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PEDIATRICS Vol. 108 No. 1 July 2001, pp. 90-97
From the Health Care Financing Administration, Baltimore,
Maryland.
Objective. Because research has not
confirmed a relationship between compliance with health supervision in
infancy and improved health outcomes, we examined the association
between adherence to prevailing guidelines for periodic health
supervision and adverse health outcome indicated by incidence of
avoidable hospitalizations.
Methods. This was a historic cohort study of 308 131
children enrolled in Medicaid at birth in California, Georgia, and
Michigan in 1990 using Medicaid records linked across 3 years. We used
avoidable hospitalizations as indicators of health in a survival
analysis. The analysis used variables that represented completeness and timeliness of well-child visits and immunizations using AAP guidelines for health supervision as the gold standard.
Results. When the children in this cohort were up-to-date
for age on their schedule of well-child visits, they were less likely
to have an avoidable hospitalization (race, illness, and level of poverty adjusted hazard ratios 0.52 [95% confidence interval (CI): 0.50-0.55] in California, 0.54 [95% CI: 0.50-0.55] in Georgia, and 0.7 [95% CI: 0.69-0.79] in Michigan). Among children who were not up-to-date with well-child visits, a sporadic preventive care visit
conferred a mild benefit. Immunizations and race/ethnicity had no
consistent relationship with incidence of avoidable hospitalizations.
Conclusions. A series of well-child visits maintained
during the first 2 years of life has a positive effect on health
outcomes as indicated by a decrease in avoidable hospitalizations among
poor and near-poor children, regardless of race, level of poverty, or
health status. National efforts to improve the quality of child health
services for young children should focus on increasing compliance with periodic preventive care for young children in addition to improving immunization levels.
ABSTRACT
Top
Abstract
Methods
Results
Discussion
References
The health of children as measured by infant mortality and
other measures such as potentially avoidable hospitalizations is improving for all, but it is not improving as quickly for the disadvantaged.1 Early health supervision, beginning at birth, purposely is frequent to accommodate the immunization schedule, monitor early development, and provide guidance for parents about what
should be done to maintain child health.2-6 Despite the
removal of financial barriers to ambulatory care, children who are
insured by Medicaid use fewer preventive services and more emergency
services and have higher hospitalization rates7-10. Medicaid-covered children are less likely to have a usual source of
care, to spend more days in bed, and to have more serious exacerbations of conditions, such as asthma, that are treatable in ambulatory care
settings.8,11,12 Recognizing this, pediatricians focus on
establishing a therapeutic partnership between the pediatrician and the
family to encourage continuity of care and to provide the family the
motivation to participate in the child's care.
The American Academy of Pediatrics (AAP) recommends frequent well-child
visits during the first 2 years of life.4 In response to
questions about the efficacy of this recommendation, the AAP issued a
public appeal for research on the effectiveness of preventive care in
1974.3 A quarter of a century later, with the exception of
immunizations, the clinical effectiveness of adherence to periodic
child care visits has not been demonstrated with
certainty.13,14 The purpose of this analysis was to
investigate the association of well-child visits and child health as
indicated by acute hospitalization for conditions that may be avoided
by having continuous access to health care. The Medicaid database
contains detailed records of hospitalizations and use of ambulatory
services on as many as half of the children born in some states. This
large database provided us with the opportunity to undertake a detailed
evaluation of well-child care of children enrolled in Medicaid during
their first 2 years of life.
Analytic Sample
Medicaid claims data come from states that use the Medicaid
Statistical Information System (MSIS). MSIS was begun in the late 1980s
in a few states and was the first data available to the Health Care
Financing Administration (HCFA) that contained information on Medicaid
beneficiaries' use of services. MSIS contains paid bills, is based on
a fiscal year, and is organized by the date the bill was paid. For each
year and state, HCFA creates a database from MSIS called the State
Medicaid Research Files (SMRF). The SMRF system is organized by
calendar year and by date of service use. The SMRF contains a number of
databases, including a file of outpatient visits and inpatient stays.
