurance Plan for at least 10 years. The outcome was lack of adherence to CRC screening with any modality (fecal occult blood test, flexible sigmoidoscopy, colonoscopy) on March 31, 2015. Our cohort contained 182,949 immigrants. Overall 70,134 (38%) individuals were not adherent to screening. Risk of non-adherence to CRC screening was higher among immigrants who were from low (adjusted relative risk [ARR] 1.35, 95%CI 1.28–1.42) or low-middle (ARR 1.27, 95%CI 1.24–1.30, population-attributable risk [PAR] 9.8%) income countries and refugees (ARR 1.09, 95%CI 1.06–1.11). Compared to those from the United States, Australia, and New Zealand, immigrants from most other world regions, particularly Eastern Europe and Central Asia (ARR 1.28, 95%CI 1.21–1.37), had higher risks of non-adherence. Non-immigration factors such as low healthcare use and lack of primary care enrolment also increased the risk of non-adherence to screening. These findings can be used to inform future efforts to improve uptake of CRC screening among immigrant groups.

Return on Investment for a Payer-Provider Partnership to Improve Care Management of Employees and Early Retirees.

A large employer partnered with local health care providers to pilot test an intensive nurse care manager program for employees and retirees. We evaluated its impact on health care utilization and costs. A database was developed containing 2011 to 2015 health care enrollment and claims data for 2914 patients linked to their nurse care manager data. We used a difference-in-difference design to compare health care costs and utilization of members recruited for the pilot program and a propensity-score-matched comparison group. We found statistically significant reductions in doctors' office visits and prescription drug costs. A return-on-investment analysis determined that the program saved $0.83 for every dollar spent over the 2-year pilot study period. Employer-driven care management programs can succeed at reducing utilization, although they may not achieve cost neutrality in the short run.

Late presentation for HIV care in Southwest Ethiopia in 2003\u20132015: prevalence, trend, outcomes and risk factors

BackgroundEarly presentation for HIV care is vital as an initial tread in the UNAIDS 90–90–90 targets. However, late presentation for HIV care (LP) challenges achieving the targets. This study assessed the prevalence, trends, outcomes and risk factorsfor LP.MethodsA 12 year retrospective cohort study was conducted using electronic medical records extracted from an antiretroviral therapy (ART) clinic at Jimma University Teaching Hospital. LP for children refers to moderate or severe immune-suppression, or WHO clinical stage 3 or 4 at the time of first presentation to the ART clinics. LP for adults refers to CD4 lymphocyte count of < 200 cells/ μl and < 350 cells/μl irrespective of clinical staging, or WHO clinical stage 3 or 4 irrespective of CD4 count at the time of first presentation to the ART clinics. Binary logistic regression was used to identify factors that were associated with LP, and missing data were handled using multiple imputations.ResultsThree hundred ninety-nine children and 4900 adults were enrolled in ART care between 2003 and 15. The prevalence of LP was 57% in children and 66.7% in adults with an overall prevalence of 65.5%, and the 10-year analysis of LP showed upward trends. 57% of dead children, 32% of discontinued children, and 97% of children with immunological failure were late presenters for HIV care. Similarly, 65% of dead adults, 65% of discontinued adults, and 79% of adults with immunological failure presented late for the care. Age between 25- < 50 years (AOR = 0.4,95% CI:0.3–0.6) and 50+ years (AOR = 0.4,95% CI:0.2–0.6), being female (AOR = 1.2, 95% CI: 1.03–1.5), having Tb/HIV co-infection (AOR = 1.6, 95% CI: 1.09–2.1), having no previous history of HIV testing (AOR = 1.2, 95% CI: 1.1–1.4), and HIV care enrollment period in 2012 and after (AOR = 0.8, 95% CI: 0.7–0.9) were the factors associated with LP for Adults. For children, none of the factors were associated with LP.ConclusionsThe prevalence of LP was high in both adults and children. The majority of both children and adults who presented late for HIV care had died and developed immunological failure. Effective programs should be designed and implemented to tackle the gap in timely HIV care engagement.

