Medicaid Status Research Articles

Determinants of Early Implant Discontinuation Among Low-Income Women

The determinants of contraceptive implant discontinuation within six months of insertion were examined among 786 low-income women attending family planning clinics in three U.S. cities. The six-month cumulative life-table discontinuation rate was 7.6%. Menstrual side effects were the most common reasons given for early implant removal, although women who discontinued use were no more likely than those who continued with the method to report menstrual irregularities. Women who opted for early removal were more likely than those who continued with the method to experience headaches, hair loss, weight gain and arm infection. Logistic regression analysis indicates that dissatisfaction with prior contraceptive methods, a partner who wants a child within the next two years, perceived pressure from health care providers to choose the implant, exposure to negative media coverage and the number of implant side effects significantly predict early implant discontinuation. Women's social and demographic characteristics, Medicaid status and motivation to avoid an unplanned pregnancy were not significantly related to early removal.

Why pregnant adolescents say they did not use contraceptives prior to conception

In this study we attempted to learn why childbearing adolescents failed to use contraceptives prior to conception. We hypothesized that among adolescents who elect to bear their children, positive and/or ambivalent feelings about having a baby are the most frequently cited reasons for not having used contraceptives. This is a cross-sectional, clinic-based survey of a racially and ethnically diverse group of 200 consecutively enrolled, poor, pregnant, 13-18-year-old patients in an adolescent-oriented maternity program. The participants completed a self-administered questionnaire which elicited information about environmental and personal risk factors for inconsistent use of contraceptives and information about the reasons they had not used contraceptives consistently prior to conception. Student's t-tests, Chi-square, and logistic regression analyses were used. The most frequently cited reasons for not using contraceptives prior to conception were: "I didn't mind getting pregnant" (20%) and "I wanted to get pregnant" (17.5%), followed by "I was using birth control but it didn't work (broke)" (12%), "I thought there was something wrong with me and I couldn't get pregnant" (9%) and "I just didn't get around to it" (9%). Teenagers who cited positive and/or ambivalent attitudes toward childbearing as their primary reason for not using contraceptives at the time of conception did not differ from others with regard to age, Medicaid status, gravidity, parity, frequency of living with parents, partner's age, depressive symptoms, or perceived family support. They were, however, more likely to have known the father of the baby for more than 6 months at the time of conception [odds ratio (OR) 2.53; 95% confidence interval (CI) 1.22-5.26) and to have dropped out of school (OR) 2.15; 95% CI 1.10-4.26]. The study hypothesis was supported. The absence of negative attitudes toward having babies rather than negative attitudes toward contraceptives is the most commonly cited reason for nonuse of contraceptives among childbearing adolescents. The results of this study may enable health care and social service providers to design more effective programs for preventing first and subsequent adolescent pregnancies.

Female Adolescent Contraceptive Use or Nonuse at First and Most Recent Coitus

The purpose of this study was to determine factors that differentiate contraceptive use behaviors of sexually active adolescent women. A sample of 159 subjects, recruited from three publicly supported family planning clinics, were classified according to nonuse, inconsistent, or consistent use of contraceptives at first and most recent coitus. The Health Promotion Model provided the organizing framework for this study. Factors entered into the discriminate functions included self-image, problem solving, health-promoting behavior, race, age at first coitus, previous pregnancy, contraceptive history, chronological age, family structure and size, mother's education, and Medicaid status. Three-group multivariate discriminate analysis resulted in two significant functions that explained 38.7% of the variance in contraceptive behavior. The three groups of adolescents were discriminated by age at first coitus, history of previous pregnancy, health-promoting behavior, self-image, problem-solving skill, chronological age, family size, and race. In particular, the findings suggest public health nurses and other health care providers can reduce unintended pregnancy through interventions that address the alterable factors.

Which teen mothers choose Norplant?

The objective of this study was to determine if there are sociodemographic differences between adolescent mothers who choose to use Norplant after delivery and those who do not. We hypothesized that those adolescent mothers who are at highest risk for repeat adolescent pregnancy are least likely to select Norplant as a postpartum contraceptive. We prospectively compared the prevalence of epidemiologic risk factors for repeat adolescent pregnancy in a group of 187 consecutively delivered 13-18-year-olds who were enrolled in a comprehensive, multidisciplinary, adolescent-oriented maternity program. The study subjects were interviewed at delivery; 100 subsequently had a Norplant inserted (Norplant users). Student's t-tests and chi-square analyses were used to compare Norplant users and refusers. We found no statistically significant differences between Norplant users and refusers with regard to: age, race, Medicaid, or marital or school status. Compared to Norplant refusers, Norplant users were less likely to be primiparous (79% compared to 90%; p = .04) and more likely to have poor school grades (20% compared to 7%; p = .001). Norplant users were more likely to state that they had had trouble remembering to use contraceptives in the past (32% compared to 14%; p = .005). These data do not support the study hypothesis and are encouraging because they suggest that Norplant may reduce repeat pregnancy among adolescent parents.

Sociodemographic characteristics of dropouts from a child guidance clinic.

