Pediatric Medicaid Population Research Articles

Identifying Post-Acute Sequelae of SARS-CoV-2 Among Children in New York State Medicaid Managed Care.

Persons who contract COVID-19 are at risk of developing post-acute sequelae of SARS-CoV-2 (PASC). The objective of this study was to describe the incidence of PASC in a pediatric Medicaid population. Using a retrospective cohort of children enrolled in New York State Medicaid Managed Care we compared incident diagnoses between children with a positive laboratory test for SARS-CoV-2 in 2021 to children without a positive test in 2021 and children with a viral respiratory diagnosis in 2019. Logistic regression models estimated adjusted odds ratios using the Cohen's d statistic to assess the strength of associations. Most unadjusted incidence of clinical outcomes were less than 1% for all cohorts. Relative to the 2021 comparison cohort, significant increases among SARS-CoV-2 cases were observed in sequela of infectious disease conditions, general signs and symptoms, and pericarditis and pericardial disease and for the 2019 comparison, sequela of infectious disease conditions and suicidal ideation. However, associations were mostly determined to be weak or marginal. In this low socioeconomic status pediatric population, incidence of new clinical sequelae was low with mostly weak or marginal increases associated with SARS-CoV-2 infection. Though the incidence was low, some outcomes may be severe. Observed associations may have been impacted by pandemic behavior modification including social distancing policies.

Asthma medication use and health care utilization evolution during pandemic times.

Pediatric asthma care was significantly impacted by the Coronavirus Disease (COVID-19) pandemic, with significant decline in asthma health care utilization noted early in the pandemic. We compared Emergency Department (ED) utilization rates and prescription fill rates of controller and quick relief asthma medications between March and December 2020 versus 2021 in a county-specific pediatric Medicaid population to evaluate for changes later in the pandemic. Our data showed an increase in ED utilization by 46.7% (p-.0371) in the second year of the pandemic. There was no significant change in prescription fills for reliever medications (p-.1309) during this time with increased ED utilization for asthma but there was a significant decline in controller medication fills (p-.0039). This data suggests a potential explanation for resurgence of asthma health care utilization because of decreased controller medication fill and use during a time frame that also saw increased viral positivity rates. The poor medication adherence rates despite this increase in ED visits suggests that new interventions may be needed to assist patients with asthma medication adherence.

Impact of pharmacist alternative therapy interventions in a pediatric Medicaid population

Impact of pharmacist alternative therapy interventions in a pediatric Medicaid population

Interest in and Barriers to Telehealth Uptake in an Obstetric and Pediatric Medicaid Population.

Telehealth has been shown to be generally well accepted by patients and physicians with an increasing desire and utilization of this practice since the COVID-19 pandemic. However, studies looking specifically at the United States' low socioeconomic populations' interest in and barriers to accessing Telehealth care are limited. In this study, we performed a survey to determine the interest of pediatric and obstetric patients on and the reasons they may or may not choose Telehealth visits in a practice that serves solely California Medicaid (Medi-Cal) patients. A total of 636 patients completed the questionnaire, 383 (60%) from an obstetric practice and 253 (40%) from a pediatric practice. The majority expressed that they were not interested in Telehealth (N=407, 64%), and 228 (36%) stated interest. Interest in Telehealth was related to domains of cost, access, and attitude (P<0.005 for each) for the entire sample. The highest scores (preference toward Telehealth) were noted in the domainof enjoyment; thissuggests that both pediatric and obstetric patients may decline Telehealth in favor of in-person meetings simply because they like meeting with their provider. Despite readily available technology/access for Telehealth visits in low socioeconomic patients, in-person healthcare may be preferred by this patient population. In the world of changing healthcare delivery and epidemics, in-person visits are an important option for disadvantaged patients.

Utilization of West Virginia Pediatric Medicaid Claims Data to Guide Outpatient Antimicrobial Stewardship Interventions.

West Virginia consistently ranks in the top two nationally for per capita antibiotic prescription rates in both pediatric and adult outpatient populations. We present the first descriptive analysis evaluating outpatient prescription rates within the WV pediatric Medicaid population, which demonstrated significant antibiotic prescribing variability by provider type, specialty, and geography.

