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PEDIATRICS Vol. 108 No. 1 July 2001, pp. 103-110
, and
From the Divisions of * Emergency Medicine and Objective. Many urban children rely
on emergency departments (ED) for ambulatory care. The objective of
this study was to determine whether enrollment in Medicaid managed care
(MMC) alters ED or other ambulatory care compared with fee-for-service
Medicaid (FFSM).
Methods. A prospective cohort study of infants born
between May 1994 and April 1995 with a 6-month follow-up period was
conducted in an urban, teaching hospital and surrounding ambulatory
settings. A consecutive sample of 644 infants enrolled in MMC or FFSM
was studied; 92% of eligible patients were enrolled, and 94%
completed follow-up. The main outcome measures were 1) proportion of
patients in each group visiting an ED, primary care practitioner (PCP), or specialist; 2) mean number of visits per group; and 3) ED reliance (EDR) defined as the proportion of all ambulatory visits occurring in
an ED.
Results. Fifty-six percent of MMC and 54% of FFSM
patients visited an ED (relative risk: 1.03; 95% confidence interval
[CI]: 0.83, 1.27). More MMC patients had a sick visit to their PCP
(relative risk: 1.34; 95% CI: 1.03, 1.74); no difference in proportion
with well-child or specialty visits was found. Although the mean number of total ambulatory, ED, and specialty visits was the same, MMC patients had fewer well-child and more sick visits to the PCP than FFSM
patients (P = .01). EDR was 21% for both groups
(P = .95). After adjustment for other factors in
multivariate analysis, insurance status remained unassociated with EDR
(adjusted odds ratio [OR]: 0.91; 95% CI: 0.56, 1.69). Factors
associated with EDR included United States-born mother (OR: 5.34; 95%
CI: 1.61, 17.68) and use of a hospital-based primary care physician
(OR: 2.00; 95% CI: 1.34, 2.98). Variables that characterized infants who were less likely to be ED reliant included adequate maternal prenatal care (OR: 0.52; 95% CI: 0.34, 0.78) and having a mother who
completed high school (OR: 0.67; 95% CI: 0.45, 0.99).
Conclusions. Enrollment in MMC did not alter ED usage
patterns when compared with FFSM. Some variation in use of other
ambulatory services was detected.
Adolescent
Medicine, The Children's Hospital of Philadelphia, and § Department of
Biostatistics and Epidemiology, University of Pennsylvania School of
Medicine, Philadelphia, Pennsylvania; and Department of Pediatrics,
Yale University School of Medicine, New Haven, CT.
ABSTRACT
Top
Abstract
Methods
Results
Discussion
References
Regular and frequent use of emergency departments (EDs) has
been criticized because of its role in decreasing continuity of primary
care and increasing health care costs.1,2 However, ED use
remains common. Estimates from the 1996 National Ambulatory Medical
Care Survey show that children incurred nearly 21 million ED visits and
that 12% of all pediatric ambulatory visits occurred in an
ED.3 Multiple factors, including Medicaid insurance and
younger patient age, have been associated with increased use of EDs by
children.14-8
Managed health care was designed to improve access to primary care,
reduce excess ED use, and limit costs. States increasingly are turning
to managed care arrangements for financing and delivering health
services to Medicaid beneficiaries. The proportion of Medicaid beneficiaries enrolled in managed care increased from 10% in 1991 to
40% in 1996.9 Children are being enrolled in managed care
plans at a higher rate than adults and now represent a
disproportionately larger share of all managed care members in both
Medicaid and commercial sectors.10 This rapid trend has
occurred primarily without conclusive evidence about the impact of
these arrangements on use of child health care services, including ED use.
Several studies of Medicaid-enrolled patients performed shortly after
initiation of the Medicaid Competition Demonstrations in the mid-1980s
revealed 30% to 40% decreases in ED use after implementation of
Medicaid managed care (MMC).11-15 These and other studies
also demonstrated decreases or no change in primary care, sick care, or
specialty visits when comparing MMC with fee-for-service Medicaid
(FFSM).14-19 This research was performed when managed
care arrangements and market forces were different from what they are
today. Issues that may have influenced the results of these studies
include methods of outcomes data collection, mode of enrollment for
patients and physicians participating in MMC plans, and methods of
capitation. Many of these factors may have biased toward decreased
health care use in MMC patients in this previous research. Several of these studies were limited to adults,11,12,16 and none
examined a newborn population. Because the best predictor of one's
future health care use is one's current use,20 investigating newborn populations may provide important information on
subsequent child health care usage patterns.