Each record in these files contains procedure and diagnostic codes for
each service for which there was a claim. An individual child may have
many records in a day, because one visit can generate >1 claim.
Another file summarizes the year's activity for each child and
contains monthly eligibility information (whether a child was enrolled in Medicaid fee-for-service or managed care or not enrolled), age,
race, and an annual sum of expenditures.
We drew a sample from the cohort of children who were born in 1990 and
enrolled in Medicaid in California, Georgia, and Michigan during their
first year of life. We then created a longitudinal analytic file from
the SMRF data, linking 1990 through 1992 SMRF outpatient and inpatient
claims records to the 1990 summary file to define use of services form
birth through 24 months of age. We decided on this study period because
the time of the most intense use of primary care services is during the
first 2 years of life, and after age 2, use of well-child services
becomes infrequent. The children in the cohort were censored at 24 months of age, on the date of disenrollment from the Medicaid program,
or enrollment in a prepaid managed care program. We excluded blind
children and children with other disabilities because of their very
small numbers, those who did not appear in the data until after age 1 month, and those who were enrolled in Medicaid managed care systems.
The last were excluded because the SMRF system contains only the dollar
amount of the monthly prepayment with no concomitant information on
individual services, limiting the usefulness of these records.
Well-Child Visits and Immunizations
In the SMRF system,
state-specifica and national
(Current Procedural Terminology [CPT]-4 and International
Classification of Diseases, Ninth Revision
[ICD-9]b) procedure codes
identify well-child visits; sick visits; and immunizations for
diphtheria, pertussis, and tetanus (DPT), poliovirus vaccine (OPV),
mumps, measles, rubella (MMR), and hemophilus influenzae type B
(HiB).15-17 Using these codes, we created an event-based
file that pinpointed each service at the child's age on the date that
the service was provided. When there were 2 well-child visits or 2 DPTs
recorded on the same date, we counted them as one. When a sick visit
and an immunization occurred on the same day, we counted the visit as a
sick visit and a well visit to account for opportunistic preventive
care.
The determination of the timeliness and number of well-child visits and
immunizations was based on the 1988 AAP recommendations for health
supervision.18 These were 6 well-child visits by 12 months
of (at ages 1, 2, 4, 6, 9, and 12 months) and another 3 visits evenly
distributed through the second year of life and 4 DPTs (3 at 2-month
intervals between 0 and 6 months of age and 1 at 15-18 months of age),
3 oral OPVs (2 between ages 0 and 6 months at least 2 months apart and
1 at 15-18 months of age), and 1 MMR and 1 HiB at 15-18 months of
age. To allow for variability in visit timing, we defined broader time
ranges for compliance on the basis of the above recommendations. Thus,
children were deemed up-to-date if they had well-child visits within
the following intervals: 1 visit by 3 months of age, 2 by 4 months of
age, 3 by 6 months of age, 4 by 8 months of age, 5 by 11 months of age, 6 by 14 months of age, 7 by 17 months of age, and 8 by 20 months of
age. When there were 2 or more well-child visits within a range, the
extra visits were not counted. The visits had to be timed appropriately. For example, if there was no visit by 3 months of age
but there were 2 visits by 4 months, then only one was counted. To be
up-to-date with immunizations, the children had to have 1 DPT by 4 months of age; 2 DPTs and 1 OPV by 6 months of age; 3 DPTs and 2 OPVs
by 12 months of age; and 4 DPTs, 3 OPVs, 1 MMR, and 1 HiB by 24 months
of age.
Avoidable Hospitalizations
We selected four common conditions that are amenable to
prevention or amelioration and that have been used by other researchers as indictors of access to ambulatory care.19 These
included hospitalizations with the following ICD-9 codes Statistical Analysis
The analyses required the creation of 2 samples. The first
consisted of children who appeared in the Medicaid files by age 1 month
and were enrolled continuously in fee-for-service Medicaid for 24 months thereafter. This sample provided descriptive statistics of
well-child services and sick visits. The second, larger, sample consisted of children who appeared in the Medicaid files by age 1 month
and who were enrolled continuously until they became disenrolled from
fee-for-service Medicaid, had an avoidable hospitalization, or were 24 months old. This sample was used to calculate hospitalization rates and
was the base sample for the survival analysis.
