Racial/Ethnic Variation in Asthma Status and Management Practices Among Children in Managed Medicaid
Objective. Racial/ethnic disparities in hospitalization rates among children with asthma have been documented but are not well-understood. Medicaid programs, which serve many minority children, have markedly increased their use of managed care in recent years. It is unknown whether racial/ethnic disparities in health care use or other processes of care exist in managed Medicaid populations. This study of Medicaid-insured children with asthma in 5 managed care organizations aimed to 1) compare parent-reported health status and asthma care processes among black, Latino, and white children and 2) test the hypothesis that racial/ethnic variations in processes of asthma care exist after adjusting for socioeconomic status and asthma status.
Methods. This cross-sectional study collected data via telephone interviews with parents and computerized records for Medicaid-insured children with asthma in 5 managed care organizations in California, Washington, and Massachusetts. The American Academy of Pediatrics (AAP) Children’s Health Survey for Asthma was used to measure parent-reported asthma status. We used multivariate models to evaluate associations between race/ethnicity and asthma status while controlling for other sociodemographic variables. We evaluated racial/ethnic variations in selected processes of asthma care while controlling for other demographic variables and asthma status.
Results. The response rate was 63%. Of the 1658 children in the respondent group, 38% were black, 19% were Latino, and 31% were white. Black children had worse asthma status than white children on the basis of the AAP asthma physical and emotional health scores, symptom-days, and school days missed in the past 2 weeks. Latino children had equivalent AAP scores but missed more school days than white children. On the basis of the AAP asthma physical health score, the black–white disparity persisted after adjusting for other sociodemographic variables. After adjusting for sociodemographic variables and asthma status, black and Latino children were less likely to be using inhaled antiinflammatory medication than white children (relative risk for blacks: 0.69; relative risk for Latinos: 0.58). They were more likely to have home nebulizers. Other processes of asthma care, including ratings of providers and asthma care, use of written management plans, use of preventive visits and specialists, and having no pets or smokers at home, were equal or better for minority children compared with white children.
Conclusions. Black and Latino children had worse asthma status and less use of preventive asthma medications than white children within the same managed Medicaid populations. Most other processes of asthma care seemed to be equal or better for minorities in the populations that we studied. Increasing the use of preventive medications is a natural focus for reducing racial disparities in asthma.
The burden of asthma falls disproportionately and increasingly on racial/ethnic minority and poor children in the United States.1–3 Black children have higher asthma hospitalization rates and emergency department (ED) visit rates than white children, and available measures of socioeconomic status do not completely explain these differences.4–7 Few studies of racial/ethnic disparities have evaluated patients’ asthma status or home management practices by direct report.8,9 The reasons for racial/ethnic disparities in child health status deserve additional exploration.10
Many minority children are insured by Medicaid,11 in which the use of managed care has sharply increased during the past decade.12 Scant evidence exists on whether managed Medicaid improves health care access or quality for children.13 Asthma is a sentinel condition for quality monitoring because it is among the most common chronic conditions and clear guidelines exist for appropriate care.14
The current study was designed to fill gaps in understanding of racial/ethnic variation in asthma and to evaluate whether managed Medicaid can reduce disparities in care. This study’s specific aims were to 1) compare parent-reported health status and asthma care processes among black, Latino, and white children in managed Medicaid and 2) test the hypothesis that racial/ethnic variations in processes of asthma care persist after adjusting for socioeconomic status and asthma status.
The Asthma Care Quality Assessment (ACQA) Project is an ongoing study of quality of care for Medicaid-insured children with asthma in Massachusetts, California, and Washington. This article reports on the cross-sectional phase of the project, in which we conducted telephone interviews with parents and collected computerized claims data for Medicaid-insured children with asthma in 5 managed care organizations.
We studied children in 5 large nonprofit health plans: the Harvard Vanguard Medical Associates population of Harvard Pilgrim Health Care in Massachusetts, Kaiser Permanente in Northern California, Group Health Cooperative of Puget Sound in Washington State, Neighborhood Health Plan in Massachusetts, and Partnership Healthplan of California. The first 3 were health maintenance organizations in which a large multispecialty provider group contracted exclusively or almost exclusively with the health insurance plan. In these health maintenance organizations, most members received employment-based health benefits and Medicaid patients were in the minority. In contrast, the last 2 were mixed-model Medicaid managed care organizations that contracted with a variety of provider groups, including multispecialty and pediatric physician groups and community health centers. In all health plans, primary care services were capitated and specialty and hospital services were paid via varying mechanisms.
