Health services research conducted over the past 25 years makes a compelling case that having health insurance or using more medical care would improve the health of the uninsured. The literature's broad range of conditions, populations, and methods makes it difficult to derive a precise quantitative estimate of the effect of having health insurance on the uninsured's health. Some mortality studies imply that a 4% to 5% reduction in the uninsured's mortality is a lower bound; other studies suggest that the reductions could be as high as 20% to 25%. Although all of the studies reviewed suffer from methodological flaws of varying degrees, there is substantial qualitative consistency across studies of different medical conditions conducted at different times and using different data sets and statistical methods. Corroborating process studies find that the uninsured receive fewer preventive and diagnostic services, tend to be more severely ill when diagnosed, and receive less therapeutic care. Other literature suggests that improving health status from fair or poor to very good or excellent would increase both work effort and annual earnings by approximately 15% to 20%.

Sicker and poorer--the consequences of being uninsured: a review of the research on the relationship between health insurance, medical care use, health, work, and income.

OBJECTIVES: This study examined the association between TV viewing, fast food eating, and body mass index. METHODS: Associations between hours of TV viewing, frequency of eating at fast food restaurants, body mass index, and behaviors were assessed cross sectionally and longitudinally over 1 year in 1059 men and women. RESULTS: Fast food meals and TV viewing hours were positively associated with energy intake and body mass index in women but not in men. TV viewing predicted weight gain in high-income women. CONCLUSIONS: Secular increases in fast food availability and access to televised entertainment may contribute to increasing obesity rates in the United States.

Epidemic obesity in the United States: are fast foods and television viewing contributing?

Background Immunization rates for children and adults are rising, but coverage levels have not reached optimal goals. As a result of low immunization rates, vaccine-preventable diseases still occur. In an era of increasing complexity of immunization schedules, rising expectations about the performance of primary care and large demands on primary care physicians, it is important to understand and promote interventions that work in primary care settings to increase immunization coverage. A common theme across immunization programs in all nations involves the challenge of determining the denominator of eligible recipients (e.g. all children who should receive the measles vaccine) and identifying the best strategy to ensure high vaccination rates. Strategies have focused on patient-oriented interventions (e.g., patient reminders), provider interventions and system interventions. One intervention strategy involves patient reminder and recall systems. Objectives To assess the effectiveness of patient reminder and recall systems in improving immunization rates and compare the effects of various types of reminders in different settings or patient populations. Search strategy A systematic search was performed for the initial review using MEDLINE (1966-1998) and four other bibliographic databases: EMBASE, PsychINFO, Sociological Abstracts, and CAB Abstracts. Authors also performed a search of The Effective Practice and Organisation of Care (EPOC) register in April 2001 to update the review. Two authors reviewed the lists of titles and abstracts and used the inclusion criteria to mark potentially relevant articles for full review. The reference lists of all relevant articles and reviews were back searched for additional studies. Publications of abstracts, proceedings from scientific meetings and files of study collaborators were also searched for references. In December 2004 the EPOC register was searched to identify relevant articles to update the review. Study design Randomized controlled trials (RCT), controlled before and after studies (CBA) and interrupted time series (ITS) studies written in English. Types of participants Health care personnel who deliver immunizations and children (birth to 18 years) or adults (18 years and up) who receive immunizations in any setting. Types of interventions Any intervention that falls within the EPOC scope (See Group Details) and that includes patient reminder or recall systems, or both, in at least one arm of the study. Types of outcome measures Immunization rates or the proportion of the target population up-to-date on recommended immunizations. Outcomes were acceptable for either individual vaccinations (e.g. influenza vaccination) or standard combinations of recommended vaccinations (e.g. all recommended vaccinations by a specific date or age). Data collection Each study was read independently by two reviewers. Disagreements between reviewers were resolved by a formal reconciliation process to achieve consensus. Analysis Results are presented for individual studies as relative rates for randomized controlled trials and as absolute changes in percentage points for controlled before and after studies. Pooled results for RCTs only were presented using the random effects model. Main results Five new studies were added for this update. Increases in immunization rates due to reminders were in the range of 1 to 20 percentage points. Reminders were effective for childhood vaccinations (OR = 1.45, 95% CI =1.28, 1.66), childhood influenza vaccinations (OR = 2.87, 95% CI = 1.65, 4.98), adult pneumococcus, tetanus, and Hepatitis B (OR = 2.19, 95% CI = 1.21, 3.99), and adult influenza vaccinations (OR = 1.66, 95% CI = 1.31, 2.09). All types of reminders were effective (postcards, letters, telephone or autodialer calls), with telephone being the most effective but most costly. Authors' conclusions Patient reminder and recall systems in primary care settings are effective in improving immunization rates within developed countries.