Survival Analysis
The analysis measured adherence with recommended well-child care
or immunizations for each child's first 2 years of life. To
accommodate the concepts of adequate numbers of visits and immunizations with timeliness, we created preventive-care variables that expressed the child's status at any time (t) between
age 1 month and the first avoidable hospitalization or, if the child did not have an avoidable hospitalization, the time when that each
child attained 24 months of age or was disenrolled from Medicaid. We
created a yes/no variable to indicate whether a child's well-child visits were up-to-date for age, meaning that the child had the correct
number and timing (using the liberalized well-child visit schedule
described previously) of well-child visits at time t. To
account for sporadic well-child visits among children who were not
up-to-date, we created another yes/no variable that measured timeliness
of the most recent visit, defined as a well-child visit that occurred
within 30 days of time t for children younger than 4 months,
60 days for ages 5 to 10 months, 90 days for ages 11 to 19 months, 120 days for 20 months, 150 days for 21 months, and 180 days if older than
22 months. A third yes/no variable that represented currency with
immunizations was defined as being up-to-date with the liberalized
immunization schedule cumulative described previously.
METHODS
Top
Abstract
Methods
Results
Discussion
References
acute
upper-respiratory infections: 460 (nasopharyngitis), 461 (acute
sinusitis), 462 (acute pharyngitis), 463 (acute tonsillitis), 464 (acute laryngitis and tracheitis), and 465 (other acute upper
respiratory infections); lower respiratory infection: 466 (acute
bronchitis and bronchiolitis), 481 (pneumococcal pneumonia), 482 (other
bacterial pneumonia), 483 (other microbial pneumonia), 485 (bronchopneumonia with unspecified organism), 486 (pneumonia with
unspecified organism); gastroenteritis and dehydration: 009 (ill-defined intestinal infection), 276.0 (hyperosmolality/hypernatremia), 276.1 (hyposmolality/hyponatremia), 276.5 (volume depletion), 558.9 (other nonspecific gastroenteritis), 775.5 (transitory neonatal electrolyte disturbance); and asthma and
chronic bronchitis: 491.21 (acute exacerbation of chronic obstructive
pulmonary disease), 491.9 (unspecified chronic bronchitis), 493 (asthma). We also selected any hospitalization for acute injury and
poisoning (ICD-9 521.1, 360.5-360.6, 376.6, 388.11, 800-994.9, 995.5-995.9, E800-E928.9, E950-E958.9, E960-E968.9, E980-E999, V71.4, V71.6 [excluding 855-859, 888-889, 898)] because
anticipatory guidance for injury prevention is a component of the
well-child visit. The injury codes exclude medical injuries.
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RESULTS |
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Top
Abstract
Methods
Results
Discussion
References
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There were 298 140 children in California, 52 223 children in Georgia, and 71 010 children in Michigan who were born in 1990 and enrolled in Medicaid sometime during their first year of life. We excluded from the California cohort 553 (0.2%) blind children or children with other disabilities, 17 (0.005%) with missing eligibility information, 3375 (1.1%) who initially were enrolled in prepaid managed care plans, and 88 356 (29.6%) for whom there was no evidence of fee-for-service Medicaid enrollment during the first 30 days of life. We excluded from the Georgia cohort 264 (0.5%) blind children or children with other disabilities and 8255 (15.8%) children for whom there was no evidence of fee-for-service Medicaid enrollment during the first 30 days of life. From Michigan, we excluded 84 (0.1%) blind children or children with other disabilities, 87 (0.1%) with missing eligibility information, 5287 (7.5%) who initially were enrolled in prepaid managed care plans, and 6964 (9.8%) for whom there was no evidence of fee-for-service Medicaid enrollment during the first 30 days of life. The final sample size was 205 839 children from California, 43 704 from Georgia, and 58 588 from Michigan, which was 69.0%, 83.7%, and 82.5%, respectively, of the original state samples. Those not selected for the analysis because they were enrolled in Medicaid after age 1 month did not differ from those selected by gender or race. However, the children in California and Georgia who were not selected for the analysis were more likely to be from the poorest group, the AFDC-eligible families (data not shown).
