bluuebunny/crossref_metadata_2025 huggingface dataset:
Applicability of common reference intervals for serum creatinine concentrations to the Croatian population
Authors: Flegar-Meštrić Zlata , Perkov Sonja , Šimonović Barbara , Juretić Dubravka
Published: November 2009

Background: In accordance with an ongoing activity for worldwide harmonization based on traceability in laboratory methods, the goal of this study was to validate the applicability of recommended “common” reference intervals for serum creatinine concentrations using a specific enzymatic method to the Croatian population.

Methods: The reference group consisted of 240 healthy subjects (120 males and 120 females), between 18 and 74 years of age (median 57 years), who were selected in accordance with the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) recommendations. Creatinine in serum was measured using the creatinine enzymatic assay (Olympus OSR61204) that was standardized to the isotopic dilution mass spectrometry (IDMS) method and National Institute of Standards and Technology (NIST) Standard Reference Material (SRM) 967. In addition, creatinine was measured using a kinetic Jaffe method (Olympus OSR6178) standardized to NIST SRM 909b level 2 standard.

Results: Method comparison between enzymatic creatinine (x) and the Jaffe kinetic method (y) gave the following P/B equation for the entire group (n=240): y=1.00x+17.00; r=0.968. Reference intervals for serum creatinine (central 95th percentiles) obtained using the enzymatic creatinine method ranged from 54 to 107 μmol/L for males and from 50 to 93 μmol/L for females. The IFCC recommended common reference intervals for global applications are 64–104 μmol/L and 49–90 μmol/L for males and females, respectively.

Conclusions: Comparability of obtained results confirmed the applicability of recently recommended “common” reference intervals to the Croatian population for all laboratories measuring serum creatinine concentrations using enzymatic methods traceable to the IDMS method and NIST SRM 967.

Clin Chem Lab Med 2010;48:231–5.
Home ranges, movements and activity of the short-tailed mongoose (Herpestes brachyurus) on Peninsular Malaysia
Authors: Jennings Andrew P. , Zubaid Akbar , Veron Geraldine
Published: November 2009

The ecology of Asian rainforest mongooses is very poorly known. The short-tailed mongoose (Herpestes brachyurus) is found in rainforests throughout Southeast Asia and very little is documented about its natural history and ecology. Here, we present results from the first radio telemetry study of this species. We captured seven short-tailed mongooses in Krau Wildlife Reserve, Peninsular Malaysia and radio-tracked five adults (three males and two females). Our observations confirmed that this is a solitary, territorial species. The mean home range size of males (233 ha, 95% MCP) was larger than females (132 ha). Females had exclusive home ranges (mean overlap was 3.7%), and male home ranges overlapped more than one female's range. Short-tailed mongooses showed a diurnal activity pattern: mean activity between 06:00 and 17:59 h was 84.7%. The mean minimum distance covered during a 24-h period by males (842 m) was significantly greater than females (468 m). Short-tailed mongooses were mainly found in lowland forest. Deforestation and pollution of watercourses could have serious impacts on this species across its range.
Preliminary account of cetacean diversity and humpback whale (Megaptera novaeangliae) group characteristics around the Union of the Comoros (Mozambique Channel)
Authors: Kiszka Jeremy , Vely Michel , Breysse Olivier
Published: November 2009

Cetacean diversity and occurrence has never been investigated in the Union of the Comoros, located in the northern Mozambique Channel. Small boat-based surveys were conducted during the austral winter of 2002, primarily to assess the occurrence of humpback whales (Megaptera novaeangliae) and whether the area represents a wintering ground where the species reproduce. All other cetacean species were also recorded. Opportunistic sighting records were used to provide information on the diversity of cetaceans occurring in the area. Between 2000 and 2003, 12 cetacean species were recorded around the Comoros, including: Megaptera novaeangliae, Stenella longirostris, Peponocephala electra, Stenella attenuata, Tursiops truncatus, Globicephala macrorhynchus, Mesoplodon densirostris, Physeter macrocephalus, Lagenodelphis hosei, Grampus griseus, Mesoplodon pacificus and possibly Tursiops aduncus. During the dedicated surveys, the humpback whale was the most commonly encountered species (72% of sightings) followed by the spinner dolphin (15%). Humpback whale group composition was heterogeneous, but mother-calf pairs were the most commonly sighted (49%). This study demonstrates that the Union of the Comoros is an important site for migrating humpback whales in the southwest Indian Ocean and for a wide variety of toothed cetacean species.
Adherence Feedback to Improve Asthma Outcomes Among Inner-City Children: A Randomized Trial
Authors: Otsuki Michiko , Eakin Michelle N. , Rand Cynthia S. , Butz Arlene M. , Hsu Van Doren , Zuckerman Ilene H. , Ogborn Jean , Bilderback Andrew , Riekert Kristin A.
Published: November 2009

OBJECTIVE: We evaluated the longitudinal effects of home-based asthma education combined with medication adherence feedback (adherence monitoring with feedback [AMF]) and asthma education alone (asthma basic care [ABC]) on asthma outcomes, relative to a usual-care (UC) control group.