Political economy of hope as a cultural facet of biomedicalization: A qualitative examination of constraints to hospice utilization among U.S. end-stage cancer patients

A growing body of social science literature is devoted to describing processes of biomedicalization. The issue of biomedicalization is especially relevant for individuals suffering from end-stage cancer and hoping that aggressive end-of-life interventions, which are riddled with uncertainty around quantity or quality of life, will produce a ‘cure’. To examine hospice underutilization among end-stage cancer patients, we apply the anthropological concept ‘political economy of hope,’ which describes how personal and collective ‘hope’ is associated with the political and economic structures that produce biomedicalization processes. Previous studies have examined hospice underutilization among end-stage cancer patients and have identified barriers stemming from patient and physician characteristics or health insurance reimbursement policies. Yet, these studies do not provide an organized synthesis of how barriers articulate, how they are part of the longitudinal decision-making process, or describe the sociocultural context surrounding hospice care enrollment decisions. This paper focuses on US-specific mechanisms and is based on qualitative, in-depth, interviews with physicians at an academic hospital (N = 24). We find that hospice underutilization results from a web of interconnected constraints surrounding end-stage cancer patients. Our research reveals how hospice care contradicts the political and economic structures associated with end-stage cancer care and illustrates how end-stage cancer patients are transformed into a form of biovalue, a fundamental commodity sustaining the political economy of hope.

Differences in do-not-resuscitate orders, hospice care utilization, and late referral to hospice care between cancer and non-cancer decedents in a tertiary Hospital in Taiwan between 2010 and 2015: a hospital-based observational study

BackgroundIn 2009, the Taiwanese national health insurance system substantially expanded hospice coverage for terminal cancer patients to include patients with end-stage brain, dementia, heart, lung, liver, and kidney diseases. This study aimed to evaluate differences in do-not-resuscitate (DNR) status and hospice care utilization between terminal cancer patients and advanced non-cancer patients after the policy change.MethodsData were obtained from the Death and Hospice Palliative Care Database of Taipei Veterans General Hospital in Taiwan. The differences between cancer and non-cancer patients who died in this hospital between 2010 and 2015 were analyzed in terms of patient characteristics, rates of DNR orders, hospice care utilization, number of living days after DNR order, duration of survival (DOS) after hospice care enrollment, and the rate of late referral to hospice care.ResultsData for 8459 patients who died of cancer and major non-cancer terminal diseases were included. DNR order rate, hospice care utilization rate, and DOS were significantly higher for cancer patients than for non-cancer patients (p < 0.001, p < 0.001, and p < 0.001, respectively). The number of living days after DNR order and the late referral rate were significantly higher for non-cancer decedents than for cancer decedents (p < 0.001 and p < 0.001, respectively). From 2010 to 2015, there were significantly increasing trends in the hospice utilization rate, number of living days after DNR order, and rate of late referral for the cancer group (p < 0.001, p = 0.001, and p < 0.001, respectively). For the non-cancer group, there were significantly increasing trends in the rate of DNR order, hospice utilization rate, and number of living days after DNR order (p < 0.001, p < 0.001, and p = 0.029, respectively).ConclusionsFurther guidelines should be developed to help clinicians to promptly refer terminal cancer and non-cancer patients to hospice care. Considering the lower hospice utilization rate and the growing need for hospice care among terminal non-cancer patients, policymakers should consider how to improve the relevant levels of professional care to enhance the accessibility and availability of hospice care in Taiwan.

A Comparison Between Subjective and Objective Methods of Predicting Health Care Expenses to Support Consumers' Health Insurance Plan Choice.

Objective. Numerous electronic tools help consumers select health insurance plans based on their estimated health care utilization. However, the best way to personalize these tools is unknown. The purpose of this study was to compare two common methods of personalizing health insurance plan displays: 1) quantitative healthcare utilization predictions using nationally representative Medical Expenditure Panel Survey (MEPS) data and 2) subjective-health status predictions. We also explored their relations to self-reported health care utilization. Methods. Secondary data analysis was conducted with responses from 327 adults under age 65 considering health insurance enrollment in the Affordable Care Act (ACA) marketplace. Participants were asked to report their subjective health, health conditions, and demographic information. MEPS data were used to estimate predicted annual expenditures based on age, gender, and reported health conditions. Self-reported health care utilization was obtained for 120 participants at a 1-year follow-up. Results. MEPS-based predictions and subjective-health status were related (P < 0.0001). However, MEPS-predicted ranges within subjective-health categories were large. Subjective health was a less reliable predictor of expenses among older adults (age × subjective health, P = 0.04). Neither significantly related to subsequent self-reported health care utilization (P = 0.18, P = 0.92, respectively). Conclusions. Because MEPS data are nationally representative, they may approximate utilization better than subjective health, particularly among older adults. However, approximating health care utilization is difficult, especially among newly insured. Findings have implications for health insurance decision support tools that personalize plan displays based on cost estimates.