Positioning operations in the dental safety net to enhance value-based care delivery in an integrated health-care setting.

Impact of implementing data-driven performance metric-tracking across a 10-dental center infrastructure established by Family Heath Center of Marshfield (FHC-M) was examined for relative impact on achieving value-based care delivery in serving a patient population characterized by 88% Medicaid representation. To track progress toward national benchmarks for preventive care delivery, dental quality analytics dashboard tracking was implemented in real time with sharing of performance metrics across centers. Compliance rate with Uniform Data Systems reporting requirements for sealant placement on permanent first molars in children aged 6-9 years of age at moderate-to-high risk of caries was targeted at FHC-M dental centers for comparison with those of other community health centers statewide and nationally. Hygienist-to-dentist ratio to support robust sealant placement capacity was further examined. Uniform Data Systems data for rate of sealant placement between 2016-2018 revealed that FHC-M consistently exceeded rates reported statewide and nationally. For this quality indicator, performance across all dental practices in 27 states reported by Centers for Medicare and Medicaid Services in 2018 achieved 23% in 2017 compared to 73% and 52% placement rates reported by FHC-M and community health centers, respectively. A 1:1 hygienist-to-dentist was documented across FHC-M dental centers compared to 0.5:1 reported nationally. Implementation of quality metric dashboard and a 1:1 dentist-to-hygienist ratio supported realization of value-based dental care delivery relative to caries prevention in a moderate-to-high risk pediatric Medicaid population through achievement of robust sealant placement. Importance of adequate hygienist staffing, "same day" sealant placement and performance feedback supported by technology are highlighted.

Justification for Collecting Urgent Care Data to Broaden Syndromic Surveillance

Objective: Provide justification for the collection and reporting of urgent care (UC) data for public health syndromic surveillance.Introduction: While UC does not have a standard definition, it can generally be described as the delivery of ambulatory medical care outside of a hospital emergency department (ED) on a walk-in basis, without a scheduled appointment, available at extended hours, and providing an array of services comparable to typical primary care offices.1 UC facilities represent a growing sector of the United States healthcare industry, doubling in size between 2008 and 2011.1 The Urgent Care Association of America (UCAOA) estimates that UC facilities had 160 million patient encounters in 2013.2 This compares to 130.4 million patient encounters in EDs in 2013, as reported by the National Hospital Ambulatory Medical Care Survey.3 Public Health (PH) is actively working to broaden syndromic surveillance to include urgent care data as more individuals use these services.4 PH needs justification when reaching out to healthcare partners to get buy-in for collecting and reporting UC data.Description: The International Society for Disease Surveillance (ISDS) Community of Practice (CoP) platform was used to host a webinar introducing the topic of urgent care participation in syndromic surveillance. This webinar provided a valuable opportunity to obtain insight from jurisdictions pursuing and using UC data. A workgroup was formed to create documentation justifying the collection and reporting of UC data. Using this forum, the workgroup brought together partners from various jurisdictions working with UC data to participate in a literature review of SCOPUS, PubMed, and the Online Journal of Public Health Informatics publications and to share their experiences. These two main sources of information – previous literature and jurisdictional experience – were combined and condensed to provide tangible justifications for the collection and use of UC data.While the workgroup found little in the literature to justify the collection of UC data as a part of syndromic surveillance, the shared experiences of the CoP jurisdictions working to onboard UC facilities provided valuable insight. From this collaborative response, three main reasons to collect UC data were identified.1) Healthcare reform is directing patients away from EDs and toward UC facilities. UC represents reduced cost and more efficient patient processing, thus easing the burden on both patient and healthcare system (according to a 2016 American Academy of Pediatrics article entitled “Urgent Care and Emergency Department Visits in the Pediatric Medicaid Population”). If syndromic surveillance does not adapt to include UC data, the potential exists to lose significant patient populations, which may lead to decreased situational awareness.2) According to the Centers for Medicare and Medicaid Services Stage 3 guidance, Meaningful Use (MU) will change the relationship between eligible professionals (EPs) and syndromic surveillance by restricting EPs to those who practice in a UC facility. This approach to EP participation simplifies the syndromic surveillance MU objective, thereby making it easier for PH jurisdictions to onboard UC facilities.3) Patients with certain conditions that are acute but non-emergent may report more frequently to an UC facility than to an ED. Broadening syndromic surveillance to include UC facilities may increase reporting of “rare event” encounters, which will lower the relative standard error for statistical calculation. Surveillance efforts for conditions like influenza-like illness and Zika virus may improve substantially with a larger data pool.How the Moderator Intends to Engage the Audience in Discussions on the Topic: The moderator will begin discussion with a brief presentation from the literature review and jurisdictional experience, highlighting three justifications for collecting and reporting UC data. The audience will be divided into 3 groups to discuss and validate 3 additional topics: creation of syndromic surveillance talking points to share with UC facility management, creation of jurisdictional UC facility listings, and UC onboarding best practices. Feedback from the 3 groups will be shared with the whole group, followed by a brief summary of the discussion and recommendations for next steps.

