ARTICLE
Disparities in Unmet Need for Care Coordination: The
National Survey of Children’s Health
AUTHORS: Sara L. Toomey, MD, MPhil, MPH, MSc,a,b Alyna T.
Chien, MD, MS,a,b Marc N. Elliott, PhD,c Jessica Ratner, BA,a
and Mark A. Schuster, MD, PhDa,b
aDivision of General Pediatrics, Department of Medicine, Boston
Children’s Hospital, Boston, Massachusetts; bDepartment of
Pediatrics, Harvard Medical School, Boston, Massachusetts;
and cRAND Corporation, Santa Monica, California
KEY WORDS
care coordination, disparities, CSHCN, variation in care
ABBREVIATIONS
aOR—adjusted odds ratio
CSHCN—children with special health care needs
NSCH—National Survey of Children’s Health
PCMH—patient-centered medical home
Dr Toomey conceptualized and designed the study, carried out
the analyses, drafted the initial manuscript, revised the
manuscript, and approved the final manuscript as submitted;
Drs Chien, Elliott, and Schuster discussed the conceptualization
and design of the study, critically reviewed and revised the
manuscript, and approved the final manuscript as submitted;
and Ms Ratner critically reviewed and revised the manuscript
and approved the final manuscript as submitted.
www.pediatrics.org/cgi/doi/10.1542/peds.2012-1535
doi:10.1542/peds.2012-1535
Accepted for publication Oct 5, 2012
Address correspondence to Sara L. Toomey, MD, MPhil, MPH, MSc,
Division of General Pediatrics, Boston Children’s Hospital, 300
Longwood Ave, Boston, MA 02115. E-mail: sara.toomey@childrens.
harvard.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2013 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr Toomey is supported by a Boston
Children’s Hospital Career Development Fellowship; the other
authors have no financial relationships relevant to this article
to disclose.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found on
page 336, and online at www.pediatrics.org/cgi/doi/10.1542/
peds.2012-3248.
WHAT’S KNOWN ON THIS SUBJECT: Care coordination has been
proposed as a key mechanism for increasing quality and reducing
costs of care. Little is known about the degree to which
disparities exist in care coordination or whether having highquality primary care attenuates disparities.
WHAT THIS STUDY ADDS: A considerable proportion of parents
reported unmet care coordination needs for their children,
especially parents of children with special health care needs.
Black and Latino children also may have more unmet needs
because they received family-centered care less often.
abstract
OBJECTIVE: To determine (1) the proportion of parents who report
a need for and receipt of effective care coordination for their child,
(2) whether unmet care coordination needs differ by children with
special health care needs (CSHCN) status and sociodemographic
characteristics, and (3) whether having a personal provider or
family-centered care mitigates disparities.
METHODS: This study was a cross-sectional analysis of the 2007 National
Survey for Children’s Health, a nationally representative survey of 91 642
parents. Outcome measures were parent report of need for and lack of
effective care coordination. We also examined the effect of parent
report of having a personal provider and family-centered care. We
conducted weighted bivariate and multivariate analyses.
RESULTS: Forty-one percent of parents reported that their child needed
care coordination. Among those who needed care coordination, 31% did
not receive effective coordination. CSHCN (41%) were more likely than
children without special health care needs (26%; P , .001) to have
unmet care coordination needs. Latino (40%) and black (37%) children
were more likely to have unmet needs than white (27%; P , .001)
children. These patterns remained in multivariate analysis. Having
a personal provider decreased the odds of having unmet need for
care coordination but did not attenuate disparities. Receiving familycentered care mitigated disparities associated with race/ethnicity but
not with health status or health insurance.
CONCLUSIONS: A considerable proportion of parents reported their
child needed more care coordination than they received. This was especially true for parents of CSHCN and parents of black and Latino
children. Interventions that enhance family-centered care might
particularly contribute to reducing racial/ethnic disparities.