Impact of regionalisation of a national rheumatic heart disease registry: the Ugandan experience

ObjectivesRheumatic heart disease (RHD) remains a major driver of cardiovascular morbidity and mortality in low-resource settings. Registry-based care for RHD has been advocated as a powerful tool to improve clinical...

The Affordable Care Act and Changes in Insurance Coverage and Source of Health Care among High-risk Rural, Substance-using, Female Offenders Transitioning to the Community.

This study examines health care coverage and health care among rural, drug-involved female offenders under the Affordable Care Act (ACA) compared with pre-ACA and whether being insured is associated with having a usual source of care. This study involved random selection, screening, and face-to-face interviews with drug-using women in three rural Appalachian jails. Analyses focused on participants who had completed a three-month follow-up interview after release from jail (N=371). Analyses indicated that women released after ACA implementation were more likely than those released pre-implementation to be insured. A multivariate logistic regression model showed that being insured was significantly related to having a usual health care source during community re-entry. Results demonstrate the benefits of the ACA, signaling important implications for public health in rural communities and the criminal justice system, including targeting underserved groups during incarceration and providing information about and resources for health care enrollment.

Parent Recommendations to Enhance Enrollment in Multidisciplinary Clinical Care for Pediatric Weight Management

To explore parents' recommendations to enhance enrollment in multidisciplinary clinical care for managing pediatric obesity. Data for this interpretative description study were collected through individual, semistructured interviews that were audiorecorded, transcribed verbatim, and analyzed thematically. Parents (n = 79) were recruited from 4 multidisciplinary weight management clinics in Canada located in Edmonton, Hamilton, Montreal, and Vancouver. Most interviewed parents had children with obesity (body mass index ≥95th percentile; 84.2%), were female (87.3%), had postsecondary education (69.6%), and were white (75.9%). Parents' recommendations referred to enrollment opportunities, information about obesity services, motivation for treatment, and accessibility to obesity services. Specifically, parents recommended to increase referral options and follow-up contacts with families during the enrollment process, inform referring physicians and families about the availability and characteristics of obesity services, enhance families' motivation for treatment, prevent families from getting discouraged, make services more appealing to families, and address accessibility issues (eg, offering multiple options for appointment times, providing support for transportation). Parents' recommendations support the need for family-centered approaches to enhance enrollment; however, their feasibility, acceptability, and effectiveness remain to be tested empirically.

Effect of privatized managed care on public insurance spending and generosity: Evidence from Medicaid.

States choose to provide Medicaid coverage via managed care or traditional fee-for-service. Managed care provided by private insurers poses higher contracting costs and information asymmetry than traditional fee-for-service but potentially improves efficiency and reduces spending. Evaluating the effect of managed care on Medicaid spending is challenging because adoption of managed care is nonrandom and may be driven by local economic shocks that simultaneously affect Medicaid spending. This study implements a dynamic panel framework to estimate the effect of managed care enrollment on spending levels and program design. Results show reductions in Medicaid spending larger than previously found in cross-state studies: A 10% increase of managed care enrollment reduces state Medicaid spending by 2.94%, or approximately $55million. The study identifies which areas of spending are differentially affected by managed care enrollment and whether savings from managed care affect Medicaid design, specifically coverage generosity.

