Title: Preventive Service Utilization by Minnesota Children
1Preventive Service Utilization by Minnesota
Children
- Minnesota Health Services Research Conference
- January 26, 2004
- April Todd-Malmlov
- Health Economics Program
- Minnesota Department of Health
2Background Cover All Kids (CAK)
- In early 2001, the Cover All Kids Coalition was
formed to promote health care coverage and
preventive care for MN children. - The Coalition is comprised of various public and
private partners including - MN Dept of Health - MHHP (now MHA)
- MN Dept of Human Services - Neighborhood
Health Care Network - Childrens Defense Fund - MN Community Action
Association - Academy of Pediatrics-MN - Minneapolis
Healthy Learners Board - MN Council of Health Plans - Legal
Services Advocacy Project - MMA - Joint Religious Legislative
Coalition - MNA - Congregations Concerned for
Children - Natl Assoc. of Pediatric NPs - MPHA
- Associates
3Background Information Needs
- In order to measure progress towards the
Coalitions goals of increasing health insurance
coverage and use of preventive services for
children, baseline information was needed for all
children in the state. - No State level survey exists that measures health
insurance coverage and use of preventive services
for all children in Minnesota - MN Health Access Survey provides information on
health insurance for all MN children, but not
preventive services. - HEDIS provides information on preventive services
for certain age groups of children enrolled in
HMOs or public health insurance programs. Only
provides information for 30-40 of children in MN
ignores children with commercial health
insurance, self insured employer coverage, and
children who are uninsured.
4Background CAK and BRFSS
- In 2001, CAK worked with the MN Department of
Health to add questions to the 2002 Behavioral
Risk Factor Surveillance System (BRFSS) for
children. - Questions in the BRFSS Child Health Module
provide information on health insurance, dental
coverage, well child visits, and dental visits
for a random sample of children ages 0 through
17. Data provided allows for detailed analysis of
factors related to preventive service
utilization. - The Child Health Module was funded by MDH, DHS,
the MN Council of Health Plans, and the St.
Paul-Ramsey County Dept of Public Health.
5Background Relationship to Prior Research
- Many studies have looked at the relationships
between demographics, insurance status and health
care utilization in general for children (Flores
et al 1999 Newacheck et al 1998 Newacheck,
Hughes, and Stoddard 1996 Short and Lefkowitz
1992). - Some studies have looked at the impact of parent
and child characteristics on general health care
utilization for children (Davidoff et al 2003
Hanson 1998 Newacheck and Halfon 1986).
6Background Relationship to Prior Research
(Continued)
- Other studies have looked at the impact of parent
and child characteristics on preventive service
utilization by children (Davidoff et al 2003
Bates et al 1994 Byrd, Hoekelman, and Auinger
1999 Ronsaville and Hakim 2000 Yu et al 2002). - However, these prior studies that have looked at
the impact of various factors on preventive
service utilization for children are limited in
scope. No study has included all of the
following - various parent, child, and household
characteristics - all children, regardless of age, insurance
status, or income - well child visit guidelines as opposed to at
least one visit
7Research Questions
- What percentage of Minnesota children are meeting
various well child visit frequency guidelines? - What percentage of Minnesota children over age
three had at least one dental visit in the past
year? - What are the characteristics of children who did
not meet well child visit guidelines or did not
have a dental visit? - What is the impact of various parent, child, and
household characteristics on whether or not
children met well child visit guidelines or had a
dental visit?
8Methods Data Source
- The BRFSS is a collaborative telephone survey
conducted by the states and CDC. - The BRFSS is designed to measure behavioral
health issues and risk factors in the adult
population over the age of 18. - All states ask a certain set of questions in
order for the data to be comparable from state to
state however, states have some flexibility in
adding their own questions. - In Minnesota, the BRFSS is conducted by the
Center for Health Statistics at the Minnesota
Department of Health.
9Methods Data Source (Continued)
- The questions in the Child Health Module added to
the 2002 MN BRFSS were asked of all adult
respondents who reported that there were children
in the household. - The adult respondent was asked to respond to the
Child Health Module questions for one randomly
selected child in the household. - In 2002, 4500 adults responded to the MN BRFSS
and the interview completion rate was 88. - Of the 4500 adults responding, 1600 completed the
Child Health Module or 99 of adult respondents
reporting children in the household.
10Methods Data Source (Continued)
- Due to the length of time allotted for the Child
Health Module, questions related to
race/ethnicity, geography, household income, and
family composition were not asked directly of the
child or of the adult respondent on behalf of the
child. The analyses assume that the responses of
the adult to these questions also apply to the
child. - In addition to data collected through the Child
Health Module, data relating to household
characteristics and parental demographics, health
care access, utilization, and coverage from the
BRFSS was used in the analyses.
11Methods Data Source (Continued)
- The analyses assume that the adult respondent is
a parent of the randomly selected child. - Some adult responses were eliminated from the
analyses comparing adults and children. In
instances where the age of the child and the age
of the adult suggest that the adult is not the
parent of the child, the responses of the adult
to some demographic, family composition, health
insurance, dental coverage, and health care
utilization questions were eliminated. - The responses of approximately 80 adults were
dropped from the descriptive and regression
analyses.