METHODS: A total of 250 inner-city children with asthma (mean age: 7 years; 62% male; 98% black) were recruited from a pediatric emergency department (ED). Health-outcome measures included caregiver-frequency of asthma symptoms, ED visits, hospitalizations, and courses of oral corticosteroids at baseline and 6-, 12-, and 18-month assessments. Adherence measures included caregiver-reported adherence to inhaled corticosteroid (ICS) therapy and pharmacy records of ICS refills. Multilevel modeling was used to examine the differential effects of AMF and ABC compared with UC.

RESULTS: ED visits decreased more rapidly for the AMF group than for the UC group, but no difference was found between the ABC and UC groups. The AMF intervention led to short-term improvements in ICS adherence during the active-intervention phase relative to UC, but this improvement decreased over time. Asthma symptoms and courses of corticosteroids decreased more rapidly for the ABC group than for the UC group. Hospitalization rates did not differ between either intervention group and the UC group. No differences were found between the ABC and AMF groups on any outcome.

CONCLUSIONS: Asthma education led to improved adherence and decreased morbidity compared with UC. Home-based educational interventions may lead to modest short-term improvements in asthma outcomes among inner-city children. Adherence feedback did not improve outcomes over education alone.
Variants in the UGT1A1 Gene and the Risk of Pediatric Nonalcoholic Fatty Liver Disease
Authors: Lin Yu-Cheng , Chang Pi-Feng , Hu Fu-Chang , Chang Mei-Hwei , Ni Yen-Hsuan
Published: November 2009

OBJECTIVE: Oxidative stress is increased in nonalcoholic fatty liver disease (NAFLD). Variants in the UGT1A1 gene contribute to increased bilirubin levels, and bilirubin can act as an antioxidant. We hypothesize that variant UGT1A1 genotypes reduce the risk for NAFLD development.

METHODS: Two hundred thirty-four obese children 6 to 13 years of age were recruited. NAFLD was determined through liver ultrasonography. The UGT1A1 genotypes UGT1A1*6 and UGT1A1*28 were detected. We assessed the effects of UGT1A1 genotypes on pediatric NAFLD.

RESULTS: In total, 12% of the obese children had NAFLD. The subjects with NAFLD had lower serum total bilirubin levels (0.25 ± 0.30 mg/dL) than did those without NAFLD (0.36 ± 0.38 mg/dL; P = .021). With conditioning on the effects of age- and gender-adjusted BMI, waist/hip ratio, and adiponectin levels, variant UGT1A1*6 genotypes were a protecting factor for NAFLD, with an estimated adjusted odds ratio of 0.31 (95% confidence interval: 0.11–0.91; P = .033), but variant UGT1A1*28 genotypes were not significantly associated with the occurrence of NAFLD.

CONCLUSIONS: Variant UGT1A1*6 genotypes are associated with a lower risk of NAFLD in obese Taiwanese children. The UGT1A1 genotype is a new risk factor for pediatric NAFLD.
Pompe Disease in Infants: Improving the Prognosis by Newborn Screening and Early Treatment
Authors: Chien Yin-Hsiu , Lee Ni-Chung , Thurberg Beth L. , Chiang Shu-Chuan , Zhang Xiaokui Kate , Keutzer Joan , Huang Ai-Chu , Wu Mei-Hwan , Huang Pei-Hsin , Tsai Fuu-Jen , Chen Yuan-Tsong , Hwu Wuh-Liang
Published: November 2009

OBJECTIVE: Pompe disease causes progressive, debilitating, and often life-threatening musculoskeletal, respiratory, and cardiac symptoms. Favorable outcomes with early intravenous enzyme-replacement therapy and alglucosidase alfa have been reported, but early clinical diagnosis before the development of severe symptoms has rarely been possible in infants.

METHODS: We recently conducted a newborn screening pilot program in Taiwan to improve the early detection of Pompe disease. Six of 206088 newborns screened tested positive and were treated for Pompe disease. Five had the rapidly progressive form of Pompe disease, characterized by cardiac and motor involvement, and were treated soon after diagnosis. The sixth patient was started on treatment at 14 months of age because of progressive muscle weakness. Outcomes were compared with treated patients whose disease was diagnosed clinically and with untreated historical control subjects.

RESULTS: At the time of this report, patients had been treated for 14 to 32 months. The 5 infants who had early cardiac involvement demonstrated normalization of cardiac size and muscle pathology with normal physical growth and age-appropriate gains in motor development. The infant without cardiac involvement also achieved normal motor development with treatment. Survival in patients who had newborn screening was significantly improved compared with those in the untreated reference cohort (P = .001). Survival in the treated clinical comparators was reduced but not statistically different from that in the newborn screening group (P = .48).

CONCLUSIONS: Results from this study indicate that early treatment can benefit infants with Pompe disease and highlight the advantages of early diagnosis, which can be achieved by newborn screening.
Nonaccidental Head Injury Is the Most Common Cause of Subdural Bleeding in Infants <1 Year of Age
Authors: Matschke Jakob , Voss Janina , Obi Nadia , Görndt Jennifer , Sperhake Jan-Peter , Püschel Klaus , Glatzel Markus
Published: November 2009

OBJECTIVE: Subdural bleeding (SDB) in infants is considered an essential symptom of nonaccidental head injury (NAHI). Recently, this view has been challenged by the “unified hypothesis,” which claims that SDB in infants is related to hypoxia and brain swelling rather than to traumatic shearing of bridging veins. We analyzed a large series of infants' autopsies for the presence and causes of SDB, which should be a common event according to the unified hypothesis.