We followed a cohort of Medicaid-enrolled infants for the first 6 months of life to determine whether enrollment in mandated MMC altered
ED usage patterns and other health care use when compared with infants
who were receiving mandated FFSM. We hypothesized that enrollment in an
MMC plan would decrease ED use and increase ambulatory visits to
primary care practitioners (PCP). In addition, this study assessed
other factors that influenced ED use.
Study Design and Participants
We performed a prospective cohort study of a consecutive sample
of infants who were born between May 1994 and April 1995, at an urban,
tertiary care center that provides primary obstetric care. Eligible
newborns included those who were enrolled in FFSM or managed care
Medicaid and had a birth weight of Five Medicaid managed health care plans provided insurance to study
enrollees from 1994 to 1997. Two plans composed 82% of managed care
plans used by study participants. Physicians who provided primary care
to MMC patients during this time period acted as case managers and were
capitated for primary care in all of the 5 MMC plans. However,
practitioners were not capitated for ED use or at risk for over
utilization of care, and there were no financial incentives for
improved performance. Patients had no required copays.
Measurement of Exposures
Information regarding insurance status was obtained via maternal
postpartum interview, medical record review, and consultation with the
maternity ward social worker. Mothers were asked to show their Medicaid
insurance card to study investigators at the time of enrollment. Other
infant, maternal, and health care variables also were obtained from
these sources. Three trained research nurses performed daily patient
enrollment and administered the postpartum survey. A research assistant
made telephone calls to study families twice during the 6-month
follow-up period to verify residence, insurance status, and PCP.
Socioeconomic status indicators included cash assistance eligibility by
self-report (individual level) and census tract data (neighborhood
level)22 on median income and percentage below the poverty
level for families with children. Adequate prenatal care was defined as
initiation of care in the first trimester of pregnancy with 8 or more
visits for a newborn at 34 to 35 weeks' gestation, and 9 or more
prenatal visits for a newborn at Outcomes
Outcomes were assessed 6 months after enrollment. Patients' ED
use included 1) proportion of patients in the MMC and FFSM groups who
incurred an ED visit, 2) mean number of visits for those with at least
1 visit, 3) age at first ED visit, and 4) ED reliance (EDR). EDR was
defined as the proportion of all ambulatory visits that occurred in an
ED.11 It was calculated as total number of ED visits
divided by all ambulatory visits (all ED visits + all well-child visits + all ambulatory sick visits outside the ED). Other ambulatory care
measurements included age at first well-child visit, proportion of
patients in the MMC and FFSM groups with a well-child visit, sick visit
to the PCP, and specialty visit, as well as mean number of well-child,
sick, specialty, and total ambulatory visits.
As there is no widely accepted definition of what constitutes an
appropriate ED visit and with increasing emphasis on providing each
child with a medical home,24 using EDR as an outcome measure is meaningful. In this study, high EDR was defined a priori as
an EDR A trained research assistant, who did not perform patient enrollment
and who was blinded to the main study hypothesis, obtained outcome data
by reviewing ED census reports and hospital, ED, and PCP records that
occurred within and outside of the principal hospital research site or
the main PCP's office. To ensure completeness of outcome data, parents
were asked during a telephone call at the end of the 6-month follow-up
period to recall all locations where an ambulatory visit took place for
their child.
Data Analysis
Estimating that 40% to 50% of infants enrolled in FFSM would
visit an ED in the first 6 months of life, we calculated a recruitment goal of ~650 patients for 80% power to detect a 35% relative
reduction in ED use by the MMC group.
For comparing 2 groups, differences for continuous variables were
assessed by t tests or by the Mann-Whitney statistic if normality could not be assumed. The Kruskal-Wallis test was used for
comparing the medians of 3 groups. Multiple logistic regression was used to explore the relationship
between the exposure variables and EDR. Initially, unadjusted odds
ratios (ORs) were used to assess the relationship between each
independent variable and EDR (EDR <33% and EDR The institutional review boards of the participating hospitals and the
Department of Public Health approved this study. Written, informed
consent was obtained from the parents of all participants.
Cohort Characteristics
Ninety-two percent of 644 eligible infants were enrolled in the
study. Sixteen percent of patients were enrolled in FFSM, and 84% were
enrolled in MMC. Six-month ambulatory care follow-up was completed on
94% of enrolled patients (Fig 1). There were no differences between patients who completed follow-up and those
who were not enrolled or were lost to follow-up with regard to type of
Medicaid, zip code of residence, gestational age, birth weight, race,
or maternal age. Two patients died during the follow-up period, 5 declined additional study participation, and the remainder were lost as
a result of the inability to contact this highly mobile population.
