Racial and Ethnic Disparities in Indicators of a Primary ... - CiteSeerX

3 downloads 19828 Views 107KB Size Report
ities compared with white children in having a medical home. Study of individual ... University of Texas M. D. Anderson Cancer Center, Houston, Tex .... Needed to call child's PDN for help or advice? If yes, got ..... Public Health Rep. 2005 ...
Medical Home

Racial and Ethnic Disparities in Indicators of a Primary Care Medical Home for Children Jean L. Raphael, MD, MPH; B. Ashleigh Guadagnolo, MD, MPH; Anne C. Beal, MD, MPH; Angelo P. Giardino, MD, PhD, MPH Objective.—Racial/ethnic disparities in access to care across a broad range of health services have been well established. In adults, having a medical home has been shown to reduce disparities. The objective of this study was to assess the extent to which children of different race/ethnicities receive primary care consistent with a medical home. Methods.—We conducted a secondary analysis of 84 101 children, ages 0–17, from the 2003–2004 National Survey of Children’s Health, a nationwide household survey. The primary independent variable was race/ethnicity of the child. The main dependent variable was a medical home as defined by the American Academy of Pediatrics. Multiple logistic regression was conducted to investigate associations between race/ethnicity and having a medical home. Results.—The odds of having a medical home were lower for non-Hispanic black (odds ratio [OR] 0.76, 95% confidence

interval [95% CI] 0.69–0.83), Hispanic (OR 0.80, 95% CI 0.72–0.89), and other (OR 0.77, 95% CI 0.69–0.87) children compared with non-Hispanic white children after adjusting for sociodemographic variables. Specific components of a medical home for which minority children had a lower odds (P < .01) of having compared with white children included having a personal provider, a provider who always/usually spent enough time with them, and a provider who always/usually communicated well. Conclusions.—Minority children experienced multiple disparities compared with white children in having a medical home. Study of individual medical home components has the potential to identify specific areas to improve disparities.

R

compassionate, and culturally effective.11 A limited number of studies on medical homes have shown potential benefits including improved health outcomes, lower health care costs, and increased patient satisfaction.12–15 Investigators from the Commonwealth Fund demonstrated that having a medical home, and not just primary care, was associated with reduction of disparities for adults.16 Over the past decade, there has been an increasing focus on more comprehensive health care delivery models in order to address disparities and overall health care performance.17–19 Although evidence on disparities has mounted, the medical home concept has evolved as a valuable model for health care delivery to children and families.20 Despite the potential of a medical home to improve the quality of care for children of minority backgrounds, little is known about the extent to which minorities have medical homes as defined by the AAP. Additionally, little has been published contrasting the usefulness of a composite medical home measure as a summary metric versus the individual components as factors amenable to improvement. Therefore, the aims of this study were to examine racial/ethnic disparities among children in having a medical home and to determine whether a composite measure of medical home care provided any different information regarding disparities compared with assessing individual components of a medical home. We hypothesized that racial/ethnic minority children were less likely to have a medical home compared with non-Hispanic white children.

KEY WORDS: pediatrics; health disparities; medical home Academic Pediatrics 2009;9:221–7

acial/ethnic disparities in access to care have been well documented in the US health care system and pose a substantial barrier to quality care.1 A limited number of studies have demonstrated that racial/ethnic minority children experience lower-quality care than non-Hispanic whites even when other important factors such as insurance coverage are considered.1–4 In terms of primary care, multiple studies have specifically examined disparities in having a usual source of care or access to specific services.5–7 A recent analysis of the 2003 National Survey of Children’s Health demonstrated racial/ethnic disparities for numerous measures of access to care, use of services, and health status.2 National initiatives increasingly include recommendations that all children have a medical home.8 Although a medical home has been historically determined by the presence of a usual source of care, more recent definitions expand on this construct.9,10 The American Academy of Pediatrics (AAP) defines a medical home as care that is accessible, continuous, comprehensive, family centered, coordinated, From the Department of Pediatrics, Baylor College of Medicine, Houston, Tex (Dr Raphael and Dr Giardino); Department of Radiation Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Tex (Dr Guadagnolo); and Commonwealth Fund, New York, NY (Dr Beal). Address correspondence to Jean L. Raphael, MD, MPH, Clinical Care Center, Suite D.1540.00, Texas Children’s Hospital, 6621 Fannin Street, Houston, Texas 77030 (e-mail: [email protected]). Received for publication July 29, 2008; accepted January 30, 2009. ACADEMIC PEDIATRICS Copyright Ó 2009 by Academic Pediatric Association