METHODS: Autopsy, clinical, and legal information for infants <1 year of age from a single institution over 50 years were analyzed regarding cause of death, presence, morphology, and cause of SDB, and brain weight.

RESULTS: From a total of 16 661 autopsies during the study period, 715 (4.3%) involved infants <1 year of age. Fifty (7.0%) of those had SDB. NAHI was identified in 17 patients. The most common cause of SDB was trauma (15 cases [30.0%]), with NAHI accounting for 14 cases. SDB was present in 82.4% of patients with NAHI but only 5.2% of infants with other causes of death. Four patients (8.0%) had unexplained SDB with no discernible cause of bleeding. Statistical analysis did not reveal any correlation between the presence of SDB and brain weight.

CONCLUSIONS: In the study population, unexplained SDB in infants was an extreme rarity. Moreover, a correlation between brain swelling and the presence of SDB could not be drawn. Our data argue strongly against the unified hypothesis and strengthen the association between SDB and NAHI in infancy.
Aripiprazole in the Treatment of Irritability in Children and Adolescents With Autistic Disorder
Authors: Owen Randall , Sikich Linmarie , Marcus Ronald N. , Corey-Lisle Patricia , Manos George , McQuade Robert D. , Carson William H. , Findling Robert L.
Published: November 2009

OBJECTIVE: The objective of this study was to evaluate short-term efficacy and safety of aripiprazole in the treatment of irritability in children and adolescents with autistic disorder who were manifesting behaviors such as tantrums, aggression, self-injurious behavior, or a combination of these.

METHODS: This 8-week, double-blind, randomized, placebo-controlled, parallel-group study was conducted of children and adolescents (aged 6–17 years) with autistic disorder. Patients were randomly assigned (1:1) to flexibly dosed aripiprazole (target dosage: 5, 10, or 15 mg/day) or placebo. Efficacy outcome measures included the Aberrant Behavior Checklist irritability subscale and the Clinical Global Impression–Improvement score (CGI-I). Safety and tolerability were also assessed.

RESULTS: Ninety-eight patients were randomly assigned to receive placebo (n = 51) or aripiprazole (n = 47). Mean improvement in Aberrant Behavior Checklist irritability subscale score was significantly greater with aripiprazole than with placebo from week 1 through week 8. Aripiprazole demonstrated significantly greater global improvements than placebo, as assessed by the mean CGI-I score from week 1 through week 8; however, clinically significant residual symptoms may still persist for some patients. Discontinuation rates as a result of adverse events (AEs) were 10.6% for aripiprazole and 5.9% for placebo. Extrapyramidal symptom-related AE rates were 14.9% for aripiprazole and 8.0% for placebo. No serious AEs were reported. Mean weight gain was 2.0 kg on aripiprazole and 0.8 kg on placebo at week 8.

CONCLUSIONS: Aripiprazole was efficacious in children and adolescents with irritability associated with autistic disorder and was generally safe and well tolerated.
Decreased Regional Brain Volume and Cognitive Impairment in Preterm Children at Low Risk
Authors: Soria-Pastor Sara , Padilla Nelly , Zubiaurre-Elorza Leire , Ibarretxe-Bilbao Naroa , Botet Francesc , Costas-Moragas Carme , Falcon Carles , Bargallo Nuria , Mercader Josep Maria , Junqué Carme
Published: November 2009

OBJECTIVE: To investigate whether preterm children with low risk for neurodevelopmental deficits show long-term changes in gray matter (GM) and white matter (WM) volumes compared with term children and to relate these changes to cognitive outcome.

METHODS: MRI was used to evaluate 20 preterm children who were determined to be at low risk for neurodevelopmental deficits and were born between 30 and 34 weeks’ gestational age without major neonatal morbidity or cerebral pathology in the neonatal period and 22 matched, term control subjects. Volumetric images were analyzed by means of voxel-based morphometry to identify regional cerebral alterations. Children also underwent cognitive and behavioral/emotional assessments.

RESULTS: Preterm children showed global and regional GM volume reductions in several brain areas, including temporal and parietal lobes and concomitant WM volume reductions in the same areas, although only the left temporal regions achieved statistical significance. Global intellectual performance in the preterm group was significantly decreased compared with control subjects. Neither behavioral nor emotional problems were found in the preterm group. In the whole sample, we found a positive correlation between GM volume bilaterally in the middle temporal and in the postcentral gyri with IQ. Positive correlations were observed between GM and gestational age at birth in parietal and temporal cerebral regions and with WM in parietal regions.

CONCLUSION: Preterm birth has an important impact on the neurodevelopmental and cognitive outcome of children at 9 years of age, being a risk factor for decreased regional cortical GM and WM even in preterm children with low risk for neurodevelopmental deficits.
Continuous Monitoring of Cerebrovascular Pressure Reactivity After Traumatic Brain Injury in Children
Authors: Brady Ken M. , Shaffner Donald H. , Lee Jennifer K. , Easley R. Blaine , Smielewski Peter , Czosnyka Marek , Jallo George I. , Guerguerian Anne-Marie
Published: November 2009

OBJECTIVE: We hypothesized that pressure reactivity index (PRx) values indicating preserved cerebrovascular pressure autoregulation would be associated with survival in children with traumatic brain injury (TBI). This hypothesis was tested in a prospective, blinded, observational, pilot study.