METHODS
Top
Abstract
Methods
Results
Discussion
References
2 kg and gestational age of 34
weeks. Newborns who were not discharged from the nursery within 10 days
of birth were excluded, as were families in which no one in the home
spoke English. In addition, mothers and their infants had to reside in
1 of 6 nearby zip codes. Previous research had shown that >80% of
pediatric emergency care is sought at our hospital by children who live
in these zip codes.21 During the study period, patients in
3 of these zip codes had mandated enrollment in MMC, and patients in
the remaining zip codes received FFSM health insurance. At the time of
the study, this system of geographically determined mandated managed
care had been in place for 8 years.
36 weeks' gestation.23
Characteristics of primary care offices and other health care-related
variables were obtained by a survey mailed to PCP offices of
participating study patients.
33% by the investigators and an expert panel of
pediatricians. American Academy of Pediatrics standards of care provide
that infants have 4 or 5 interactions with their PCP by 6 months of age.25 Two or more ED visits during this time period would
render the patient highly ED reliant, provided that he or she complied
with the routine recommended ambulatory care (2 ED visits/4 ambulatory + 2 ED visits = EDR 33%). One ED visit in 6 months is believed to
be reasonable in an urban low-income area, where accessibility to
primary care often is not optimal (1 ED visit/4 ambulatory + 1 ED
visit = EDR 20%).26-29
2 tests and
relative risk (RR) with 95% confidence intervals (CIs) were determined
for dichotomous exposure and outcome variables. Fisher's exact test
was used when an expected cell value was <5. All statistical tests
were 2-tailed with a 5% level of significance.
33%).
Variables with a P value <0.2 were chosen for inclusion as
potential predictors in a stepwise logistic regression analysis. The
risk of developing the outcome, adjusting simultaneously for all other
predictors included in the logistic regression model, is presented as
adjusted ORs with 95% CIs.
RESULTS
Top
Abstract
Methods
Results
Discussion
References
View larger version (19K):
[in a new window]
Fig. 1.
Patient participation summary.
Infant, maternal, and health care characteristics are compared for the MMC and FFSM groups in Tables 1 through 3. Both groups were very similar with respect to most characteristics studied. Other socioeconomic status indicators were collected by analysis of Philadelphia census tract data combined for eligible zip codes. Median income for families with children ranged from $19 724 to $31 286. The percentage of families with children living below the poverty level ranged from 17% to 51% with a mean of 31% and a standard deviation of 12.
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Ninety-eight percent (46 of 47) of PCP offices responded to a mailed survey about office attributes. These offices provided a mean of 37.2 (±8.6) hours of weekday daytime office hours, 2.6 (±3.8) hours of weekday evening hours, and 1.6 (±2.4) hours of weekend office hours each week. All offices reported availability for seeing sick patients during office hours, and 43% stated that there was no limit on the number of sick visits that they could accommodate. Furthermore, all offices provided telephone advice during regular office hours. There were no differences between these office attributes for patients with MMC and FFSM.
ED Use
There was no difference between the MMC and FFSM groups in ED use. Fifty-six percent (N = 260) of MMC patients and 54% (N = 46) of FFSM patients visited an ED at least once during the 6-month study period (RR: 1.03; 95% CI: 0.83, 1.27). Of the 306 patients who visited an ED during the follow-up period, there were no differences in the number of visits per patient according to insurance type: FFSM and MMC groups had means of 2.5 (±2.3) and 2.3 (±2.0) ED visits per patient, respectively (P = .69). These patients incurred a total of 689 visits, with a median of 2 visits and a range of 1 to 13 visits per patient.
There were no differences between ED visits by FFSM or MMC patients with regard to diagnoses or other measures of visit appropriateness. Fifty-two percent of all study patient visits were categorized by experienced pediatric triage nurses as nonurgent, compared with an overall 46% nonurgent triage category for all ED visits. Admission rates for study patients after ED visits were 12%, compared with an overall ED admission rate of 15%. Thirty percent of patients had laboratory studies, and 23% had radiographs obtained. Thirty-eight percent of all study ED visits occurred between 8 AM and 4 PM, when most PCP offices were open. Five diagnostic categories composed 52% of the 689 ED visits. These included upper-respiratory infection (19%), fever (12%), bronchiolitis (11%), gastroenteritis without dehydration (5%), and localized rash (5%). There were no statistically significant differences between MMC and FFSM for any of these comparisons.