This study examined the characteristics of families who dropped out and families who maintained contact with a children's psychiatric outpatient clinic through various phases of intake and treatment. One year after intake, the authors examined the status of all patients (N = 555) who had sought treatment at an urban, university-affiliated children's psychiatric outpatient clinic over a two-year period and had completed the intake process. Factors associated with dropout were identified at four points in the clinic process: during intake, during evaluation, at completion of evaluation, and during treatment. Urban residence, minority status, single-parent status, and Medicaid status were related to dropout at intake and during evaluation but not at subsequent clinic phases. Nonminority, two-parent, suburban families of higher socioeconomic status were more likely to drop out at the completion of the evaluation. These results indicate that factors associated with attrition vary with the clinic phase. Further investigations of the clinical course of minority children and families involved with children's mental health services are necessary to understand the needs of this population and to design interventions such as increasing minority staff and providing training in multi-cultural competence.

Incentives enhance postpartum compliance among adolescent prenatal patients

Objective: To test the hypothesis that incentives enhance compliance with postpartum appointments. Method: We studied a multiracial group of 240, poor, 12-to-19 year olds. At 34 weeks gestation consecutively enrolled patients were randomized to incentive and non-incentive groups. Patients in the incentive group were told that they would receive a Gerry “Cuddler” if they returned for an examination within 12 weeks of delivery. The groups were compared with Student's t-tests and chi-square and logistic regression analyses. Results: We found no significant group differences in age, race, Medicaid status, gravidity, parity, the timing of the first prenatal visit, compliance with prenatal appointments, or well-baby care site. One hundred and seventy-five (73%) of the 240 patients returned for a postpartum examination. Patients randomized to the incentive group were significantly more likely to return for an examination within 12 weeks of delivery (82.4% vs. 65.2%, x 2 = 9.0; p = .003). The logistic regression analysis revealed that in addition to membership in the incentive group, three characteristics were significantly associated with postpartum compliance: primiparity, compliance with prenatal care, and school enrollment. Conclusions: Among adolescents who obtained prenatal care in a multidisciplinary adolescent-oriented maternity program, the offer of an incentive significantly improved compliance with the 6-week postpartum appointment. Since other factors associated with improved postpartum compliance are less amenable to change we recommend that health care providers consider offering a postpartum incentive, especially to their multiparous adolescent patients who are not enrolled in school and/or are non-compliant with prenatal appointments.

The Effects of Alcohol Abuse on Readmission for Trauma

To determine the effect of admission for trauma with concurrent acute alcohol intoxication or chronic alcohol abuse on the risk of subsequent recurrence of trauma. Prospective cohort study. Level I regional trauma center. A total of 2578 patients 18 years or older admitted with blunt or penetrating trauma within 24 hours of injury and surviving to discharge. All patients had a blood alcohol concentration (BAC) test, a gamma-glutamyltransferase (GGT) test, and the short Michigan Alcohol Screening Test (SMAST) performed on admission. Readmission to the trauma center for new trauma. Average follow-up was 28 months (range, 16 to 40 months). The overall rate of readmission for new injuries was 1.3 per 1000 patient-months of follow-up. Patients who were intoxicated on the initial admission (BAC > 22 mmol/L [100 mg/dL]) were 2.5-fold as likely to be readmitted than those not intoxicated (95% confidence limits, 1.6, 3.9). The relative risks for patients with positive SMAST scores and abnormal GGT values were 2.2 (95% confidence limits, 1.4, 3.5) and 3.5 (95% confidence limits, 2.2, 5.5), respectively. The increased risks remained significant for intoxication and abnormal GGT values after adjustment for gender, race, Medicaid status, and mechanism of injury. Alcohol abuse is associated with an increased risk of readmission for new trauma. Trauma patients should be screened for alcohol problems; referral of problem drinkers for appropriate care may decrease their risk of admission for subsequent trauma.

The effects of alcohol abuse on readmission for trauma

<h3>Objective.</h3> —To determine the effect of admission for trauma with concurrent acute alcohol intoxication or chronic alcohol abuse on the risk of subsequent recurrence of trauma. <h3>Design.</h3> —Prospective cohort study. <h3>Setting.</h3> —Level I regional trauma center. <h3>Patients.</h3> —A total of 2578 patients 18 years or older admitted with blunt or penetrating trauma within 24 hours of injury and surviving to discharge. All patients had a blood alcohol concentration (BAC) test, a γ-glutamyltransferase (GGT) test, and the short Michigan Alcohol Screening Test (SMAST) performed on admission. <h3>Main Outcome Measurement.</h3> —Readmission to the trauma center for new trauma. Average follow-up was 28 months (range, 16 to 40 months). <h3>Results.</h3> —The overall rate of readmission for new injuries was 1.3 per 1000 patient-months of follow-up. Patients who were intoxicated on the initial admission (BAC &gt;22 mmol/L [100 mg/dL]) were 2.5-fold as likely to be readmitted than those not intoxicated (95% confidence limits, 1.6, 3.9). The relative risks for patients with positive SMAST scores and abnormal GGT values were 2.2 (95% confidence limits, 1.4, 3.5) and 3.5 (95% confidence limits, 2.2, 5.5), respectively. The increased risks remained significant for intoxication and abnormal GGT values after adjustment for gender, race, Medicaid status, and mechanism of injury. <h3>Conclusion.</h3> —Alcohol abuse is associated with an increased risk of readmission for new trauma. Trauma patients should be screened for alcohol problems; referral of problem drinkers for appropriate care may decrease their risk of admission for subsequent trauma. (<i>JAMA</i>. 1993;270:1962-1964)