The major ethnic group among the California children was Hispanic (53%), among the Georgia children was black (57%), and among the Michigan children was white (58%; Table 1). Eligibility categories varied on the basis of each state's policies. For example, in Georgia, 71% of the children qualified for Medicaid under expansions to cover near-poor children compared with California (52%) and Michigan (34%). Compared with the baseline 1-month enrollment group, the children who stayed enrolled for 2 years were more likely to be black and from the poorest eligibility category.
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Table 2 gives rates of well-child visits, immunizations, and sick visits among the children who remained in the cohort for 2 years. Although the rates differed among the states, substantial numbers of children had 1 or fewer well-child visits (30% in California, 51% in Georgia, and 35% in Michigan). Similarly, few children had all of their DPTs by age 2 (15% in California, 21% in Georgia, and 10% in Michigan) or their OPV (22% in California, 28% in Georgia, and 16% in Michigan). The majority of children had frequent (7 or more) sick visits in all three states. There was almost no variation by race or ethnicity in rate of well-child visits or immunizations. In Michigan, black children made fewer well-child visits than did white children.
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The Kaplan-Meier estimate for avoidable hospitalization for the entire sample was 117/1000 children in the 3 states combined, 12.8/1000 with acute upper-respiratory infections, 48.1/1000 with acute bronchitis or pneumonia, 14.0/1000 with gastroenteritis or dehydration, and 28.3/1000 with an injury. The distribution of avoidable hospitalizations by diagnostic group did not vary substantially among the 3 states (data not shown). Georgia had the highest rate of avoidable hospitalizations (160.9/1000 children), followed by Michigan (120/1000) and California (70/1000). Boys had higher avoidable hospitalization rates than did girls (Table 3). In California and Michigan, black children had the highest rates of avoidable hospitalizations, but in Georgia, white children had higher rates. The AFDC group, the poorest category of children, had higher rates of avoidable hospitalizations overall.
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The survival analysis indicated that being up-to-date for age with the AAP's recommended number of well-child visits was associated with a statistically significant reduction in risk of avoidable hospitalizations. In California, children who were up-to-date with their well-child visits had a 48% lower likelihood of experiencing an avoidable hospitalization (hazard ratio [HR]: 0.52; 95% confidence interval [CI]: 0.50-0.55), after controlling for proxies for illnesses, gender, race/ethnicity, Medicaid eligibility category, and local medical resources and poverty (Table 4). This finding was similar for the Georgia children (HR: 0.54; 95% CI: 0.50-0.58). In Michigan, the hazard ratio was higher (HR: 0.74; 95% CI: 0.69-0.79) but still statistically significant. A recent well-child visit among the children who were not up-to-date for age was associated with having fewer avoidable hospitalizations but not as strongly as being up-to-date (HR: 0.87; 95% CI: 0.82-0.92 in California; HR: 0.90; 95% CI: 0.83-0.97 in Georgia; and HR: 0.86; 95% CI: 0.78-0.94 in Michigan). Being up-to-date with immunizations was associated with fewer avoidable hospitalizations only in Michigan.
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In the 3 states, the variables that represented health, male gender, and Medicaid eligibility (level of poverty indicator) were related to hospitalization (Table 4). In California and Michigan, black children were more likely to experience an avoidable hospitalization but were less likely in Georgia than whites. These associations were not as strong as the association with well-child visits or indicators of illness, suggesting a minor role for race; other risk factors held constant. Finally, having more pediatricians per 10 000 population was associated with fewer avoidable hospitalizations in Georgia (HR: 0.74; 95% CI: 0.72-0.76) and Michigan (HR: 0.92; 95% CI: 0.87-0.96).