In addition, age at first ED visit was similar for the 2 groups. FFSM patients presented to the ED for their first visit at a mean age of 63 (±49) days and the MMC patients at a mean of 61 (±51) days (P = .63). Finally, EDR did not differ between the 2 groups. Mean EDR for the MMC group was 21% (±24), and the mean EDR for the FFSM group was 21% (±25) (P = .95).
Other Ambulatory Care Use
The proportion of patients in the MMC and FFSM groups that used various types of ambulatory services is shown in Fig 2A. Although there were no other differences, MMC patients (57%) were more likely to have a sick visit with their PCP than the FFSM group (42%) (RR: 1.34; 95% CI: 1.03, 1.74). The number of ambulatory visits by Medicaid insurance type is displayed in Fig 2B. The number of ED visits, specialty visits, and total ambulatory visits was virtually identical for the FFSM and MMC groups. Interestingly, there were statistically significant (albeit not clinically significant) differences in the number of well-child and sick visits that occurred at the PCP for the 2 groups.
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There was borderline significance with regard to initiation of well-child care by type of Medicaid insurance. FFSM patients first visited their PCP for a well-child visit at 28 (±22) days compared with 36 (±35) days for the MMC group (P = .06). On average, FFSM patients were seen by their PCP 36 days before an ED visit, and MMC patients were seen 23 days before an ED visit. For both groups, the first well-child visit occurred significantly before the first ED visit (P = .001). There was no difference in the time interval between first well-child visit and first ED visit by Medicaid insurance type (P = .12).
Although there was little influence on use of ambulatory services by type of Medicaid insurance, site of primary care was associated with significant variations in outpatient visits (Fig 3A). Other than sick visits to the PCP, all other types of ambulatory visits studied were statistically different between sites of primary care, with a trend toward higher use by the hospital-based clinic population. This increased use of ambulatory services by the hospital-based clinic patients is confirmed in Fig 3B. Hospital-based clinic patients have more total ambulatory, ED, and specialty visits than their community clinic or private office counterparts. Although patients who attend a private office have fewer well-child visits, they also are seen by their PCP more often and the ED less often for sick care.
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Factors Associated With EDR
Seven independent variables were identified as being associated
with EDR 33%. These included male gender (P = .16), teenage mother (P = .03), USA-born mother
(P = .0008), inadequate maternal prenatal care
(P = .002), mother had not completed high school (P = .005), receiving cash assistance
(P = .13), and hospital-based primary care
(P = .0009). Type of Medicaid insurance was not
associated with EDR 33% (P = .85).
After adjustment for these infant, maternal, and health care variables
in multivariate analysis, insurance status remained unassociated with
EDR 33% (adjusted OR: 0.91; 95% CI: 0.56, 1.69). Multivariate
analysis revealed several factors associated with EDR, including having
a USA-born mother and using a hospital-based PCP. Variables that
characterized infants who were less likely to be ED reliant included
having a mother with adequate maternal prenatal care and who completed
high school (Table 4).
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DISCUSSION |
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Top
Abstract
Methods
Results
Discussion
References
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Enrollment in MMC did not alter ED usage patterns when compared with FFSM patients in this study population. Multiple measures of ED use were virtually identical for the MMC and FFSM patients. With regard to other ambulatory service use, MMC patients were more likely to be seen at the PCP for a sick visit and to incur more PCP sick visits than FFSM patients. Conversely, FFSM patients had more well-child encounters with their PCPs, and these visits began at a younger age. These findings may be related to forces from primary care capitation. In a setting in which MMC had been well established at the onset of the study and the study groups were very similar with regard to need for ambulatory care, few differences in ambulatory care-seeking behavior between insurance types were found.
Our study population reflects those at highest risk for significant reliance on the ED for ambulatory care and, thus, those most able to benefit from managed care via a close link with a PCP. Twenty-one percent of our infants' ambulatory visits occurred in an ED as compared with the 1996 national estimate of 12% for all children.3 The 1987 National Medical Expenditure Survey revealed that ED use was associated with Medicaid, black race, age <2 years, and attending a hospital-based primary care site.4 In addition, the 1988 National Health Interview Survey on Child Health found that ED use was associated with black race, poverty, single maternal marital status, less formal maternal education, urban residence, and community-based primary care.1 Other studies have confirmed the association of increased ED use with Medicaid insurance,5,6 younger maternal age,7 single maternal marital status,8 and younger patient age.5 The association of several of these variables with ED use was confirmed in our study.