Identification of Children With Asthma
The target population was Medicaid-insured children who were aged 2 to 16 years and had asthma as based on both computerized utilization data and parent report. First, we identified the group of potentially eligible children on the basis of computerized data during a 12-month period before attempted interviews. The criteria were 1) a physician’s diagnosis of asthma as based on an International Classification of Diseases, Ninth Revision code of 493.0 to 493.9 at an outpatient clinic visit, ED visit, or hospitalization or 2) 1 or more prescriptions for cromolyn, nedocromil, or inhaled corticosteroids or 2 or more prescriptions for β-agonist medications. All children who were identified as potentially eligible were included in interview and survey attempts, except at Neighborhood Health Plan, where we drew a random sample of 1000 because of the large population size. For a child to be eligible for study, the parent had to confirm at the start of the interview that the child had asthma based on a doctor’s diagnosis.
Each health plan mailed a contact letter that described the study and reviewed the voluntary nature of participation and other elements of informed consent. The letter offered a $10 incentive for interview participation and included a postcard to enable the parent to decline. Research assistants at Kaiser Permanente conducted telephone interviews in English or Spanish for all sites and made up to 16 attempts per telephone number. Telephone interviews were conducted during February to October 1999. In August to September 1999, surveys with identical content were mailed to families that we had not yet reached by telephone. The study protocols were approved by the Institutional Review Boards of the participating sites.
The closed-ended telephone interview averaged 27 minutes. Its format was based on previously validated instruments, including the American Academy of Pediatrics (AAP) Children’s Health Survey for Asthma and the Consumer Assessment of Health Plans Survey instrument for childhood asthma.15 The interview included 3 of the 5 domains from the AAP instrument: the child’s asthma-related physical health, emotional health, and activities. Interviewers asked parents about their primary care and specialty services for asthma in the last 6 months. The interviewers also asked about specific practices and tools for the home management of asthma.
The demographic section of the interview included 2 questions on race/ethnicity that were adapted from formats for the US Census.16,17 Each respondent was asked, “What is your child’s race or ethnicity? Please name all that apply.” Respondents who initially named Hispanic or Latino were prompted for subcategories: Mexican-American or Chicano, Puerto Rican, Cuban, Central or South American, or other. Respondents who said that their child was more than 1 race or ethnicity were asked, “If you had to choose ONE race or ethnicity to describe your child, which one would that be?” We also asked about the language spoken by adults at home, family size, type of residence, pets, smokers, child care, the respondent’s educational level, and household income.
In the telephone interview, we asked about total household income during the preceding calendar year, by increments of $5000 or $10 000. In analyses, we created two different types of household income variables: 1) income categories (<$20 000, $20 000 to $40 000, and >$40 000), and 2) poverty categories based on federal definitions that take household size as well as income into account (≤100%, 101%–150%, 151%–200%, and >200% of the poverty level). Asthma symptom-days out of the past 14 days was defined as the number of days when the parent reported the child having any asthma symptoms, including cough, wheeze, shortness of breath, or limited activity.18
Recommendations from the National Asthma Education and Prevention Program state that patients with persistent asthma should take daily antiinflammatory medications.14 On the basis of national criteria, we classified children as having persistent asthma when their parent reported that they had either 1) 5 or more symptom-days in the past 2 weeks or 2) used β-agonist medications 3 or more times per week in the past 2 weeks, or 3) used antiinflammatory medications daily in the past 2 weeks.
Computerized Data Collection
For all children whose parents completed interviews, we gathered computerized data from electronic medical records and claims on asthma-related health care use for the year January to December 1998. These included medications as well as hospitalizations, ED visits, and outpatient clinic visits, which were counted as asthma-related if they had any diagnosis of asthma (International Classification of Diseases, Ninth Revision codes 493.9–493.0).