12Methods Descriptive Statistics
- The American Academy of Pediatrics (AAP), Child
and Teen Checkup (CTC), and the Institute for
Clinical Systems Improvement (ICSI) guidelines
are all used to analyze the percent of children
in Minnesota who met well child visit frequency
guidelines in 2002. - Children were classified as meeting the well
child visit frequency guidelines if they received
the recommended number of well child visits in
the past year(s) based on their age (in months
for children under age two). The survey did not
attempt to assess whether all of the recommended
services were provided during the well child
visits reported by parents.
13Methods Descriptive Statistics (Continued)
- Due to question wording, an exact estimate of
children meeting ICSI guidelines is not possible.
It is assumed that a child over the age of two
meets ICSI guidelines if they had a well child
visit in the past two years. This assumption may
underestimate those meeting ICSI guidelines. - Question wording does not allow for an analysis
of children meeting dental guidelines. It only
allows for an analysis of children having at
least one dental visit in the past year. - The data was analyzed using Stata survey commands
to account for complex survey design and
weighting.
14Methods Logistic Regression
- Logistic regression is used to quantify the
relative impact of various parent, child, and
household characteristics on dental and well
child visit utilization. - The dependent variables include
- Whether or not children age three or older had a
dental visit in the past year - Whether or not children met the CTC or ICSI well
child visit frequency guidelines CTC
guidelines are applied to uninsured children and
those with public coverage and ICSI guidelines
are applied to children with private coverage.
15Methods Logistic Regression (Continued)
- Conceptual Framework Aday and Andersons model
of health services utilization (1974, 1981).
Dental and well child visit utilization are
modeled as a function of predisposing, enabling,
need, and availability factors. - Analyses were conducted using svylogit commands
to account for complex survey design and
weighting. - Odds ratios are reported for the logistic
regression analyses.
16Methods Logistic Regression (Continued)
- Interactions between parent and child dental
coverage and parent and child health insurance
coverage were detected. - To deal with these interactions and account for
the importance of coverage for both parents and
children, three logistic regression models were
conducted for both dental and well child
utilization - One model was constructed including coverage for
parents and children to obtain odds ratios for
other variables in the model excluding parent and
child coverage. - In a second model, an odds ratio for parental
coverage was derived by excluding child coverage
from the model. - In a third model, an odds ratio for child
coverage was derived by excluding parental
coverage from the model.
17Methods Independent Variables in Dental and Well
Child Models
18Results Percent of Children 3 With Dental Visit
in Past Year
Indicates statistically significant difference
(90 level) from all children Indicates
statistically significant difference (90 level)
from White, Non-Hispanic
19Results Characteristics of Children With and
Without a Dental Visit
Indicates statistically significant difference
(90 level) from children who had a dental visit
20Results Percent of Children Meeting Well Child
Visit Guidelines
Indicates statistically significant difference
(90 level) from all children Indicates
statistically significant difference (90 level)
from White, Non-Hispanic Indicates
statistically significant difference (90 level)
from Greater MN
21Results Characteristics of Children Who Did and
Did Not Meet Well Child Guidelines
Indicates statistically significant difference
(90 level) from children who met guidelines
22Results Logistic Regression Dental Visit Model
23Results Logistic Regression Well Child Visit
Guideline Model
24Conclusions
- Over 87 of Minnesota children ages three or
older had at least one dental visit in the past
year. - Depending on the guideline, roughly 72 to 83 of
MN children met well child visit guidelines in
2002. - A childs age, parental dental care, household
income, and type of child and parental dental
coverage had a greater impact on dental
utilization than other factors. - A childs age, parental and child health
coverage, household income, parental age,
continuity of care, and geography had a greater
impact on meeting well child visit guidelines
than other factors.
25Conclusions (Continued)
- Similar themes for dental and well child
utilization - Younger children and children of young parents
were less likely to have a dental visit or meet
well child guidelines - Insurance coverage for parents and children is
associated with having a dental visit and meeting
well child guidelines - Different themes for dental and well child
utilization - Income higher income important factor for dental
visit and lower income important factor for
meeting well child visit guidelines - Geography no impact for dental visit, but Twin
Cities location important factor for meeting well
child visit guidelines - Parental preventive actions important for dental
visit, but not important for meeting well child
visit guidelines
26Limitations and Future Work
- Limitations
- Health status not asked of children in Child
Health Module - Type of insurance coverage for adults not asked
on BRFSS - Self-reported information from parents
- Limitations mentioned earlier regarding question
wording and assumptions of parent and child
characteristics - Future Work
- Rewording of some questions in Child Health
Module - Addition of some questions to Child Health Module
- More research on the impact of geography and
parental preventive actions on use of preventive
care by children. - SLAITS National Survey of Childrens Health
- Similar questions to 2002 MN BRFSS Child Health
Module - Data collected during 2003 and available sometime
in 2004 - 2000 sample size per state
27Take Home Message
- Various strategies in addition to increasing
insurance coverage for children, could
potentially increase the use of preventive
services for Minnesota children. Other strategies
include - Improving continuity of care for children
- Increasing preventive service utilization and
insurance coverage for parents - Increasing outreach efforts in Greater MN and for
young parents with young children - Outreach efforts may be more effective and easier
for providers and parents to understand and
remember if one set of guidelines is used for all
kids