Studies of MMC published to date have demonstrated between 27% and 40% decreases in the use of the ED, decreases in specialty visits, and varying effects on use of primary care.11-19 As stated previously, issues that may have influenced the results of these studies include methods of outcomes data collection, mode of enrollment for patients and physicians who participated in the plans, and methods of capitation.
Two studies of adult populations that demonstrated decreased ED use with MMC used patient recall alone to determine ED usage patterns.11,12 One more recent adult study that used patient recall during a survey found no difference in ED or physician office use.16 Reliance solely on patient recall as a source of outcomes may result in inaccurate and incomplete information for both MMC and FFSM patients. Additional studies, which included pediatric patients, used Medicaid claims data.13-18 Concern exists regarding the completeness of claims data, particularly in a capitated environment. Office staff may be less motivated to file a claim when they receive a single fee for all ambulatory care provided. This may result in an underreporting of ambulatory visits for patients who receive MMC. One study of children was unable to differentiate ED from other ambulatory services as a result of using Medicaid claims data.15 Actual medical record review, although more time consuming and costly, provides a more complete assessment of ambulatory service patterns.
Although some studies enrolled patients in MMC in a mandatory13 or randomized15 manner, the only study that involved children exclusively used voluntary enrollment of patients and physicians.14 This study demonstrated a 38% decrease in ED use and an 8% decrease in ambulatory visits to non-PCP physicians, whereas primary care visits to the PCP remained constant. Physicians who elect to participate in a new MMC program are likely to be very motivated gatekeepers. Studies that evaluated voluntary enrollment into MMC found that children who choose to enroll in health maintenance organizations have lower baseline costs.15,17,30 This again may bias toward a decreased use of all ambulatory services in the MMC population. As our patients were mandated into FFSM and MMC by area of residence, voluntary enrollment forces did not influence our results.
Furthermore, the effect of managed care on access to ambulatory services may depend on the payment structure within the MMC program. Reduction in use of services is more likely to occur when physicians receive capitated payments for the services that they provide.18 In many previous studies, PCPs were at risk for ED as well as other ambulatory service use.11,12,14,15 Some received financial bonuses for unexpended funds at the end of the year.12,14 In our study area, PCPs were capitated for primary care visits for their managed care patients. This influence may be evident in the fact that MMC patients attended fewer well-child visits than their FFSM counterparts. PCPs did not risk-share in ED care and worked in a structure in which they were likely to treat FFSM, MMC, privately insured, and uninsured patients. Although this arrangement may address concerns that programs that treat only Medicaid patients may be more likely to reduce access to needed services, it also may reduce incentives for physicians to act as case managers.31 Conversely, the PCPs may use their gatekeeper position to channel more care directly to themselves, thereby reducing ED use for conditions that they can treat in their own offices. Although our patients used the ED similarly, MMC patients were statistically more likely to have a sick visit to their PCP.
Our study demonstrated no difference between MMC and FFSM patients with regard to ED use. Several factors besides the absence of capitation for ED visits and mandatory enrollment into managed care may contribute to these findings. First, many EDs are reluctant to deny care to a patient who presents to their facility. During the study period, PCPs were telephoned to approve all nonurgent ED visits by MMC patients. However, many PCPs may be reluctant to make absentee refusals of authorization when they have no chance to examine directly the patient in question.
Consequently, reduction in ED use and increased PCP use must come from 2 other more indirect sources. One of these is increased availability and accessibility of the PCP as an alternative to the ED. PCPs of our patients had extremely limited evening and weekend office hours. Data from Medicaid expansions in the early 1990s revealed that expanding office hours to evenings and weekends decreased ED use in a capitated health maintenance organization system.32 The second source is parent and patient education. Guidelines developed by the American Academy of Pediatrics suggest that on enrollment in a managed care plan, parents should be educated about how to obtain health care services and incentives should be structured to reward those who comply with the rules of a given managed care organization.33
Strengths of this study included an excellent follow-up rate; mandatory, not self-selected, enrollment in MMC; and using medical record review as the source of outcome data. However, there also were several limitations. Many more MMC patients were enrolled in the study than FFSM patients. Although the enrolling hospital is located on the periphery of a mandated managed care zip code, it is geographically equidistant from MMC and FFSM areas of the city. We do not believe that there was selection bias in that there were no significant differences in sociodemographic factors, patients refusing study participation, or patients lost to follow-up by type of Medicaid insurance. In addition, some may argue that the 6-month follow-up period was too brief. However, the first 6 months of life require the most frequent encounters with a PCP for preventive ambulatory care visits. Also influential in the decision regarding follow-up was the knowledge that this population is difficult to track. Although studying the influence of MMC in a community where it had been established for 8 years is a strength, it also may be viewed as a limitation. With time, PCPs may treat all of their patients similarly without regard to type of insurance. Confounding by zip code of residence could have occurred. However, zip code was not associated with ambulatory care use in our analyses. Finally, our study population was restricted to newborns from an urban teaching hospital, which limits our generalizability to other, similar health care settings.