In preliminary analyses, we examined frequency distributions and univariate statistics for measures of asthma status and processes of asthma care. Next, we evaluated these outcomes stratified by race/ethnicity. Finally, we conducted multivariate analyses for each outcome to evaluate whether racial/ethnic variation persisted after adjusting for other demographic factors and asthma status. We used logistic regression for dichotomous variables (eg, whether antiinflammatory medications were being used), linear regression models in analyses of ordinal variables (eg, ratings of care), and Poisson regression with allowance for overdispersion in analyses of rates (eg, health care use including hospitalization and outpatient clinic visits).19
We followed the theoretical framework proposed by Aday and Andersen,20,21 by including predisposing, needs, and enabling variables in sequential multivariate models. To construct efficient models, we first used stepwise regression to identify candidate demographic predictors for each outcome. In these stepwise regressions, age, race/ethnicity, and gender were forced to enter, followed by other demographic variables that were entered and retained if P ≤ .15. We then built an iterative, forced-entry model for each outcome using those demographic predictors identified in stepwise regression. When either household income or poverty level was identified as a candidate predictor in initial modeling, we chose the income variable that had the stronger association with the outcome for the final model.
In models in which asthma status was the outcome variable, we evaluated racial/ethnic variation while adjusting for other sociodemographic variables. In models in which asthma management practices were the dependent variables, we adjusted for sociodemographic and asthma status variables. In most models, asthma status variables included the AAP asthma physical health score and β-agonist and antiinflammatory medication use. For models in which inhaled antiinflammatory medication use was the outcome variable, we adjusted for the AAP score and β-agonist use (but not inhaled antiinflammatory use); the reverse was true for models in which β-agonist use was the dependent variable.
To identify whether selected health system characteristics explained observed racial/ethnic differences, we created sets of dummy variables to denote the 5 health plans and practice site types (multispecialty group, pediatric group, community health center, academic practice, or solo or 2-person practice) studied. These were added to the models that evaluated race/ethnicity, sociodemographic factors, and asthma status as predictors of daily antiinflammatory use.
From computerized data, we identified an initial sample of 4094 children with asthma health care use. Of these, 141 families (3%) returned postcards declining participation. Of the remaining 3953 children, we excluded 603 because they did not have health plan membership at the time of interview attempts, completed contact with the parent or guardian of 2568, and did not complete contact with 782. Among the group with completed contact, 628 (24%) were ineligible because they did not have asthma (430), they already had a sibling in the study (66), there was a language barrier (65), they stated that they were not with the health plan under study (54), and other reasons (13). The parents of another 277 declined to be interviewed. We completed interviews with 1663 parents.
For calculating the denominator for the completion rate, the Council of American Survey Research Organizations recommends subtracting the number of ineligibles from the initial sample.22 The number of ineligibles among the groups who opted out before contact attempts (141) or had incomplete contact (782) was estimated at 221 by multiplying the numbers in these groups by the proportion ineligible among the group with completed contact (24%). The estimated number of patients eligible for interview was 2642 (4094 − 603 ineligible because of not having health plan membership at the time of interview attempts—628 ineligible on the basis of interview screening questions—221 estimated ineligible among patients with incomplete contact). The completion rate was 63% (1663 of 2642).
The study population (Table 1) was 38% black, 19% Latino, and 31% white. Multiracial/ethnic children whose parents chose 1 race/ethnicity with whom they most strongly identified were included in these proportions. Five children for whom race/ethnicity was completely missing were excluded from the current analysis. The remaining 12% were Asian, American Indian, or multiracial/ethnic children whose parents did not choose 1 race/ethnicity. These 12% were excluded from additional analyses because their numbers were too small to permit meaningful inferences.
Household income was lowest among Latinos compared with whites and blacks, who had similar income distributions. Single-parent families were most common among blacks, followed by Latinos then whites. Latinos had less education and a higher proportion in poverty than black or white families (P = .001). In 44% of Latino families and 99% of black and white families, English was the language usually spoken by the adults at home.
Black children had worse asthma status than their white and Latino peers (Table 2). This finding was consistent across several different measures, including the AAP physical and emotional subscales, symptom-days and school days missed in the past 2 weeks, and the parent’s global assessment of severity. In contrast, Latino children had similar AAP physical scores and fewer symptom-days compared with white children but seemed worse on the basis of school days missed and the parent’s global assessment of severity.