Acute care revisits after adenotonsillectomy in a pediatric Medicaid population in Ohio

IntroductionGuidelines for inpatient admission after pediatric tonsillectomy have been proposed to improve the safety of this procedure. This study examined the association between performing adenotonsillectomy in an inpatient setting and acute care revisits within 30 days among children enrolled in a Medicaid Accountable Care Organization in Ohio. MethodsThe Accountable Care Organization's claims database was queried for adenotonsillectomies performed in children ages 0–18 years in 2008–2014. Procedures associated with an inpatient facility stay were classified as inpatient adenotonsillectomies. The primary outcome was emergency department visit or inpatient re-admission within 30 days. Secondary outcomes were revisits within 7 days and >7 days post-discharge. Logistic regression was used to test for association between inpatient procedure and need for revisits. ResultsAdenotonsillectomies in 8835 girls and 7773 boys (age 6.8 ± 3.8 years) were analyzed, of which 842 (5%) were inpatient procedures. Revisits were required in 2511 (15%) cases and were primarily visits to the emergency department. In multivariable analysis, inpatient and outpatient procedures had comparable need for 30-day revisits (OR = 0.85; 95% CI: 0.69, 1.05; p = 0.124). In sub-analyses, inpatient adenotonsillectomy was associated with lower odds of early (≤7 days post-discharge; OR = 0.76; 95% CI: 0.58, 0.99; p = 0.045) but not later (≥8 days) revisits. ConclusionsIn a pediatric Medicaid population, inpatient adenotonsillectomy was not associated with greater odds of acute care revisits, compared to outpatient procedures. Appropriate risk stratification of children undergoing adenotonsillectomy can reduce the need for early acute care revisits by scheduling high-risk patients for prolonged observation.

Effect of Attribution Length on the Use and Cost of Health Care for a Pediatric Medicaid Accountable Care Organization.

Little is known about the effect of pediatric accountable care organizations (ACOs) on the use and costs of health care resources, especially in a Medicaid population. To assess the association between the length of consistent primary care (length of attribution) as part of an ACO and the use and cost of health care resources in a pediatric Medicaid population. A retrospective study of Medicaid claims data for 28,794 unique pediatric patients covering 346,277 patient-attributed months within a single children's hospital. Data were collected for patients attributed from September 1, 2013, to May 31, 2015. The effect of the length of attribution within a single hospital system's ACO on the use and costs of health care resources were estimated using zero-inflated Poisson distribution regression models adjusted for patient characteristics, including chronic conditions and a measure of predicted patient use of resources. Receiving a plurality of primary care at an ACO clinic during the preceding 12 months (attribution to the ACO). The primary outcome measure was the length of attribution at an ACO clinic compared with subsequent inpatient hospitalization and subsequent use and cost of outpatient and ancillary health care resources. Among the 28,794 pediatric patients receiving treatment covering 346,277 patient-attributed months during the study period, continuous attribution to the ACO for more than 2 years was associated with a decrease (95% CI) of 40.6% (19.4%-61.8%) in inpatient days but an increase (95% CI) of 23.3% (2.04%-26.3%) in office visits, 5.8% (1.4%-10.2%) in emergency department visits, and 15.3% (12.5%-18.0%) in the use of pharmaceuticals. These changes in the use of health care resources combined resulted in a cost reduction of 15.7% (95% CI, 6.6%-24.8%). At the population level, the impact of consistent primary care was muted by the many patients in the ACO having shorter durations of participation. These findings suggest significant and durable reductions of inpatient use and cost of health care resources associated with longer attribution to the ACO, with attribution as a proxy for exposure to the ACO's consistent primary care. Consistent primary care among the pediatric Medicaid population is challenging, but these findings suggest substantial benefits if consistency can be improved.