/pdf/patient-reminder-and-patient-recall-systems-to-improve-1do2wwr0mo.pdf

Patient reminder and patient recall systems to improve immunization rates.

Objective To examine the neurosensory and cognitive status of extremely low-birth-weight (ELBW; Design An inception cohort of ELBW infants admitted to the neonatal intensive care unit (NICU) and observed to 20 months' corrected age. Setting A tertiary level urban NICU and follow-up clinic at a university hospital. Population Of 333 ELBW infants without major congenital malformations admitted to the NICU, 241 (72%) survived to 20 months' corrected age. We studied 221 children (92%) at a mean of 20 months' corrected age. The mean birth weight was 813 g; mean gestational age, 26.4 weeks. Main Outcome Measures Assessments of cognitive and neurosensory development. Results Major neurosensory abnormality was present in 54 children (24%), including 33 (15%) with cerebral palsy, 20 (9%) with deafness, and 2 (1%) with blindness. The mean (± SD) Bayley Mental Developmental Index (MDI) score was 74.7 ± 17. Ninety-two children (42%) had a subnormal MDI score ( 171 µmol/L [>10 mg/dL]) (OR, 4.80; 95% CI, 1.46-15.73). Conclusion There is an urgent need for research into the etiology and prevention of neonatal morbidity.

https://jamanetwork.com/journals/jamapediatrics/articlepdf/350278/poa90461.pdf

Neurodevelopment and Predictors of Outcomes of Children With Birth Weights of Less Than 1000 g: 1992-1995

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Report of the Committee on Infectious Diseases.

To determine the rate of childhood undervaccination, rate and types of missed opportunities (MOs) for vaccinations, and the contribution of MOs to the undervaccination of preschool-age children, the authors conducted a retrospective medical chart review in seven primary care settings in the Rochester, NY, area: a hospital clinic, a neighborhood health center, a group-model health maintenance organization, an urban group practice, a suburban group practice, a rural health center, and a rural private practice. The random sample included 1124 children having birth dates between March 15, 1988, and September 15, 1989. The main outcome measures were cumulative undervaccination rate, defined as the proportion of patients from each practice who were ever >60 days past-due for a vaccination by 12, 18, or 24 months of age; undervaccination time, defined as the median number of months during which children were undervaccinated; number of MOs; visit types and conditions associated with the MOs; and the duration of undervaccination time attributable to MOs. The cumulative undervaccination rate by 12 months was at least 20% in each practice except for the suburban practice, where it was 4%. The frequency of MOs varied from a high of 1.8 MO per patient per year at the rural private practice to a low of 0.3 MO per patient per year at the suburban practice. More than one quarter of MOs occurred during either health supervision or follow-up visits in all practices. In 28% of visits during which an MO occurred, patients had no fever or acute illness. The impact of MOs was twice as great for children having Medicaid or no health insurance as for children covered by private insurance. Missed opportunities contributed 13% of the total undervaccination time in the suburban practice, 27% in the clinic, and more than 40% in the other practices. It is concluded that missed opportunities for vaccination occur frequently and contribute significantly to the undervaccination of preschool children. The effect of MOs is greatest in practices serving impoverished children. Reducing MOs would substantially improve the vaccination levels of preschool-age children.

Missed Opportunities for Childhood Vaccinations in Office Practices and the Effect on Vaccination Status