METHODS: Twenty-one children admitted between May 2006 and September 2008 with severe TBI necessitating invasive intracranial pressure monitoring were enrolled in this study. The PRx was continuously monitored as a moving, linear correlation coefficient between low-frequency waves of intracranial and arterial blood pressures. Positive values of PRx approaching 1 indicate impaired cerebrovascular pressure reactivity, whereas negative PRx values or values close to 0 indicate preserved cerebrovascular pressure reactivity. Survival was the primary outcome and was compared with the average PRx value obtained during the intracranial pressure-monitoring period.

RESULTS: PRx was associated with survival in this cohort; survivors (N = 15) had a mean PRx ± SD of 0.08 ± 0.19, and nonsurvivors (N = 6) had a mean PRx of 0.69 ± 0.21 (P = .0009). In this sample, continuous PRx monitoring suggested impaired cerebrovascular pressure reactivity at low levels of cerebral perfusion pressure (CPP) and intact cerebrovascular pressure reactivity at higher levels of CPP.

CONCLUSIONS: Intact cerebrovascular pressure reactivity quantified with the PRx is associated with survival after severe head trauma in children. The PRx is CPP dependent in children. The PRx may be useful for defining age-specific and possibly patient-specific optimal targets for CPP after TBI.
Attitudes of Adolescent Cancer Survivors Toward End-of-Life Decisions for Minors
Authors: Pousset Geert , Bilsen Johan , De Wilde Joke , Benoit Yves , Verlooy Joris , Bomans An , Deliens Luc , Mortier Freddy
Published: November 2009

OBJECTIVES: The present study aimed to investigate the attitudes of adolescent cancer survivors toward end-of-life decisions with life-shortening effects, including nontreatment decisions (NTDs), intensified alleviation of pain and symptoms (APS), and euthanasia, and the influence of illness experience on these attitudes.

METHODS: Adolescent cancer survivors were interviewed with a structured questionnaire using hypothetical case descriptions. The results were compared with a study of 1769 adolescents without experience of chronic illness.

RESULTS: Eighty-three adolescents, 11 to 18 years of age, were interviewed. In terminal situations, 70% to 90% found requests for NTDs acceptable, 84% requests for APS, and 57% to 64% requests for euthanasia. Requests for end-of-life decisions were less acceptable in nonterminal situations, where 28% found requests for NTDs acceptable, 39% to 47% requests for APS, and 11% to 21% requests for euthanasia. Frequently cited reasons for holding back physicians from administering a lethal drug to a child were the child not being well informed about his or her condition (92%) and the parents' opinion not being asked (92%). Compared with adolescents without experience with chronic illness, cancer survivors were more accepting toward requests for NTDs and APS in terminal situations.

CONCLUSIONS: Adolescent cancer survivors, like other adolescents, want to be involved in medical decision-making at the end of life. They value autonomous decision-making, without excluding parents from the process. The experience of living through a life-threatening illness can alter adolescents' attitudes toward requests for NTDs and APS.
Depressive Symptoms in Nonresident African American Fathers and Involvement With Their Sons
Authors: Davis R. Neal , Caldwell Cleopatra Howard , Clark Sarah J. , Davis Matthew M.
Published: November 2009

OBJECTIVE: Our objective was to determine whether paternal depressive symptoms were associated with less father involvement among African American fathers not living with their children (ie, nonresident fathers).

METHODS: We analyzed survey data for 345 fathers enrolled in a program for nonresident African American fathers and their preteen sons. Father involvement included measures of contact, closeness, monitoring, communication, and conflict. We used bivariate analyses and multivariate logistic regression analysis to examine associations between father involvement and depressive symptoms.

RESULTS: Thirty-six percent of fathers reported moderate depressive symptoms, and 11% reported severe depressive symptoms. In bivariate analyses, depressive symptoms were associated with less contact, less closeness, low monitoring, and increased conflict. In multivariate analyses controlling for basic demographic features, fathers with moderate depressive symptoms were more likely to have less contact (adjusted odds ratio: 1.7 [95% confidence interval: 1.1–2.8]), less closeness (adjusted odds ratio: 2.1 [95% confidence interval: 1.3–3.5]), low monitoring (adjusted odds ratio: 2.7 [95% confidence interval: 1.4–5.2]), and high conflict (adjusted odds ratio: 2.1 [95% confidence interval: 1.2–3.6]). Fathers with severe depressive symptoms also were more likely to have less contact (adjusted odds ratio: 3.1 [95% confidence interval: 1.4–7.2]), less closeness (adjusted odds ratio: 2.6 [95% confidence interval: 1.2–5.7]), low monitoring (adjusted odds ratio: 2.8 [95% confidence interval: 1.1–7.1]), and high conflict (adjusted odds ratio: 2.6 [95% confidence interval: 1.1–5.9]).

CONCLUSION: Paternal depressive symptoms may be an important, but modifiable, barrier for nonresident African American fathers willing to be more involved with their children.
Unmet Health Care Needs Among CSHCN With Neurologic Conditions
Authors: Bitsko Rebecca H. , Visser Susanna N. , Schieve Laura A. , Ross Danielle S. , Thurman David J. , Perou Ruth
Published: November 2009

OBJECTIVE

Children with neurologic conditions require a variety of services. With this study we examined health care needs and unmet needs among children with neurologic conditions.