Urgent Care and Emergency Department Visits in the Pediatric Medicaid Population

Urgent Care and Emergency Department Visits in the Pediatric Medicaid Population

Prevalence and characteristics of medication sharing behavior in a pediatric Medicaid population with asthma

Prevalence and characteristics of medication sharing behavior in a pediatric Medicaid population with asthma

Potential barriers associated with increased prevalence of perforated appendicitis in Colorado's pediatric Medicaid population

ObjectiveWe sought to identify barriers and delays in care associated with the increased prevalence of perforated appendicitis among Colorado's pediatric Medicaid population. MethodsWe conducted a retrospective cohort study of all cases of pediatric appendicitis, which had Colorado Medicaid from 2007 to 2008 using descriptive statistics, bivariate analysis, and multivariable logistic regression. ResultsOf the 479 appendicitis cases, 42.6% were perforated. In both the bivariate and multivariate analysis, perforated cases did not significantly differ from nonperforated cases with respect to sex, rurality of residence, or race with the exception of black race in the multivariate model. Perforated cases were more likely to be younger, have been enrolled in Medicaid for less than 6 months, have seen a provider within 5 days of their diagnosis, and have been transferred to another hospital for treatment. ConclusionsThe high prevalence of perforated appendicitis in Colorado children with Medicaid coverage is not associated with race or physical proximity to care but may be associated with the duration of Medicaid coverage, which highlights the importance of establishing medical homes to direct patients on where and how to seek care.

Association of daily asthma emergency department visits and hospital admissions with ambient air pollutants among the pediatric Medicaid population in Detroit: Time-series and time-stratified case-crossover analyses with threshold effects

BackgroundAsthma morbidity has been associated with ambient air pollutants in time-series and case-crossover studies. In such study designs, threshold effects of air pollutants on asthma outcomes have been relatively unexplored, which are of potential interest for exploring concentration–response relationships. MethodsThis study analyzes daily data on the asthma morbidity experienced by the pediatric Medicaid population (ages 2–18 years) of Detroit, Michigan and concentrations of pollutants fine particles (PM2.5), CO, NO2 and SO2 for the 2004–2006 period, using both time-series and case-crossover designs. We use a simple, testable and readily implementable profile likelihood-based approach to estimate threshold parameters in both designs. ResultsEvidence of significant increases in daily acute asthma events was found for SO2 and PM2.5, and a significant threshold effect was estimated for PM2.5 at 13 and 11μgm−3 using generalized additive models and conditional logistic regression models, respectively. Stronger effect sizes above the threshold were typically noted compared to standard linear relationship, e.g., in the time series analysis, an interquartile range increase (9.2μgm−3) in PM2.5 (5-day-moving average) had a risk ratio of 1.030 (95% CI: 1.001, 1.061) in the generalized additive models, and 1.066 (95% CI: 1.031, 1.102) in the threshold generalized additive models. The corresponding estimates for the case-crossover design were 1.039 (95% CI: 1.013, 1.066) in the conditional logistic regression, and 1.054 (95% CI: 1.023, 1.086) in the threshold conditional logistic regression. ConclusionThis study indicates that the associations of SO2 and PM2.5 concentrations with asthma emergency department visits and hospitalizations, as well as the estimated PM2.5 threshold were fairly consistent across time-series and case-crossover analyses, and suggests that effect estimates based on linear models (without thresholds) may underestimate the true risk.

Asthma exacerbation and proximity of residence to major roads: a population-based matched case-control study among the pediatric Medicaid population in Detroit, Michigan.