Barriers to Immunization and Missed Opportunities

Background. The recently enacted State Children9s Health Insurance Program (SCHIP) is modeled after New York State9s Child Health Plus (CHPlus) program. Since 1991, CHPlus has provided health insurance to children 0 to 13 years old whose annual family income was below 222% of the federal poverty level and who were ineligible for Medicaid or did not have equivalent health insurance coverage. CHPlus covered the costs for ambulatory, emergency, and specialty care, and prescriptions, but not inpatient services. Objectives . To assess the change associated with CHPlus regarding 1) access to health care; 2) utilization of ambulatory, inpatient, and emergency services; 3) quality of health care; and 4) health status . Setting. Six western New York State counties (including the city of Rochester). Subjects. Children (0–6.99 years old) enrolled for at least 9 consecutive months in CHPlus. Methods. The design was a before-and-after study, comparing individual-level outcomes for the 12 months immediately before CHPlus enrollment and the 12 months immediately after enrollment in CHPlus. Parent telephone interviews and medical chart reviews conducted 12 months after enrollment to gather information. Subjects9 primary care charts were located by using interview information; emergency department (ED) charts were identified by searching patient records at all 12 EDs serving children in the study; and health department charts were identified by searching patient records at the 6 county health department clinics. Logistic regression and Poisson regression were used to compare the means of dependent measures with and without CHPlus coverage, while controlling for age, prior insurance type, and gap in insurance coverage before CHPlus. Results. Complete data were obtained for 1730 children. Coverage by CHPlus was associated with a significant improvement in access to care as measured by the proportion of children reported as having a usual source of care (preventive care: +1.9% improvement during CHPlus and sick care: +2.7%). CHPlus was associated, among children 1 to 5 years old, with a significant increase in utilization of preventive care (+.23 visits/child/year) and sick care (+.91 visits/child/year) but no measurable change in utilization of specialty, emergency, or inpatient care. CHPlus was also associated, among children 1 to 5 years old, with significantly higher immunization rates (up-to-date for immunizations: 76% vs 71%), and screening rates for anemia (+11% increased proportion screened/year), lead (+9%), vision (+11%), and hearing (+7%). For 25% of the children, a parent reported that their child9s health was improved as a result of having CHPlus. Conclusion. After enrollment in CHPlus, access to and utilization of primary care increased, continuity of care improved, and many quality of care measures were improved while utilization of emergency and specialty care did not change. Many parents reported improved health status of their child as a result of enrollment in CHPlus. Implication. This evaluation suggests that SCHIP programs are likely to improve access to, quality of, and participation in primary care significantly and may not be associated with significant changes in specialty or emergency care.

https://pediatrics.aappublications.org/content/pediatrics/105/Supplement_E1/711.full.pdf

Evaluation of New York State's Child Health Plus: access, utilization, quality of health care, and health status

Background. The recently enacted State Children9s Health Insurance Program (SCHIP), designed to provide affordable health insurance for uninsured children, was modeled in part on New York State9s Child Health Plus (CHPlus), which was implemented in 1991. All SCHIP programs involve voluntary enrollment of eligible children. Little is known about characteristics of children who enroll in these programs. Objectives. To provide a profile of children enrolled in CHPlus between 1993 and 1994 in the 6-county upstate New York study area, and to estimate the participation rate in CHPlus. Methods. A parent interview was conducted to obtain information about children, 0 to 6.9 years old, who enrolled in CHPlus in the study area. Two school-based surveys and the Current Population Survey were used to estimate health insurance coverage. Enrollment data from New York State9s Department of Health, together with estimates of the uninsured, were used to estimate participation rates in CHPlus. Results. Most children enrolled in CHPlus in the study area were white. Although 17% of all children in the study area who were 1 month. Children were generally healthy; only 4% had fair or poor health. Eighty-eight percent of parents of enrolled children had completed high school or a higher level of education. Parents reported that loss of a job was the main reason for loss of prior health insurance for their child. Most families learned about CHPlus from a friend (30%) or from their doctor (26%). The uninsured rate among children in the study area was approximately 4.1%. By 1993, the participation rate in CHPlus was about 36%. Conclusion. Blacks were underrepresented in CHPlus. Because the underlying uninsured rate was relatively low and parental education and family income were relatively high, the effects of CHPlus observed in this evaluation may be conservative in comparison to the potential effects of CHPlus for other populations of children. Participation rates during the early years of the program were modest.

https://pediatrics.aappublications.org/content/pediatrics/105/Supplement_E1/706.full.pdf

A Profile of the Population Enrolled in New York State's Child Health Plus

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Missed Opportunities for Childhood Vaccinations in Office Practices and the Effect on Vaccination Status

Barriers to Immunization and Missed Opportunities

Evaluation of New York State's Child Health Plus: access, utilization, quality of health care, and health status

A Profile of the Population Enrolled in New York State's Child Health Plus