METHODS

Cross-sectional data reported by parents of 3-to 17-year-olds in the 2005–2006 National Survey of Children With Special Health Care Needs were analyzed. Demographic characteristics, health care needs, and unmet needs of children with special health care needs (CSHCN) and neurologic conditions were descriptively compared with an independent referent group of children without special health care needs; statistical contrasts were performed as a function of the type (conditions included in the Diagnostic and Statistical Manual of Mental Disorders [DSM] or not) and number of reported neurologic conditions.

RESULTS

Compared with the parents of children without special health care needs, parents of CSHCN with neurologic conditions were more likely to report unmet health care needs for their child. After adjustment for demographic factors and severity of functional limitation, CSHCN with at least 2 conditions had more visits to a health care provider, needed more services, and reported more unmet needs than CSHCN with a single DSM condition. The magnitude of need among CSHCN was greatest among those with at least 1 of each type of neurologic condition.

CONCLUSIONS

Unmet health care needs exist among CSHCN with neurologic conditions and are particularly pronounced among children with a combination of both DSM and non-DSM disorders. The health care needs among CSHCN with multiple neurologic conditions may be better served by targeted efforts to improve care coordination.
Geographic Disparities in Access to the Medical Home Among US CSHCN
Authors: Singh Gopal K. , Strickland Bonnie B. , Ghandour Reem M. , van Dyck Peter C.
Published: November 2009

OBJECTIVES: In this study we examined geographic disparities in medical home access among US children with special health care needs (CSHCN) aged 0 to 17 years.

METHODS: The 2005–2006 National Survey of Children With Special Health Care Needs was used to estimate prevalence and odds of not having a medical home and 5 component outcomes according to state. Logistic regression was used to examine individual-level and state-level determinants of access.

RESULTS: Medical home access varied substantially across geographic areas. CSHCN in Alaska, Arizona, Washington, DC, Florida, Illinois, Massachusetts, New Jersey, Nevada, and Virginia had at least 50% higher adjusted odds of not having a medical home than CSHCN in Iowa. The adjusted prevalence of CSHCN lacking a medical home varied from a low of 46% in Iowa and Ohio to a high of 59% in Alaska and 61% in New Jersey. CSHCN in several western and southwestern states experienced greater problems with access to a personal doctor/nurse, a usual source of care, specialty care referrals, care coordination, and family-centered care. Adjustment for age, gender, race/ethnicity, household socioeconomic status, language use, insurance coverage, and functional limitation reduced state disparities in access. CSHCN in states with higher immigrant and non–English-speaking populations had significantly lower medical home access. Increases in state health care expenditure and infrastructure and Medicaid/State Children's Health Insurance Program eligibility were associated with increased access to a personal doctor/nurse.

CONCLUSIONS: Although individual-level sociodemographic and state-level health policy variables are important predictors of access, substantial geographic disparities remain, with CSHCN in several western and northeastern states at high risk of not having a medical home.
The Well-Being of the Health Care Environment for CSHCN and Their Families: A Latent Variable Approach
Authors: Blumberg Stephen J. , Carle Adam C.
Published: November 2009

OBJECTIVE: Using structural equation modeling, we sought to assess the system of services for children with special health care needs (CSHCN) and their families by using 14 key indicators of functional abilities of CSHCN, health insurance coverage, access to care, and the impact of their conditions on their families.

METHODS: With data from the 2001 and 2005–2006 National Surveys of Children With Special Health Care Needs, we used confirmatory factor analysis for ordered-categorical measures to model the relationship between an indirectly observed (ie, latent) variable and the key indicators and evaluate changes in this relationship over time.

RESULTS: For both survey periods, a single-factor model fit well. The latent construct was defined as the well-being of the health care environment for CSHCN and their families. Family financial problems caused by the child's condition, unmet needs for family support services, and negative impact on employment were most strongly related to the latent well-being construct. The lowest levels of the well-being construct were associated with families that had unmet needs for support services, CSHCN who lacked a usual place for care, and families that spent ≥11 hours/week providing or coordinating care. CSHCN and their families with family-centered care and with adequate health insurance were likely to have average or better levels of the well-being construct. Mean levels of the well-being construct were unchanged over time.

CONCLUSIONS: The 14 key indicators can be used to reliably assess a single latent construct. The relative ordering of the indicators' thresholds (a model parameter) may be useful for guiding pediatricians' evaluations of the health care environment for CSHCN and their families. Researchers may use the scores available from the latent-variable model to assess outcomes related to the health care environment and the system of services for CSHCN and their families.
Oral Health Care in CSHCN: State Medicaid Policy Considerations
Authors: Kenney Mary Kay
Published: November 2009

OBJECTIVE: Low dental care service utilization among Medicaid-enrolled children has often been attributed to low Medicaid reimbursement levels. The purpose of this study was to provide estimates of preventive dental care utilization by Medicaid-enrolled children with special health care needs (CSHCN) and investigate the association of Medicaid preventive dental care reimbursement levels with the receipt of preventive dental care.

METHODS: We analyzed data for 40256 CSHCN (1–17 years of age). Unadjusted estimates of not needing, needing and receiving, and needing but not receiving preventive dental care are presented. Multilevel logistic regression models were fitted to examine associations between state Medicaid dental-procedure reimbursement and receipt of preventive dental care.