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DISCUSSION |
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Top
Abstract
Methods
Results
Discussion
References
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This analysis revealed a statistically significant association between adherence to the periodic well-child visit schedule during the first 2 years of life and fewer potentially avoidable hospitalizations among a birth cohort of Medicaid-enrolled children in 3 states with large numbers of Medicaid-enrolled newborns. The association was present regardless of race or ethnicity, level of illness, gender, level of poverty, or local resources. Our results help substantiate conventional wisdom that has fueled efforts to ensure that poor children receive early periodic preventive care. The results of this research are consistent with findings from 2 other studies. A mid-1960s experiment that offered primary care to a group of poor families found that free comprehensive services increased physician use and reduced hospitalizations, and an evaluation of a Medicaid managed care program in Maryland found that the number of primary care visits was inversely associated with avoidable hospitalizations.14,25 Neither of these studies examined specifically the concept of adherence to guidelines for pediatric care.
Evaluation of Medicaid expansions has shown that providing insurance increases use of pediatric preventive services among low-income families.26 Utilization of health care services is a multidimensional phenomenon that involves more than financial access to care. Individual circumstances; family dynamics; social, cultural, political, and economic factors; provider characteristics; and the characteristics of health care systems all come into play to affect health behaviors that might improve use of pediatric child health care.13 Although a study, such as the present one, that uses claims data cannot identify either barriers or forces that affect them, other studies have. These include education, minority status, use of other health services, birth order, family size, maternal age and age of the child, family support system, a usual source of care, parental misinformation, private physician as a provider, scheduling and transportation difficulties, long waiting room times or care perceived to be unresponsive or disrespectful, social disenfranchisement and racial discrimination, level of Medicaid reimbursement, and being in a health plan with a Medicaid primary care provider.1427-41 Because of the limitations of Medicaid data, this analysis cannot clarify the pathway that underlies the association that we found between well-child visits and reduced avoidable hospitalization. Thus, it is not possible to attribute our findings to the content of the well-child visits. Instead, this study may be measuring intangible factors related to the health of families and relationships between the family and the pediatric provider that may act on adherence and avoidable hospitalizations.
Most of the children in this study had inadequate levels of well-child care and immunizations, a finding consistent with studies of well-child care and immunization prevalence among poor children 10 years ago. Evidence suggests that things are improving. For example, a more recent study that used 1994-1995 enrollment records from a New York Medicaid managed care system found that only 36% of the Medicaid children younger than 2 years received all of the recommended visits, findings not dissimilar from our 1990-1992 findings.42 However, a North Carolina study that followed a 1994-1995 birth cohort for 2 years found that 75% of the Medicaid children had at least 5 well-child visits by age 2.28 In addition, government programs may have improved immunization levels substantially. National estimates indicated that in 1996, vaccination coverage levels for DPT were over 70% and for poliovirus were nearly 90% among poor children younger than 3 years.43 There is concern that providing immunizations outside the context of the well-child visit for children younger than 2 years will provide a disincentive for compliance with early well-child visit schedules.43 Alternatively, as the North Carolina data suggest, levels of preventive care may be improving, perhaps because of immunization efforts. The authors are currently analyzing more recent Medicaid cohorts in more states for well-child levels, screenings, and immunizations.
Unlike results from national data sets that suggest that black and Hispanic children use fewer preventive services at all income levels, we did not find any striking racial/ethnic disparities in the use of preventive services in the states in this analysis.10 Rates of avoidable hospitalizations did vary by race and ethnicity, but not in a predictable manner. State, gender, and poverty level had more marked effects on hospitalization. The results suggest that the effects of race and ethnicity cannot be predicted and that instead, state policies and programs, demographics other than race, and availability of health resources may be more important predictors of use of health services.
Other factors were associated with avoidable hospitalizations.
Consistent with most other studies, greater poverty was associated consistently with increased avoidable hospitalization.9 The two Medicaid categoriesmedically needy and other povertyare a
result of expansions that occurred in the 1980s that allowed children
whose families had incomes that were higher than those in families that
received AFDC benefits to become Medicaid eligible. Thus, children who
were eligible under these two categories were less poor than the AFDC
group and were less likely to experience an avoidable hospitalization
than the AFDC reference group.