221

Volume 9, Number 4 July–August 2009

222

Raphael et al

METHODS Survey Design and Participants Data for this study were drawn from the 2003 National Survey of Children’s Health (NSCH), a telephone survey sponsored by the Maternal and Child Health Bureau (MCHB).21 The purpose of the NSCH was to assess health indicators in children ages 0 to 17 years of age and to measure their experiences in the health care system. The NSCH used the State and Local Area Integrated Telephone Survey program, an ongoing surveillance initiative available for tracking and monitoring the health and well-being of children and adults. The NSCH used a multistage cluster design based on a random-digit-dialed sample of households with children younger than 18 years of age selected from each of the 50 states and the District of Columbia, allowing computation of reliable state and national estimates. The NSCH was conducted from January 2003 to July 2004, with a total of 102 353 interviews completed. The publicuse data and documentation for the NSCH is available at: http://www.cdc.gov/nchs/about/major/slaits/nsch.htm. Dependent Variables The primary outcome measure was a composite medical home determination reflective of the AAP criteria for a medical home. The definition of medical home and its components as enumerated here was derived from a definition set forth and operationalized for the National Center for Health Statistics by an advisory group consisting of the Child and Adolescent Health Measurement Initiative (CAHMI), MCHB, and its NSCH Technical Expert Panel.22–24 The scoring algorithm developed by the advisory group uses a dichotomous medical home composite measure that classifies children as either having or not having a medical home. The components of the medical home operationalized in the NSCH are shown in Table 1. Of the 7 AAP medical home components, 5 are operationalized in the NSCH. Continuous and accessible care are not assessed given the limitations of a cross-sectional, point-in-time survey in measuring these components via parent report.24 According to the scoring algorithm, access to a medical home must meet the following criteria: 1) the child must have a personal doctor or nurse; and 2) the child must have had at least one preventive medical care visit in the last 12 months; and 3) the child must consistently get needed medical care. This final criterion is intended to encompass family-centered, compassionate, culturally appropriate, comprehensive, and coordinated care. To fulfill the criterion of getting needed care, the respondent must have indicated all of the following: 1) the child’s personal doctor or nurse ‘‘always or usually’’ spends enough time and communicates well; and 2) the child ‘‘always or usually’’ gets needed care and advice from a personal provider; and 3) if applicable, the respondent reported ‘‘no or few problems’’ accessing needed specialist care, services, or equipment; and 4) if applicable, the respondent indicated that a personal doctor or nurse ‘‘always or usually’’ follows up after the child receives specialist care, services, or equipment.