RESULTS: Some significant associations were found between state-level Medicaid dental-procedure reimbursements and receipt of preventive dental care. The strongest individual-level factor associated with not receiving needed preventive dental care was not receiving needed preventive medical care. Parents of Medicaid-enrolled CSHCN were less likely to report receiving needed preventive dental care and more likely to report not needing or not receiving preventive dental care than non–Medicaid-enrolled CSHCN.

CONCLUSIONS: Medicaid-enrolled CSHCN received less needed preventive dental care than non–Medicaid-enrolled CSHCN. An important link to receiving appropriate dental care may be the primary care provider. Raising the level of preventive dental care reimbursement along with other policy changes should increase the frequency of CSHCN receiving preventive dental services. State Medicaid agencies must develop models of medical-dental care management for CSHCN in their programs to ensure the most appropriate care.
Does Private Insurance Adequately Protect Families of Children With Mental Health Disorders?
Authors: Busch Susan H. , Barry Colleen L.
Published: November 2009

OBJECTIVE: Although private insurance typically covers many health care costs, the challenges faced by families who care for a sick child are substantial. These challenges may be more severe for children with special health care needs (CSHCN) with mental illnesses than for other CSHCN. Our objective was to determine if families of privately insured children who need mental health care face different burdens than other families in caring for their children.

PATIENTS AND METHODS: We used the 2005–2006 National Survey of Children With Special Health Care Needs (NS-CSHCN) to study privately insured children aged 6 to 17 years. We compared CSHCN with mental health care needs (N = 4918) to 3 groups: children with no special health care needs (n = 2346); CSHCN with no mental health care needs (n = 16250); and CSHCN with no mental health care need but a need for other specialty services (n = 7902). The latter group was a subset of CSHCN with no mental health care need. We used weighted logistic regression and study outcomes across 4 domains: financial burden; health plan experiences; labor-market and time effects; and parent experience with services.

RESULTS: We found that families of children with mental health care needs face significantly greater financial barriers, have more negative health plan experiences, and are more likely to reduce their labor-market participation to care for their child than other families.

CONCLUSIONS: Families of privately insured CSHCN who need mental health care face a higher burden than other families in caring for their children. Policies are needed to help these families obtain affordable, high-quality care for their children.
Access to and Satisfaction With School and Community Health Services for US Children With ASD
Authors: Montes Guillermo , Halterman Jill S. , Magyar Caroline I.
Published: November 2009

OBJECTIVE: Our objective was to compare access to and satisfaction with school and community health resources among families with a child with an autism spectrum disorder (ASD) and families of other children with special health care needs (CSHCN).

METHODS: Parents of 40256 children aged 0 to 17 were surveyed by the 2005–2006 National Survey of Children With Special Health Care Needs. Autism was defined by the question, “To the best of your knowledge, does (child) currently have autism or autism spectrum disorder, that is, ASD?” We used χ2 and multivariate regression analyses to compare access to and satisfaction with services for parents of children with ASDs and parents of other CSHCN.

RESULTS: Children with ASDs (n = 2123) comprise 5.4% of the CSHCN. More parents of children with ASDs reported difficulty using school and community services (27.6% vs 9.7%) and dissatisfaction (19.8% vs 7.9%) than parents of other CSHCN. Multivariate models determined that parents of children with ASDs were 3.39 times more likely to experience difficulty in obtaining services and 2.65 times more likely to be dissatisfied with services received than parents of other CSHCN, after controlling for household demographics and insurance status. Parents of children with ASDs reported a lack of available services and skilled providers.

CONCLUSIONS: Parents of children with ASDs reported less access to and more dissatisfaction with school and community health services than parents of other CSHCN. An increased supply of appropriate services with qualified providers for children with ASDs is needed in the United States.
The Impact of Insurance on Satisfaction and Family-Centered Care for CSHCN
Authors: Thompson Lindsay A. , Knapp Caprice A. , Saliba Heidi , Giunta Nancy , Shenkman Elizabeth A. , Nackashi John
Published: November 2009

BACKGROUND: Children with special health care needs (CSHCN) have worse health outcomes and satisfaction compared with children with typical needs. Although individual characteristics influence satisfaction and family-centered care, additional effects of health insurance and state child health policies are unknown.

OBJECTIVES: To determine if satisfaction and family-centered care varied among CSHCN, after adjusting for individual characteristics, according to insurance type and state child health policies.

METHODS: We performed descriptive and multivariate analyses by using demographic, insurance, and satisfaction data from the 2006 National Survey of Children With Special Health Care Needs (N = 40723). Additional state data included Medicaid and State Children's Health Insurance Program (SCHIP) characteristics and the supply of pediatricians. We supplemented the national findings with survey data from Florida's SCHIP comprehensive care program (CMS-Duval [“Ped-I-Care”]) for CSHCN (N = 300).