Weight gain attitudes among pregnant adolescents

Maternal weight gain is the most important, manageable determinant of infant birth weight among adolescents. Negative attitudes toward weight gain may adversely affect maternal weight gain. We hypothesized that (a) negative attitudes toward pregnancy weight gain are more common among younger pregnant adolescents, and (b) negative attitudes toward pregnancy weight gain adversely affect adolescent maternal weight gain. The study subjects, 99, radially diverse, pregnant 13 through 18 year olds, completed the 18-item, Likert-format, Pregnancy and Weight Gain Attitude Scale. Responses to the questionnaire indicated that most (83.8%) of the adolescents we interviewed had a positive attitude toward pregnancy weight gain when they entered prenatal care. Univariate analyses revealed that attitudes toward weight gain were unrelated to the respondents' ages but inversely related to their prepregnant weights (-0.16; p = 0.06) and the severity of their symptoms of depression (r = -0.26; p = 0.004). Attitudes toward weight gain were also directly related to their family support (r = 0.17; p = 0.06). Weight gain was significantly related to 4 of the 18 scale items but not to the total attitude scale score. We conclude that (a) the developmental task of formulating a positive body image does not foster more negative attitudes toward pregnancy weight gain among younger adolescents; (b) negative weight gain attitudes are most common among heavier adolescents, depressed adolescents, and adolescents who do not perceive their families as supportive; and (c) negative weight gain attitudes could adversely affect pregnancy weight gain.

Follow-up of the Use of Local Health Department Clinics for Preventive Care Among Young Children

We followed 18,490 infants from their first visit to a county child health clinic (CHC) in Maryland through visits through their third year of age to investigate whether their continued use of the CHCs was related to their characteristics or to the services they were provided as an infant. We classified as provided services immunization, an Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT) recommended screening, and number of visits. Immunization was associated with an increased percentage of infants who returned to the CHCs at two and three years of age. Half of the children, on the other hand, never returned to the clinics if they were not immunized as infants. These findings persisted, regardless of race, Medicaid status, completion of a screening, or number of visits in the first year of life. One-fifth of infants did not receive an immunization during one or more visits to CHCs in their first year. Failure to administer an immunization to infants appears to impede subsequent use of public health clinics for well child care.

Predictors of the placement of cognitively impaired residents on special care units.

Nursing homes that have both special care units (SCUs) and traditional units were examined to determine the factors that cause homes to place cognitively impaired residents on the specialized units. Wandering, other problem behaviors, and Medicaid status were not significant predictors of placement. Logistic regression results indicated that functional status was the critical placement factor.

Medicaid maternal and child health care: Prepaid plans vs. private fee‐for‐service

A randomly selected sample of 98 inner-city new mothers was interviewed with regard to (a) their level of satisfaction with and perceived barriers to pediatric and maternal health care, and (b) the health status of their infants. The mothers were divided according to their Medicaid status: 39 (40%) were enrolled into a Medicaid prepaid plan (PPP) and 59 (60%) were enrolled as regular Medicaid fee-for-service (FFS) patients. Comparison of the two groups showed that infant health status was similar but that PPP mothers reported a higher incidence of untreated infant problems and perceived more barriers to pediatric care. Birth outcomes also were similar for the two groups but FFS mothers and infants were hospitalized for significantly longer periods postpartum. The implications of these findings for the delivery of maternal and child health services to low-income populations through the Medicaid program are discussed.

Effect of Clinical Pharmacy Services on the Quality of Family Practice Physician Prescribing and Medication Costs

This study assessed the impact of physician exposure to clinical pharmacy services on the appropriateness of physician prescribing and on medication costs. Two study sites were used: FPC (primary resident training office without clinical pharmacist) and PMC (satellite office with clinical pharmacist). The same physicians provided care at both study sites. Exposed patient encounters were selected from encounters during each resident's rotation at the PMC satellite. Unexposed patient encounters were selected from encounters at the FPC immediately prior to each resident's exposure to clinical pharmacy services. A blind review panel evaluated case abstracts of the patient encounters for appropriateness of drug choice, daily dosage, dosing interval, duration of treatment, clarity of instructions, and monitoring data; potential severity of the patient problem; and difficulty of the clinical decision. After adjusting for covariables (potential severity, difficulty, patient age, sex, Medicaid status, therapeutic category, and type of medical problem), physician-patient encounters in which family practice residents were exposed to clinical pharmacy services were rated significantly more appropriate for choice of drug prescribed, daily dosage chosen, dosing interval selected, clarity of prescription instructions, and monitoring data. Costs of acute medications, as measured by average wholesale price per day, per dose, and per treatment course, were also significantly lower for clinical pharmacy-exposed physician-patient encounters.