We constructed a multivariate model to test whether the black–white disparities in the AAP asthma subscales persisted after adjusting for other sociodemographic variables. In the final model, worse asthma physical health status was associated with household income of <$20 000/y (8.5 points lower; P = .0002), household income of $20 001 to $40 000/y (5.6 points lower; P = .02), increasing family size (1.2 points for each additional member; P = .002), and living in a single-adult household (3 points lower; P = .02). Even after adjusting for these other variables, black children had AAP asthma physical health scores an average of 6 points lower (on a 1–100 scale) than white children (P = .0001).
Asthma Health Care Use
Black children experienced more hospitalizations and ED visits than Latino or white children during the preceding year (Table 2). However, in Poisson regression models, the interracial differences in hospitalization rates were not significant after adjustment for age (relative risk [RR]: 0.86 for each category; P = .30), gender (RR: 0.54 for females compared with males; P = .07), and family size (RR: 1.19 for each additional child; P = .25). For ED visits, Latino children (RR: 1.71; P = .10) and black children (RR: 1.31; P = .25) were not significantly more likely to have ED visits than white children after adjusting for age, gender, parental education, and language. Older children (RR: 0.91 for each category; P = .0008) were less likely to make ED visits.
Antiinflammatory Medication Use
Both black and Latino children were less likely to be using daily inhaled antiinflammatory medications than white children (Table 3). In a subgroup analysis of children with persistent asthma (n = 975), 33% (111 of 336) of whites, 28% (125 of 453) of blacks, and 22% (41 of 186) of Latinos were using these preventive medications (P = .025). Daily inhaled antiinflammatory use also varied by health plan, and the racial/ethnic differences were similar across health plans (Fig 1). Race/ethnicity was significantly associated with daily inhaled antiinflammatory use after controlling for health plan (Cochran-Mantel-Haenszel test, P = .003).
In multivariate modeling (Table 4), minority children were less likely than white children to be using daily inhaled antiinflammatories after adjusting for other demographic variables and asthma status (for blacks, odds ratio [OR]: 0.64; 95% confidence interval [CI]: 0.45–0.90; for Latinos, OR: 0.52; 95% CI: 0.33–0.82). Younger children (OR: 1.05 per year; 95% CI: 1.02–1.10), those with larger families (OR: 1.13 per person; 95% CI: 1.02–1.25), and those in single-adult families (OR: 1.78; 95% CI: 1.27–2.57) were more likely to be using daily inhaled antiinflammatories. The respondent’s education and the family’s income and primary language were not associated with inhaled antiinflammatory use.
Because >10% of the sample reported daily antiinflammatory use, ORs from logistic regression models may exaggerate the actual differences between racial/ethnic groups.23 For this reason, we also calculated RRs using the method proposed by Zhang and Yu.24 The RR of using an antiinflammatory medication was 0.69 for blacks and 0.58 for Latinos compared with whites.
To determine whether variation among the 5 health plans explained the observed racial/ethnic differences in antiinflammatory use, we created a multivariate model that included health plan as well as race/ethnicity, age, gender, respondent’s education, poverty level, numbers of children and adults in the family, and asthma status. This model found no significant differences among health plans, and the associations between race/ethnicity and daily antiinflammatory use remained significant.
Similarly, we created a multivariate model that included type of practice site in addition to the other variables. In this model, patients of solo or 2-person practices were less likely to report using daily antiinflammatories than patients of multispecialty groups, although this difference was not statistically significant (OR: 0.16; 95% CI: 0.02–1.23; P = .078). No significant differences were identified among other types of practice sites. In this model, the association between black race and lower antiinflammatory use persisted (OR: 0.69; 95% CI: 0.48–0.99), but the association between Latino race and lower antiinflammatory use was diminished (OR: 0.65; 95% CI: 0.39–1.07).
Other Asthma Management Practices
In models that adjusted for demographic variables and asthma status, black and Latino children were equally as likely as white children to be using β-agonist medication daily and to have made an outpatient visit for preventive asthma care in the past 6 months (Table 4). Other home management practices seemed to be followed more consistently among the families of minority children, including having a written management plan, having no smokers in the home, and having no pets in the home.
Compared with whites, blacks were equally likely (OR: 1.09; 95% CI: 0.73–1.63) and Latinos were more likely (OR: 1.65; 95% CI: 1.04–2.60) to have made a specialist visit for asthma during the last 6 months. In both unadjusted and adjusted analyses, parents of black, Latino, and white children gave equal ratings to the provider in charge of their child’s asthma care and to their child’s overall asthma care.