RESULTS: Nationally, 59.8% of parents were satisfied with their child's health services, and two thirds (65.7%) received family-centered care. Adjusting for individual predictors, those uninsured and those with public insurance were less satisfied (odds ratios [ORs]: 0.45 and 0.83, respectively) and received less family-centered care (ORs: 0.43 and 0.80, respectively) than privately insured children. Of note, satisfaction increased with state Medicaid spending. Survey data from Ped-I-Care yielded significantly higher satisfaction (91.7%) compared with national levels of satisfaction in the SCHIP (54.2%) and similar rates of family-centered care (65.6%). These results suggest that satisfaction is based more on experiences with health systems, whereas family-centered care reflects more on provider encounters.

CONCLUSIONS: Insurance type affects both satisfaction and family-centered care for CSHCN, and certain state-level health care characteristics affect satisfaction. Future studies should focus on interventions in the health care system to improve satisfaction and patient encounters for family-centered care.
Financial Burden of Raising CSHCN: Association With State Policy Choices
Authors: Parish Susan L. , Shattuck Paul T. , Rose Roderick A.
Published: November 2009

OBJECTIVE: We examined the association between state Medicaid and State Children's Health Insurance Program (SCHIP) income eligibility and the financial burden reported by low-income families raising children with special health care needs (CSHCN).

SAMPLE AND METHODS: Data on low-income CSHCN and their families were from the National Survey of Children With Special Health Care Needs (N = 17039), with a representative sample from each state. State Medicaid and SCHIP income-eligibility thresholds were from publicly available sources. The 3 outcomes included whether families had any out-of-pocket health care expenditures during the previous 12 months for their CSHCN, amount of expenditure, and expenditures as a percentage of family income. We used multilevel logistic regression to model the association between Medicaid and SCHIP characteristics and families' financial burden, controlling state median income and child- and family-level characteristics.

RESULTS: Overall, 61% of low-income families reported expenditures of >$0. Among these families, 30% had expenses between $250 and $500, and 34% had expenses of more than $500. Twenty-seven percent of the families reporting any expenses had expenditures that exceeded 3% of their total household income. The percentage of low-income families with out-of-pocket expenses that exceeded 3% of their income varied considerably according to state and ranged from 5.6% to 25.8%. Families living in states with higher Medicaid and SCHIP income-eligibility guidelines were less likely to have high absolute burden and high relative burden.

CONCLUSIONS: Beyond child and family characteristics, there is considerable state-level variability in low-income families’ out-of-pocket expenditures for their CSHCN. A portion of this variability is associated with states' Medicaid and SCHIP income-eligibility thresholds. Families living in states with more generous programs report less absolute and relative financial burden than families living in states with less generous benefits.
Variation in Provider Vaccine Purchase Prices and Payer Reimbursement
Authors: Freed Gary L. , Cowan Anne E. , Gregory Sashi , Clark Sarah J.
Published: November 2009

OBJECTIVE: The purpose of this work was to collect data regarding vaccine prices and reimbursements in private practices. Amid reports of physicians losing money on vaccines, there are limited supporting data to show how much private practices are paying for vaccines and how much they are being reimbursed by third-party payers.

METHODS: We conducted a cross-sectional survey of a convenience sample of private practices in 5 states (California, Georgia, Michigan, New York, and Texas) that purchase vaccines for administration to privately insured children/adolescents. Main outcome measures included prices paid to purchase vaccines recommended for children and adolescents and reimbursement from the 3 most common, non-Medicaid payers for vaccine purchase and administration.

RESULTS: Detailed price and reimbursement data were provided by 76 practices. There was a considerable difference between the maximum and minimum prices paid by practices, ranging from $4 to more than $30 for specific vaccines. There was also significant variation in insurance reimbursement for vaccine purchase, with maximum and minimum reimbursements for a single vaccine differing from $8 to more than $80. Mean net yield per dose (reimbursement for vaccine purchase minus price paid per dose) varied across vaccines from a low of approximately $3 to more than $24. Reimbursement for the first dose of vaccine administered ranged from $0 to more than $26, with a mean of $16.62.

CONCLUSIONS: There is a wide range of prices paid by practices for the same vaccine product and in the reimbursement for vaccines and administration fees by payers. This variation highlights the need for individual practices to understand their own costs and reimbursements and to seek opportunities to reduce costs and increase reimbursements.
Primary Care Physician Perspectives on Reimbursement for Childhood Immunizations
Authors: Freed Gary L. , Cowan Anne E. , Clark Sarah J.
Published: November 2009

OBJECTIVES: The purpose of this research was to explore physicians' attitudes and behaviors related to vaccine financing issues within their practice. Amid the increasing number of vaccine doses recommended for children and adolescents, anecdotal reports suggest that physicians are facing increasing financial pressures from vaccine purchase and administration and may stop providing vaccines altogether to privately insured children. Whether these sentiments are widely held among immunization providers is unknown.

METHODS: We conducted a cross-sectional mail survey from July to September 2007 of a random sample of 1280 US pediatricians and family physicians engaged in direct patient care. Main outcome measures included delay in the purchase of specific vaccines for financial reasons; reported decrease in profit margin from immunizations; and practice consideration of whether to stop providing all vaccines to privately insured children.

RESULTS: The response rate was 70% for pediatricians and 60% for family physicians. Approximately half of the respondents reported that their practice had delayed the purchase of specific vaccines for financial reasons (49%) and experienced decreased profit margin from immunizations (53%) in the previous 3 years. Twenty-one percent of respondents strongly disagreed that “reimbursement for vaccine purchase is adequate,” and 17% strongly disagreed that “reimbursement for vaccine administration is adequate.” Eleven percent of respondents said their practice had seriously considered whether to stop providing all vaccines to privately insured children in the previous year.