Managed care has rapidly transformed our previous health care system on the basis of consumer choice of providers into a managed system in which consumer choice is limited, access to health care services is more tightly controlled, and financial risk is shared. The unique needs of children, particularly poor children who are enrolled in Medicaid, must be considered and researched as we develop further managed care models.
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ACKNOWLEDGMENTS |
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Grant support for this study was received from The Pew Charitable Trusts, The University of Pennsylvania Research Foundation, and Public Health Services Research Grant MDI-RR00040 from the National Institutes of Health (Clinical Research Center, University of Pennsylvania).
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FOOTNOTES |
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Received for publication Jun 15, 2000; accepted Oct 10, 2000.
Address correspondence to Evaline A. Alessandrini, MD, MSCE, Division of Emergency Medicine, The Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104.
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ABBREVIATIONS |
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ED, emergency department; MMC, Medicaid managed care; FFSM, fee-for-service Medicaid; PCP primary care practitioner; EDR, emergency department reliance; RR, relative risk; CI, confidence interval; OR, odds ratios.
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REFERENCES |
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Abstract
Methods
Results
Discussion
References
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1997. Available:
http://www.hcfa.gov/medicaid/mcdata97.htm1997. Available: http://www.hcfa.gov/medicaid/plantyp7.htmThis article has been cited by other articles:
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  E. Y. Friedlaender, D. M. Rubin, E. R. Alpern, D. S. Mandell, C. W. Christian, and E. A. Alessandrini Patterns of Health Care Use That May Identify Young Children Who Are at Risk for Maltreatment Pediatrics, December 1, 2005; 116(6): 1303 - 1308. [Abstract] [Full Text] [PDF]
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 I. Nathanson, G. Ramirez-Garnica, and S. A. Wiltrout Decreased Attendance at Cystic Fibrosis Centers by Children Covered by Managed Care Insurance Am J Public Health, November 1, 2005; 95(11): 1958 - 1963. [Abstract] [Full Text] [PDF]
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D. M. Rubin, E. A. Alessandrini, C. Feudtner, A. R. Localio, and T. Hadley Placement Changes and Emergency Department Visits in the First Year of Foster Care Pediatrics, September 1, 2004; 114(3): e354 - e360. [Abstract] [Full Text] [PDF]
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D. M. Rubin, E. A. Alessandrini, C. Feudtner, D. S. Mandell, A. R. Localio, and T. Hadley Placement Stability and Mental Health Costs for Children in Foster Care Pediatrics, May 1, 2004; 113(5): 1336 - 1341. [Abstract] [Full Text] [PDF]
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D. C. Brousseau, J. R. Meurer, M. L. Isenberg, E. M. Kuhn, and M. H. Gorelick Association Between Infant Continuity of Care and Pediatric Emergency Department Utilization Pediatrics, April 1, 2004; 113(4): 738 - 741. [Abstract] [Full Text] [PDF]
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W. G. Johnson and M. E. Rimsza The Effects of Access to Pediatric Care and Insurance Coverage on Emergency Department Utilization Pediatrics, March 1, 2004; 113(3): 483 - 487. [Abstract] [Full Text] [PDF]
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 K. J. Dombkowski, R. Stanley, and S. J. Clark Influence of Medicaid Managed Care Enrollment on Emergency Department Utilization by Children Arch Pediatr Adolesc Med, January 1, 2004; 158(1): 17 - 21. [Abstract] [Full Text] [PDF]
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U. R. Kotagal, P. J. Schoettker, H. D. Atherton, R. W. Hornung, D. Bush, W. J. Pomerantz, and C. J. Schubert Relationship Between Early Primary Care and Emergency Department Use in Early Infancy by the Medicaid Population Arch Pediatr Adolesc Med, July 1, 2002; 156(7): 710 - 716. [Abstract] [Full Text] [PDF]
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