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Preventive Service Utilization by Minnesota Children

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Title: Preventive Service Utilization by Minnesota Children


1
Preventive Service Utilization by Minnesota
Children
  • Minnesota Health Services Research Conference
  • January 26, 2004
  • April Todd-Malmlov
  • Health Economics Program
  • Minnesota Department of Health

2
Background 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

3
Background 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.

4
Background 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.

5
Background 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).

6
Background 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

7
Research 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?

8
Methods 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.

9
Methods 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.

10
Methods 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.

11
Methods 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.

12
Methods 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.

13
Methods 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.

14
Methods 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.

15
Methods 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.

16
Methods 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.

17
Methods Independent Variables in Dental and Well
Child Models
18
Results 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
19
Results Characteristics of Children With and
Without a Dental Visit
Indicates statistically significant difference
(90 level) from children who had a dental visit
20
Results 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
21
Results Characteristics of Children Who Did and
Did Not Meet Well Child Guidelines
Indicates statistically significant difference
(90 level) from children who met guidelines
22
Results Logistic Regression Dental Visit Model
23
Results Logistic Regression Well Child Visit
Guideline Model
24
Conclusions
  • 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.

25
Conclusions (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

26
Limitations 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

27
Take 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
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