Enrolment of children in psychosocial care: problems upon entry, care received, and outcomes achieved

Psychosocial care systems have been designed so that specific problems are treated by specific care types. There is insufficient evidence as to which problem types are actually presented to the various care types. This study assessed types and severity of problems among children and adolescents upon enrolment in psychosocial care, compared to children not enrolled; also outcomes after 3 and 12 months, overall and per care type. We obtained data on a cohort of 1382 Dutch children aged 4–18 years (response rate 56.6%), included upon enrolment in psychosocial care, and on 443 not-enrolled children (response rate 70.3%), all from one region. Results showed that enrolled children had more problems than children not enrolled in care. In child and adolescent mental healthcare (CAMH), relatively many children had internalizing problems, and in child and adolescent social care (CASC) relatively many children had externalizing, parenting, family and multiple problems. Regardless of the type of problem, care duration in preventive child healthcare (PCH) was relatively short; and in CASC and CAMH longer. After 3 and 12 months, rates of problem solution were highest in PCH. These rates were also substantial among children not in care. To conclude, our findings show that the system of psychosocial care functions as intended regarding the distribution of problems across care types. Extended demarcation of clients by problem type and severity towards type and contents of care may further improve the system.

"Testing, Testing": Multiple HIV-Positive Tests among Patients Initiating Antiretroviral Therapy in Ethiopia.

Repeat HIV testing after receiving a positive result has never been studied systematically and may give insight into reasons for delayed linkage to care. Among 831 adults in 6 secondary facilities in Oromia, Ethiopia, who completed an interviewer-administered structured questionnaire within 2 weeks of initiating antiretroviral therapy in 2012 to 2013, 110 (13.2%) reported having retested after an HIV-positive result. The odds of repeat (versus single) HIV-positive testing were higher among those who had doubted their HIV status (adjusted odds ratio [AOR]ref=nodoubt = 6.5; 95% confidence interval [CI]: 3.7-11.4) and those who initially tested at another facility, whether another secondary facility (AOR ref=studyfacility = 22.7; 95% CI: 11.0-46.9) or a lower-level facility (AORref=studyfacility = 19.1; 95% CI: 10.5-34.5). The odds of repeat (versus single) HIV-positive testing were lower among those who initially tested because of symptoms (AORref=not a reason = 0.40; 95% CI: 0.24-0.66). Median time between initial diagnosis and enrollment in care was 12.3 versus 1.0 month for repeat and single HIV-positive testers, respectively ( P < .001). Repeat HIV-positive testing-not a rare occurrence-appears to stem from doubt, seeking care at a facility other than where diagnosed, and testing for a reason other than having symptoms. Because repeat HIV-positive testing is associated with delay in linkage to care, providers should be aware of this potential when counseling those who test HIV positive.

Effects of Early Dual-Eligible Special Needs Plans on Health Expenditure.

To examine the effects of the penetration of dual-eligible special needs plans (D-SNPs) on health care spending. Secondary state-level panel data from Medicare-Medicaid Linked Enrollee Analytic Data Source (MMLEADS) public use file and Special Needs Plan Comprehensive Reports, Area Health Resource Files, and Medicaid Managed Care Enrollment Report between 2007 and 2011. A difference-in-difference strategy that adjusts for dual-eligibles' demographic and socioeconomic characteristics, state health resources, beneficiaries' health risk factors, Medicare/Medicaid enrollment, and state- and year-fixed effects. Data from MMLEADS were summarized from Centers for Medicare and Medicaid Services (CMS)'s Chronic Conditions Data Warehouse, which contains 100 percent of Medicare enrollment data, claims for beneficiaries who are enrolled in the fee-for-service (FFS) program, and Medicaid Analytic Extract files. The MMLEADS public use file also includes payment information for managed care. Data in Special Needs Plan Comprehensive Reports were from CMS's Health Plan Management System. Results indicate that D-SNPs penetration was associated with reduced Medicare spending per dual-eligible beneficiary. Specifically, a 1 percent increase in D-SNPs penetration was associated with 0.2 percent reduction in Medicare spending per beneficiary. We found no association between D-SNPs penetration and Medicaid or total spending. Involving Medicaid services in D-SNPs may be crucial to improve coordination between Medicare and Medicaid programs and control Medicaid spending among dual-eligible beneficiaries. Starting from 2013, D-SNPs were mandated to have contracts with state Medicaid agencies. This change may introduce new effects of D-SNPs on health care spending. More research is needed to examine the impact of D-SNPs on dual-eligible spending.