Among the 313 children who were identified as Hispanic or Latino, 137 (44%) were Puerto Rican, 89 (28%) were Mexican-American or Chicano, and 87 (28%) were from other Latino subgroups. Puerto Rican (mean: 76.8; P = .02) and Mexican (mean: 77.2; P = .01) children had worse parent-reported AAP asthma physical scores compared with other Latino children (mean: 84.6) after adjusting for age, gender, respondent’s education, and single-adult family structure. Puerto Rican children also had worse AAP asthma emotional and activity scores than other Latino children. In multivariate analyses of asthma-related ED visits, young age (OR: 1.30; 95% CI: 1.56–1.10) and English being the language spoken by adults at home (OR: 4.22; 95% CI: 1.19–15.0) were associated with increased risk, but no significant differences among Latino subgroups existed. Analyses of asthma-related hospitalizations, outpatient visits, antiinflammatory use, and β-agonist use revealed no differences among Latino subgroups.
Black and Latino children in the managed Medicaid populations that we studied had worse asthma status and were less likely to be using preventive asthma medications than white children. The disparities in asthma status persisted after adjusting for socioeconomic status and family structure. The racial/ethnic differences in preventive medication use were modest but were significant after adjusting for asthma status and other covariates. For other processes of asthma care, including specialist use, preventive visits, and home management practices, blacks and Latinos seemed to be similar to or better than whites.
Interpretation and Context
To our knowledge, this is the first study to evaluate racial/ethnic variation in pediatric asthma status and home management practices based on direct report by parents. Patient-oriented outcome measures, such as those reported here, provide a much more complete picture of asthma impact than hospitalization and ED visit data alone.25 Elevated asthma hospitalization rates among black children have been well-documented,2,4,6,26 but the causes are not well-understood. Black people have equal or higher rates of ambulatory visits for asthma compared with white people nationally,2 but studies in selected populations suggest that preventive care use among blacks may be disproportionately low when asthma severity or prevalence is taken into account.27–29
In the current study, many processes of asthma care were equally good or better for minority children. Some of our findings were unexpected but encouraging. For example, black and Latino children were as equally likely to use asthma self-management tools as white children. However, all of children had low rates of use of specialty care and written management plans, elements of an asthma intervention program recently found effective among Medicaid children.30
Our finding that minority children were more likely to underuse asthma preventive medicines suggests that even when financial access to health care is equalized by managed Medicaid, variation in health care quality may persist.31 Underuse of preventive asthma medications has been described in various settings, especially inner-city and ED populations.32–34 A study at one children’s hospital found that black and Latino children were less likely to be using appropriate medications before hospital admission and also were less likely to have preventive medications prescribed on discharge.35 However, past studies did not disentangle whether these lapses were attributable chiefly to financial barriers. In the current study, all patients were insured by Medicaid, which provided full coverage for all prescription medications.
Past studies suggest that financial access alone does not eliminate racial/ethnic disparities in health care.3,36–38 Studies of adults also suggest that the use of managed care does not eliminate racial/ethnic variation in asthma-related care.29,39,40 Although racial/ethnic disparities have been observed in many different health services for both adults and children,41–48 no uniform explanation has been established. Possible reasons include system-level differences in health care access on the basis of insurance and other nonfinancial factors49; provider-level variations in medical practices or communication patterns50–52; and patient-level characteristics, including socioeconomic status, health status, comorbidities, and cultural and behavioral characteristics.53,54
Our findings, like those of other recent studies,55,56 suggest that nonfinancial barriers may play an important role in suboptimal medication use. Preliminary findings from a clinician survey in the study health plans suggest that most were aware of national or provider-group guidelines for asthma care and most agreed with current recommendations for antiinflammatory prescribing. Although the health plans varied in their methods of support for appropriate asthma care, the racial/ethnic disparities in antiinflammatory use were consistent across health plans.