As expected, the variables associated with acute and chronic illness were the most important predictors of avoidable hospitalization. Timely and adequate immunization levels, which may be markers for preventive care use, were not associated independently with hospitalizations, except in Michigan. Immunizations may be indirect markers for well-child visits.
Pediatric preventive care intervention research, which has been concerned primarily with improving immunization coverage, has demonstrated that many efforts to immunize children work.44-47 Improved immunization coverage is associated with improved preventive care but does not absolutely ensure that children will receive other aspects of preventive care. Care should be taken to ensure that efforts to immunize children in venues other than the primary care setting do not preclude the periodic health supervision visit.
There are a number of cautions in interpreting the findings reported in this article. First, there is substantial attrition in Medicaid enrollment. It was for this reason that we chose to evaluate preventive care effectiveness during the first 2 years, which is the time of the lowest Medicaid disenrollment and the highest concentration of use of preventive services. However, because of the attrition, we cannot determine whether preventive care has benefits after the first 2 years of life. Second, we chose the AAP guidelines for health supervision because of their general acceptance in the pediatric community and by state Medicaid programs. However, our analysis does not provide specific endorsement of the AAP schedule over others because these data do not support a precise assessment of >5 well-child visits in 2 years. This is because few children in this cohort made more than this number of visits. Fourth, we dropped nearly 30% of California children because they did not have utilization information during the first few months after birth, but because we controlled for income category, this did not change the effect of income on the California cohort. Finally, we know anecdotally that health care and immunizations are provided to Medicaid-enrolled children that are never billed, either because mothers do not remember to bring their Medicaid cards and are provided with care that is not billed to Medicaid, providers do not bother to bill for the injections, or the children receive care in settings with state or local funding. Thus, our levels of health service use probably are underestimates of the true utilization levels in the early 1990s. However, the levels of preventive care service use from other studies of pediatric preventive care service use in the early 1990s are close to the figures presented here.48-50 Despite these limitations, the association between preventive care and a reduction in avoidable hospitalizations was robust and was consistent across the states and racial and ethnic groups.
The results of this study provide evidence that a series of early well-child visits prevents avoidable hospitalizations among children in Medicaid, despite race, ethnicity, region, and level of poverty. These findings are particularly timely in light of the recent implementation of the Children's Health Insurance Program, which aims to provide insurance coverage for all U.S. children who previously were not eligible for Medicaid coverage. Although the Medicaid data do not allow us to explain the mechanism of the associations that we found, the broad policy implication is that every child needs to be in a health care system in which they can be assured of continuous primary care, the providers actively engage in outreach, a personal bond is formed between the physician and the family, and education and support are provided to families. The Children's Health Insurance Program, enacted by the 1997 Balanced Budget Act, is increasing the effort to provide health coverage for every uninsured child in the United States. However, we must work harder to ensure that these children are receiving the care that they need for a healthy life.
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ACKNOWLEDGMENTS |
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We thank Harold Cooper, a consultant, who was responsible for the data management and programming for this study, and David Baugh of HCFA for his expert advice on Medicaid data issues.
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FOOTNOTES |
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The views expressed in this study are those of the authors and do not reflect those of the Department of Health and Human Services or the Health Care Financing Administration.
a
State-specific 1990 codes included the
followingCalifornia: 9000-1, 90010, 90015, 90020-4, 90026, 90030, 90040, 90050, 90060, 90070, 90080, 90083-4, 12603-9, 12701-15, 12817-22, 12840-2, 12844, 12846, 12850, 12860, 90720-3, 12823-6, 00807,
00813, 00814, 00720, 83022, 83033, 85401, 85014, 85018, 85020-6, 85025, 85030-4, 81005, 81010, 81015-6, 85660, 83020, 86592-3, and 84128-9;
Georgia: X9198, X9147, and Y0800-3; Michigan: 0X9010-19, 009877, 009888, 169522, 169525, 409040, 409912, 409950, 40000-1, 0Y60013,
169019, 0X8890, 88700-1, 88703, 884288534, and 70116.