Pediatrics 2013;131:217–224
PEDIATRICS Volume 131, Number 2, February 2013
217
In the United States, there is tremendous interest in improving the frequency with which patients experience
health care that is well coordinated.1–4
Care coordination is “the deliberate
organization of patient care activities
between two or more participants . . .
involved in a patient’s care to facilitate
appropriate delivery of health care
services.”5 Clinicians, researchers, and
policymakers all maintain that increasing care coordination is essential
for improving health care processes
and outcomes, particularly for medically or socially complex populations.1,2
Recently, the need to improve care coordination has been codified into law
as a central tenet of the 2010 Patient
Protection and Affordable Care Act.6,7
Studies have associated poor care coordination with delayed access to care,
inferior quality of care, ineffective use of
resources, inflated health care costs,
and patient and provider dissatisfaction.7–18 However, there is no nationally
representative study on the degree to
which inequities may exist in the receipt of care coordination for children
with special health care needs
(CSHCN), black and Latino children, and
those with lower socioeconomic backgrounds. Reports of unmet need for
care coordination within these groups
could help identify who should be targeted for improvements.
Two other tenets of high quality of
primary care have been associated with
improved pediatric health outcomes:
(1) having a personal provider (ie,
a doctor or nurse who knows the child
well) and (2) receiving family-centered
care (ie, care that treats the patient and
family as integral members of the care
team and is grounded in the consideration of patients’ and families’ preferences and values).19–22 These 2
factors should be taken into account
when assessing whether care is well
coordinated or whether disparities can
be mitigated.
218
TOOMEY et al
Our study therefore aims to determine
the following: (1) the proportion of
parents who report a need for and
receipt of effective care coordination
for their child, (2) whether unmet care
coordination needs differ by CSHCN
status23 and sociodemographic characteristics, and (3) whether having
a personal provider or family-centered
care mitigates disparities in care coordination. We hypothesized that unmet care coordination needs exist for
children in general and are particularly pervasive for children with special health care needs. We also
postulated that black and Latino children and children in families with
lower incomes will report more unmet
care coordination needs than others.
Last, we posited that having a personal
provider and receiving family-centered
care will decrease the odds of parents
indicating unmet need for care coordination.
METHODS
2007 National Survey of Children’s
Health
We analyzed the 2007 National Survey of
Children’s Health (NSCH), which was
conducted by the National Center for
Health Statistics to cover physical,
emotional, and behavioral child health
as well as family context and neighborhood environment.24 The NSCH is
a telephone survey (∼30 minutes) conducted in English, Spanish, Mandarin,
Cantonese, Vietnamese, and Korean
with a random-digit-dial sample in all
50 states and the District of Columbia.
Participants were drawn from a randomly selected subset of telephone
numbers from the National Immunization Survey sample by using State and
Local Area Integrated Telephone Survey
methodology.25 The parent/guardian
of 91 642 children aged 0 to 17 years
completed the interview, with a response rate of 46.7%.26
The subjects of this analysis were
parents of children who reported
needing care coordination in the previous 12 months at the time the survey
was administered. A child was considered to be in need of care coordination if
the parent reported that the child had
$2 of the following: (1) preventive visit
with a health care provider, (2) visit
with a mental health specialist, or (3)
specialist visit or need for specialist
visit (not including mental health specialists).
The Boston Children’s Hospital Institutional Review Board found the
study exempt from human subject review.
Primary Outcome
We used a dichotomous variable to
categorize whether a child had unmet
need for care coordination. This variable was developed by the Data Resource Center for Child and Adolescent
Health as a component of the patientcentered medical home (PCMH) and
has been used extensively in this context.26,27 Receipt of effective care coordination has 3 components: getting
as much help as needed with arranging
or coordinating care, parental satisfaction with communication among
doctors and health care providers, and
parental satisfaction with communication between health care providers
and non–medical service providers
(eg, school). To meet criteria for receipt of effective care coordination (no
unmet need), the parent must report
“usually” receiving help coordinating
child’s care when care coordination is
needed and the parent must report
being “very satisfied” with the 2 communication variables (when applicable). The outcome variable was unmet
need for care coordination.
Independent Variables of Interest
CSHCN were included because we
anticipated that they would have
ARTICLE
increased unmet need for care coordination. The NSCH uses the CSHCN
screener developed by Bethell et al.23
We also included in part of our analysis
the presence of specific chronic conditions and number of reported chronic
conditions. Parents had to answer
whether their child currently had any
of the following specific chronic
conditions: anxiety; asthma; attentiondeficit/hyperactivity disorder; autism;
bone, joint, or muscle problems; brain
injury or concussion; conduct disorder; depression; diabetes; hearing
problem; other developmental delay; seizure disorder; stuttering or other speech
problem; Tourette syndrome; or vision
problem not corrected with glasses.