BackgroundThe relationship between asthma and traffic-related pollutants has received considerable attention. The use of individual-level exposure measures, such as residence location or proximity to emission sources, may avoid ecological biases.MethodThis study focused on the pediatric Medicaid population in Detroit, MI, a high-risk population for asthma-related events. A population-based matched case-control analysis was used to investigate associations between acute asthma outcomes and proximity of residence to major roads, including freeways. Asthma cases were identified as all children who made at least one asthma claim, including inpatient and emergency department visits, during the three-year study period, 2004-06. Individually matched controls were randomly selected from the rest of the Medicaid population on the basis of non-respiratory related illness. We used conditional logistic regression with distance as both categorical and continuous variables, and examined non-linear relationships with distance using polynomial splines. The conditional logistic regression models were then extended by considering multiple asthma states (based on the frequency of acute asthma outcomes) using polychotomous conditional logistic regression.ResultsAsthma events were associated with proximity to primary roads with an odds ratio of 0.97 (95% CI: 0.94, 0.99) for a 1 km increase in distance using conditional logistic regression, implying that asthma events are less likely as the distance between the residence and a primary road increases. Similar relationships and effect sizes were found using polychotomous conditional logistic regression. Another plausible exposure metric, a reduced form response surface model that represents atmospheric dispersion of pollutants from roads, was not associated under that exposure model.ConclusionsThere is moderately strong evidence of elevated risk of asthma close to major roads based on the results obtained in this population-based matched case-control study.

High asthma prevalence and increased morbidity among rural children in a Medicaid cohort

Urban children represent a group at high risk for asthma development and adverse asthma outcomes. Although rural children also encounter sociodemographic disparities that might be expected to worsen asthma, asthma in the rural United States is poorly studied. To determine rural-urban differences in childhood asthma diagnosis and morbidity. We studied a statewide population of 117,080 children continuously enrolled in Tennessee Medicaid from birth through the sixth year of life, using linked Tennessee Medicaid, vital records, and pharmacy claims databases to determine asthma diagnosis and residence. The cohort was 45% urban, 23% suburban, and 33% rural. Compared with urban children, rural children were more likely to be white, have a history of bronchiolitis, and have mothers who smoked. Eleven percent of urban, 12% of suburban, and 13% of rural children met study criteria for asthma diagnosis (adjusted odds ratio for rural children, 1.16; 95% confidence interval, 1.09-1.24; adjusted odds ratio for suburban children, 1.22; 95% confidence interval, 1.14-1.30; with urban as the referent; P < .001). Rural children had greater use of outpatient asthma care, whereas urban children had greater use of inhaled corticosteroids. Compared with urban children, rural children had fewer asthma emergency department visits but were hospitalized for asthma at similar rates and had similar use of asthma rescue medications. In this pediatric Medicaid population, rural children had increased asthma prevalence and similar asthma morbidity compared with urban children but differences in patterns of asthma care and resource use, suggesting that optimal interventions for asthma may differ in rural compared with urban populations.

Variation in Pediatric Asthma Quality Improvement Programs by Managed Care Plans

Although asthma quality improvement (QI) programs are common, little is known about the scope and content of QI initiatives in managed care arrangements. The authors conducted a cross-sectional survey of all managed care plans in Michigan serving the pediatric Medicaid population. Using semi-structured interviews, they assessed the comprehensiveness of the asthma QI program regarding provider, allied health professional, pharmacy, and member services. Although all QI initiatives included some type of physician-directed component and patient-directed components, only half included allied health professionals and one quarter included pharmacy-directed components. Interactive physician continuing medical education was associated with plans whose members were concentrated in only 1 or 2 counties. The authors noted wide variation in content, format, inclusion of incentives, inclusion of other health professionals, and outcome goals. The variation in QI approaches by each of the managed care organizations suggests that there is a dearth of information on appropriate and cost-effective methods to improve pediatric asthma quality at the plan level.

Surgical management of uncomplicated otitis media in a pediatric Medicaid population.