b CPT-4/HCPCS codes included 90225, 90753-7, 90763-4, 90701-9, 90712-4, 90717-9, 90724-8, 90731-3, 90737, 90741-2, J2750, J1670, J6015, J6025, J6045, 85014, 85018, 85021, 85031, 81000, 81002, 86580, 86585, 83020, 83052, 87072, 87110, 84030-1, 88150, 86592, 83645, 83650, 83660, and 83670. ICD-9 codes included V03.5, V03.6, V03.7, V04.0, V04.2-.3, V04.6, V06.1, V06.3, V06.4, V20.1, V20.2, V210, V72.0, V72.1, and 721.2.
Received for publication Jun 6, 2000; accepted Nov 6, 2000.
Reprint requests to (R.B.H.) HCFA OSP Mail Stop C3-19-07, 7500 Security Blvd, Baltimore, MD 21244.
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ABBREVIATIONS |
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AAP, American Academy of Pediatrics; MSIS, Medicaid Statistical Information System; HCFA, Health Care Financing Administration; SMRF, State Medicaid Research Files; CPT, Current Procedural Terminology; ICD-9, International Classification of Diseases, Ninth Revision; DPT, diphtheria, pertussis, and tetanus; OPV, poliovirus vaccine; MMR, mumps, measles, rubella; HiB, hemophilus influenzae type B; AFDC, Aid to Families with Dependent Children; HR, hazard ratio; CI, confidence interval.
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REFERENCES |
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Methods
Results
Discussion
References
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B. Strickland, M. McPherson, G. Weissman, P. v. Dyck, Z. J. Huang, and P. Newacheck Access to the Medical Home: Results of the National Survey of Children With Special Health Care Needs Pediatrics, May 1, 2004; 113(5/S1): 1485 - 1492. [Abstract] [Full Text] [PDF]
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G. Flores, M. Abreu, C. E. Chaisson, and D. Sun Keeping Children Out of Hospitals: Parents' and Physicians' Perspectives on How Pediatric Hospitalizations for Ambulatory Care-Sensitive Conditions Can Be Avoided Pediatrics, November 1, 2003; 112(5): 1021 - 1030. [Abstract] [Full Text] [PDF]
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T. K. McInerny, J. R. Meurer, and C. Lannon Incorporating Quality Improvement Into Pediatric Practice Management Pediatrics, November 1, 2003; 112(5): 1163 - 1165. [Full Text] [PDF]
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Committee on Child Health Financing Principles of Child Health Care Financing Pediatrics, October 1, 2003; 112(4): 997 - 999. [Abstract] [Full Text] [PDF]
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 S E Levy, M C Souders, J Wray, A F Jawad, P R Gallagher, J Coplan, J K Belchic, M Gerdes, R Mitchell, and A E Mulberg Children with autistic spectrum disorders. I: Comparison of placebo and single dose of human synthetic secretin Arch. Dis. Child., August 1, 2003; 88(8): 731 - 736. [Abstract] [Full Text] [PDF]
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A. A. E. El-Mohandes, K. S. Katz, M. N. El-Khorazaty, D. McNeely-Johnson, P. W. Sharps, M. H. Jarrett, A. Rose, D. M. White, M. Young, L. Grylack, et al. The Effect of a Parenting Education Program on the Use of Preventive Pediatric Health Care Services Among Low-Income, Minority Mothers: A Randomized, Controlled Study Pediatrics, June 1, 2003; 111(6): 1324 - 1332. [Abstract] [Full Text] [PDF]
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S. M. Yu, H. A. Bellamy, M. D. Kogan, J. L. Dunbar, R. H. Schwalberg, and M. A. Schuster Factors That Influence Receipt of Recommended Preventive Pediatric Health and Dental Care Pediatrics, December 1, 2002; 110(6): e73 - 73. [Abstract] [Full Text] [PDF]
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R. B. Hakim and D. S. Ronsaville Effect of Compliance With Health Supervision Guidelines Among US Infants on Emergency Department Visits Arch Pediatr Adolesc Med, October 1, 2002; 156(10): 1015 - 10 |