CONCLUSIONS: Physicians who provide vaccines to children and adolescents report dissatisfaction with reimbursement levels and increasing financial strain from immunizations. Although large-scale withdrawal of immunization providers does not seem to be imminent, efforts to address root causes of financial pressures should be undertaken.
Net Financial Gain or Loss From Vaccination in Pediatric Medical Practices
Authors: Coleman Margaret S. , Lindley Megan C. , Ekong John , Rodewald Lance
Published: November 2009

OBJECTIVE: The goal was to determine the net return (gain or loss after costs were subtracted from revenues) to private pediatric medical practices from investing time and resources in vaccines and vaccination of their patients.

METHODS: A cross-sectional survey of a convenience sample of private medical practices requested data on all financial and capacity aspects of the practices, including operating expenses; labor composition and wages/salaries; private- and public-purchase vaccine orders and inventories; Medicaid and private insurance reimbursements; patient population; numbers of providers; and numbers, types, and lengths of visits. Costs were assigned to vaccination visits and subtracted from reimbursements from public- and private-pay sources to determine net financial gains/losses from vaccination.

RESULTS: Thirty-four practices responded to the survey. More than one half of the respondents broke even or suffered financial losses from vaccinating patients. With greater proportions of Medicaid-enrolled patients served, greater financial loss was noted. On average, private insurance vaccine administration reimbursements did not cover administration costs unless a child received ≥3 doses of vaccine in 1 visit. Finally, wide ranges of per-dose prices paid and reimbursements received for vaccines indicated that some practices might be losing money in purchasing and delivering vaccines for private-pay patients if they pay high purchase prices but receive low reimbursements.

CONCLUSIONS: We conclude that the vaccination portion of the business model for primary care pediatric practices that serve private-pay patients results in little or no profit from vaccine delivery. When losses from vaccinating publicly insured children are included, most practices lose money.
Cost of Vaccine Administration Among Pediatric Practices
Authors: Glazner Judith E. , Beaty Brenda , Berman Stephen
Published: November 2009

OBJECTIVE: The goal was to describe variable costs to providers of delivering childhood immunizations.

METHODS: We documented variable costs (costs that vary with the amount of services rendered), including time spent by pediatric staff members and physicians on immunization-related activities, as well as supply costs and medical waste disposal costs. Ten private pediatric practices in the Denver, Colorado, metropolitan area participated in the study. Among the 7 practices that provided us with payment data, 8 health plans were mentioned by ≥2 practices. There were 37 different agreements between the health plans and practices for vaccine administration payments.

RESULTS: The total documented variable cost per injection (excluding vaccine cost) averaged $11.51, calculated from the following categories: nursing time, $1.71; billing services, $2.67; nonroutine services, $1.64; registry use, $0.96; physician time, $4.05; supplies, $0.36; medical waste disposal, $0.12. Nonroutine activities primarily included performing vaccine inventory and ordering, providing vaccination records to requesters, and answering parent telephone questions about vaccinations. With the use of a simulation model to compensate for the small number of participating practices, the calculated total variable cost per injection was $11.83. When 2 vaccines were administered, we compared the sum of the 2 payments with the sum of the 2 variable costs ($23.02). More than one third of the payment agreements (13 of 37 agreements) paid the practices less than the combined variable costs for 2 immunizations.

CONCLUSION: This study shows that the variable costs of vaccine administration exceeded reimbursement from some insurers and health plans.
Health Insurance Plans and Immunization: Assessment of Practices and Policies, 2005–2008
Authors: Hunsaker John , Veselovskiy German , Gazmararian Julie A.
Published: November 2009

OBJECTIVES: The goals were to assess private health insurance plans' policies and practices regarding recommended immunizations in 2008 and to identify trends since the America's Health Insurance Plans (AHIP) 2005 Immunization Assessment.

METHODS: In May 2008, AHIP staff members e-mailed a survey containing 46 questions on immunization practices to 101 AHIP member private health insurance plans. Of those, 58 responded (representing 121345521 covered individuals) and 43 declined to participate, yielding a response rate of 57% (compared with 53% in 2005). Data are reported as proportions of enrollees (weighted data) or of responding plans (unweighted data).

RESULTS: In 2008, almost all enrollees (99.8%) represented in the survey were in health insurance plans that used Advisory Committee on Immunization Practices (ACIP) recommendations to determine coverage. The vast majority (≥99.0%) of enrollees were in plans covering all ACIP-recommended child and adolescent vaccines in ≥75% of the health insurance product lines offered, and ≥16.5% of enrollees were in plans covering these vaccines in all products. The majority of enrollees (≥83.3%) were in plans covering ACIP-recommended pediatric and adolescent vaccines without cost-sharing. Plans covering 95.5% of enrollees updated benefits to reflect changes in vaccine recommendations within ≤3 months, compared with 60.0% in 2005. In 2008, 96.7% of enrollees were in plans that could reimburse providers for vaccines within 3 months once the vaccines were included in benefit designs, compared with 59.2% in 2005.

CONCLUSION: The survey shows widespread private health insurance plan coverage of vaccines, consistent with, or better than, the coverage levels reported in the AHIP 2005 survey.