The objective of this study was to document the frequency and timing of otitis media-related visits, audiological consultations, and surgical interventions following a new episode of otitis media. A retrospective descriptive study was performed on a Medicaid administrative database that follows individual patients over time. The study included 14,453 children enrolled in Medicaid during 1991 and 1992 who were 30 months of age or younger and had a "new" episode of otitis media. Among 14,321 patients with an uncomplicated episode of otitis media, there were 10,443 with additional otitis media visits. Audiological testing was performed in 1,134 (10.9%). The testing occurred within 2 months of the onset of otitis media in 52.2% of the children and within 3 months in 66.6%. Physicians referred 400 children (3.8%) to an otolaryngologist; 299 (75%) underwent 1 or more surgical procedures. These surgical interventions included placement of ventilating tubes in 296 children, adenoidectomy in 34 children (all of whom also had placement of ventilating tubes), mastoidectomy in 2 children, and tympanoplasty in 1 child. The proportion of children who underwent surgical placement of ventilating tubes who had prior audiological testing was 174 of 296 (58.8%). The overall surgical rate for ventilating tubes was 2.9%. Among children who underwent surgery, the procedure occurred within 2 months of the onset of otitis media in 21.4% of children. Attempts to rationalize the management of otitis media in early childhood must deal with the difficulties in distinguishing among the otitis media conditions. The findings of this study suggest a need to know whether insertions of ventilating tubes within 3 months after a new episode of otitis media are related to unresponsive or recurrent infections.

Otitis media-related antibiotic prescribing patterns, outcomes, and expenditures in a pediatric medicaid population.

Treatment of otitis media is the most frequent reason for administering antibiotics to children in the United States. However, only limited data are available on medical effectiveness of antibiotic prescribing patterns for otitis media and their associated expenditures or the factors that influence antibiotic prescribing. The study population consisted of 131 169 children during 1991 and 157 065 children during 1992 who were </=13 years of age and enrolled in Colorado's fee-for-service Medicaid program. Among these children, 5127 (1991) and 7254 (1992) were enrolled in the cohort treated for a "new" episode of acute otitis media. An analysis using this cohort was performed to document the antibiotics used to treat a new episode of acute otitis media, factors influencing antibiotic selection, and the short-term outcomes of therapy. An analysis using the entire Medicaid population was performed to document the annual use of antibiotics for otitis, the associated antibiotic expenditures, and factors influencing antibiotic selection. In the cohort analysis, office-based physicians prescribed second- and third-generation cephalosporins more often than did physicians in other settings (17% vs 9.7% and 11.8%), whereas hospital clinics prescribed trimethoprim plus sulfamethoxazole more frequently than did office-based physicians (19.2% vs 7.1% and 10.9%). Family physicians prescribed second- and third-generation cephalosporins more often than did pediatricians (16.6% vs 12.3%) but trimethoprim plus sulfamethoxazole and erythromycin plus sulfisoxazole less often than did pediatricians (10.5% vs 17%). The average rate of prescribing a second course of antibiotics within 24 days after initial antibiotic treatment of a new acute otitis media episode was 11.6% when less expensive antibiotics (amoxicillin, trimethoprim plus sulfamethoxazole, or erythromycin plus sulfisoxazole) were prescribed, and 13.2% when more expensive antibiotics (cefaclor, amoxicillin plus clavulanate, or cefixime) were prescribed. The average adverse drug reaction rate was 5.9% when less expensive antibiotics were prescribed, compared with 6.1% when more expensive antibiotics were prescribed. In each of the two study years, amoxicillin accounted for almost half of the total antibiotic fills but only 9% to 10% of the expenditures. Low-cost antibiotics (amoxicillin, trimethoprim plus sulfamethoxazole, and erythromycin plus sulfisoxazole) were prescribed for 66% to 67% of the total fills and accounted for 21% of the total projected expenditures. More expensive antibiotics (cefaclor, cefixime, amoxicillin plus clavulanate) prescribed for 30% of the fills generated 76% to 77% of expenditures. Cefaclor, prescribed for 17% to 18% of the total fills, generated 43% to 45% of total antibiotic expenses. The findings of this study document a preference for amoxicillin as the initial antibiotic for a new episode of acute otitis media. Although there was a wide variation in the selection of antibiotics to treat otitis, the more expensive antibiotics were not associated with better outcomes. This wide variation has important financial implications because of differences in antibiotic costs. Changes in prescribing patterns among initially uncomplicated children that reduce the use of high-cost antibiotics could reduce expenditures substantially without compromising short-term outcomes.