ACADEMIC PEDIATRICS

In addition to the composite medical home, the individual questions related to having a medical home were also used as variables. Two of the questions had dichotomous yes/no responses: having a personal doctor/nurse and having a preventive care visit in the last 12 months. Five of the questions had responses categorized as usually/always versus sometimes/never. These questions addressed the following: whether the provider spent enough time with the patient; whether the provider communicated well; whether the patient received phone care and advice; whether the patient received needed care right away; and whether the provider followed up on specialty care. The last question used as a variable asked whether a patient had any problems gaining access to specialty care, services, or equipment. The responses were categorized as small/no problem versus moderate/big problem. Independent Variables The primary independent variable, race/ethnicity, was determined using the categories defined by the survey.21 Parents were first asked if the child was of Hispanic or Latino origin. Parent were then asked to choose one or more of the following categories to describe child’s race: white, black or African American, American Indian, Alaska Native, Asian, Native Hawaiian, or other Pacific Islander. Parents were allowed to select as many categories as applicable. For the purposes of this study, an algorithm was created to create mutually exclusive and relevant race/ ethnicity categories such that non-Hispanic whites, nonHispanic blacks, Hispanic, and non-Hispanic others were the final groups (hereafter, white, black, Hispanic, and other, respectively). The ‘‘other’’ category consists of American Indian, Alaska Native, Asian, Native Hawaiian, and other Pacific Islander. This composite category was set by the NSCH to protect the confidentiality of individual respondents and children belonging to particularly small groups,21 so access to data regarding specific individual groups within this category were not available for study. Child health status was assessed with the question, ‘‘In general, how would you describe [child]’s health? Would you say [his/her] health is excellent, very good, good, fair, or poor?’’ Special needs status was assessed separately. Children in the survey were screened for special health care needs by using the Child and Adolescent Health Measurement Initiative Children with Special Health Care Needs screener.25 The screener had 5 stem items inquiring about a condition that has lasted or is expected to last $1 year and results in the need for medical and other services, special therapies, or prescription medications, limitations of ability, or emotional, behavioral, or developmental issues requiring counseling. Insurance status in the last 12 months was categorized as insured for entire year, not insured at some point during the year, or uninsured. Age and gender were also recorded. In addition to child characteristics, family characteristics were also measured. Primary language was assessed by the question, ‘‘What is the primary language spoken in your home?’’ We dichotomized primary language as English versus any other language. Nativity, or immigration status,

ACADEMIC PEDIATRICS

Health Disparities in Indicators for a Primay Care Medical Home for Children

223

Table 1. American Academy of Pediatrics Medical Home Components and Corresponding Survey Questions Medical Home Component

Corresponding Survey Questions

Specific provider

Child has one or more health care providers considered to be personal doctor or nurse

Accessible

(Not assessed in survey)

Family centered

How often does child’s PDN*  Spend enough time with child?  Explain things in ways that child and parents can understand? (Not assessed in survey)

Continuous Comprehensive

A) Timely access to needed care or phone advice during past 12 months:  Needed to call child’s PDN for help or advice? If yes, got needed help from child’s PDN?  Needed care right away from child’s PDN? If yes, got needed care right away from child’s PDN? B) Access to needed specialty care and services during past 12 months:  Needed specialist doctor care recommended by child’s PDN? If yes, problems getting needed specialist care?  Needed special services or equipment not available from PDN? If yes, problems getting needed special health services or equipment? C) Preventive care visit  Number of preventive care visits during past 12 months with any health provider

Coordinated

Follow-up after specialty care visits during past 12 months:  How often did PDN follow up with parents after child visited a specialist?  How often did PDN follow up with parents after child received special health services or equipment?

Compassionate

(Addressed in the Family-Centered Care component questions)

Culturally effective

Availability of language services during past 12 months:  Needed an interpreter to help speak with child’s doctors or nurses? If yes, how often able to get someone other than a family member to help speak with child’s doctors or nurses?

*PDN ¼ personal doctor or nurse.

was categorized into 4 groups 1) immigrant parents, immigrant child; 2) immigrant parents, US-born child; 3) one immigrant parent, US-born child; and 4) US-born parents, US-born child. Family structure was categorized as 2 parent (biological or adopted); 2 parents, step; single parent; and any other family structure. Parental education was assessed by the question, ‘‘What is the highest level of education attained by anyone in your household?’’ and categorized as less than high school, high school, or more than high school. Income data relative to the federal poverty level were also recorded. Data Analysis All statistical data analyses were performed by SPSS version 16.0 (Apache Software Foundation) with SPSS Complex Samples, which accounted for the complex survey design of NSCH, including clustering of children within households, stratification of households within states, and unequal sampling weights. The composite measure for having a medical home was calculated from the individual components of a medical home included in the survey, as described above. Differences between proportions were compared by the c2 statistic. Bivariate and multivariable logistic regression analyses were used to examine the associations between sociodemographic variables and having a medical home or its individual components. Odds ratios (OR) and 95% confidence intervals (95% CI) were

calculated for the bivariate logistic regression models. Adjusted odds ratios (AORs) from the multivariable logistic models controlled for independent variables. A 2-sided 0.05 a level was considered as a statistically significant result. For all variables except income, immigration status, and family structure, 400% FPL 300–400% FPL 200–300% FPL 100–200% FPL