The variation that we observed might be attributable to racial/ethnic differences in health beliefs and concepts of disease,57 differences in beliefs about the value of prevention, fears about steroids, and/or lack of regularity in the life of the family. Medicaid-insured children with asthma may be less likely than privately insured children to obtain refills on prescriptions, even when they are prescribed.35 Interactional issues between providers and patients should be explored, including reducing communication barriers and improving understanding of patients’ health beliefs.58–62 The effectiveness of culturally competent health care system practices, including making available interpreter services and black and Latino clinicians, also deserves more study.63
This project’s response rate of 63% is considered excellent for a study of Medicaid-insured patients, who are notoriously difficult to survey.64 Other well-done Medicaid studies have reported response rates of approximately 50%.65 Low-income children have high rates of family relocation,66 and almost two thirds of new Medicaid enrollees lose coverage within 12 months.67 Our results may underestimate the problems experienced by nonrespondents or by patients who did not remain enrolled in Medicaid long enough to receive asthma diagnosis or treatment.
Because the study population was identified on the basis of asthma health care use during the past year, children who had asthma without any clinical care or prescription medications could not be included. Many low-income children may have undiagnosed asthma,68,69 and black race is more strongly associated with a mother’s report of asthma than with a doctor’s diagnosis.70 Thus, these results may underrepresent the true extent of disparities in asthma status and health care use among all low-income children.
The measures of socioeconomic status that we used—parental education and annual household income from all sources—did not completely adjust for differences in wealth among families of different races. Even at equivalent income levels, black families tend to have less savings and other financial resources than white families.71,72 However, our findings are in accordance with a recent study that found that lifetime income and sociodemographic characteristics do not explain the excess risks of asthma and asthma health care use among black children.6
This study relied on parent-reported data for medication use and other asthma management practices. Compared with children’s reports, parents’ reports of asthma status may underestimate symptom frequency and be less sensitive to changes in quality of life.73,74 However, children with asthma may dramatically overreport their own medication use.75 In analyses to validate parent report, we found good concordance between parent-reported medication use and computerized records of recent medication dispensing.
The tendency for respondents to give socially desirable answers is a limitation of all survey-based research. However, minority patients tend to give worse reports or ratings of their care than white patients.76–78 This would have biased against our study’s finding of no significant differences in ratings of care among different racial/ethnic groups.
Our findings on Latino children are consistent with previous studies that found that Puerto Ricans tend to have higher asthma prevalence and morbidity than other Hispanic subgroups.79,80 Although we interviewed Spanish-speaking parents using a version of the AAP asthma measure that had been translated and back-translated, other instruments that are more tailored to this population are now available.81
Black and Latino children had worse asthma status and less use of preventive asthma medications than white children within the same managed Medicaid populations. Most other processes and ratings of asthma care seemed to be equal or better for minorities in the populations that we studied. Increasing the use of preventive medications seems to be a natural focus for improving quality of care for minority children with asthma.
The ACQA Project was supported by the Agency for Healthcare Research and Quality (grant HS09935), the American Association of Health Plans Foundation, and the Maternal and Child Health Bureau.
We thank Bernard Friedman, PhD, Irene Fraser, MD, Charles Cutler, MD, and Marie Mann, MD, at our funding agencies for advice and support throughout. We are grateful to our senior advisors at the health plans in this study, including Chris Cammisa, MD (PHC), Robert Master, MD (NHP), James Glauber, MD (NHP), Edward Wagner, MD (GHC), and Richard Platt, MD (HPHC). Richard Marshall, MD, and Ken Paulus of Harvard Vanguard Medical Associates and Joe Dorsey, MD of HPHC contributed thoughtful reviews. We also thank Lynn Olson, PhD, and Linda Asmussen, MA, of the American Academy of Pediatrics, Charles Homer, MD, of the National Institute for Children’s Healthcare Quality, and William Vollmer, PhD, for guidance.
This project relied on the hard work and intellectual contributions of many other members of the ACQA Study Team, including Cynthia Sisk, MA, Julia Hecht, PhD, MPH, Kachen Streiff, MS, Irina Miroshnik, MS, Cindi Turner, Ming Yuan, and the ACQA interviewers: Georgina Berrios, Sylvia Chan, Yoko Chavez, Pete Dorin, MPA, Danielle Hauptman, Diane Hinkley, Regina Mason, Valerie Ramirez, MS, Monica Soto, and Lynda Tish. We thank Ursula Lebron for assistance with manuscript development. We are grateful to the hundreds of parents and children who shared their experiences and opinions in the interviews for this study.
- Received July 2, 2001.
- Accepted November 14, 2001.
Reprint requests to (T.A.L.) Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, 126 Brookline Ave, Ste 200, Boston, MA 02215. E-mail:
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- Copyright © 2002 by the American Academy of Pediatrics