Parent report of child’s race/ethnicity
was categorized into the following
groups: black/non-Latino, Latino, white/
non-Latino, or other.
To meet criteria for having a personal
provider, parents must have answered
affirmatively to the following yes/no
question: “A personal doctor or nurse
is a health professional who knows
your child well and is familiar with your
child’s health history. This can be
a general doctor, a pediatrician, a specialist doctor, a nurse practitioner, or
a physician’s assistant. Do you have one
or more persons you think of as [child’s
name]’s personal doctor or nurse?”
The composite measure of receipt of
family-centered care had several elements, all of which were required to be
present (“usually” or “always”) to meet
the following criteria: (1) health care
providers spend enough time, (2)
health care providers listen carefully,
(3) health care providers are sensitive
to your family’s values and customs, (4)
you received specific information you
needed from your health care providers, and (5) when you needed an
interpreter, someone other than
a family member helped you speak
with health care providers (when applicable).
PEDIATRICS Volume 131, Number 2, February 2013
Additional Covariates
We adjusted for additional covariates
previously found or likely to be associated
with care coordination need.28–30 Child
demographic covariates included gender
and age. Household covariates included
primary language at home (English, not
English), family structure (2-parent
household [biological/step/adoptive],
mother-only household, and other [eg,
grandparent as primary parent figure
in household]), insurance status (private, public, none), and household income (,100%, 100 to ,200%, 200 to
,400%, $400% of the federal poverty
level adjusted for family size). We tested
the covariates for collinearity and included all in the model because the
variance inflation factors were #1.7.
Missing values for adjusted poverty
level were imputed by using sequential
multivariable regression according to
the Centers of Disease Control and
Prevention and the National Center for
Health Statistics.25 Missing values for
the remainder of the covariates were
imputed by using mean imputation
methodology. Dummy variables flagging whether the value was imputed
were created for those variables that
had .1% missing data.
Analysis
Analyses incorporated sampling
weights with the use of Stata survey
procedures (StataCorp, College Station, Texas), following National Center
for Health Statistics analysis guidelines.26 We first determined the percentage of parents reporting need for
care coordination. Among children in
need of care coordination, we also determined the percentage of parents
reporting unmet care coordination
need. We used weighted x2 statistics to
determine bivariate associations between each covariate and (1) need for
care coordination and (2) for those
with need, unmet care coordination need.
Covariates included the following:
child gender, age, race/ethnicity,
type of health insurance, family structure, highest parental educational
level, poverty level, and primary language spoken at home. We then examined the need for care coordination
and percentage of unmet care coordination need for CSHCN. We also
examined the association of unmet
care coordination need and (1) number of chronic conditions and (2)
presence of the specific chronic conditions listed above. We determined the
percentage of children who were
reported to have a personal provider
and to receive family-centered care. We
then built a multivariable logistic regression model to test the association
between unmet care coordination need
and covariates. The model included
parents of children who met the criteria for needing care coordination. Two
additional multivariate logistic regression models were built to test the
effect of adding (1) report of having
a personal provider and (2) report of
receiving family-centered care.
We ran 3 sensitivity analyses. First, to
address the concern that parental
satisfaction with provider communication should not be included in the
NSCH definition of effective care coordination, we reran our analysis based
only on parental report of “usually”
getting as much help as needed with
arranging or coordinating care. Second, we examined the degree to which
our findings differed if we included
a physical versus mental health condition in models assessing familycentered care. Last, we analyzed
whether the degree to which the
number of chronic conditions a child
may have (perhaps a proxy for illness
severity) is associated with care coordination needs.
RESULTS
Overall, 41% of parents reported that
they needed care coordination for their
219
child (Table 1). Of those in need of care
coordination, 31% of children had
unmet care coordination needs. In
bivariate analysis, there was no significant difference by race/ethnicity in
needing care coordination. Children
with either private (41%) or public insurance (44%) were more likely than
uninsured children (28%; P , .001) to
need care coordination.
Black (38%) and Latino (40%) children
were more likely to have unmet care
coordination need than were white
(27%; P , .001) children. A lower
percentage of children with higher
household income had unmet care coordination need. In addition, children
with public insurance (37%) or no
insurance (49%) were more likely to
have unmet care coordination need in
comparison with children with private
insurance (26%; P , .001). Children
who were from non–English-speaking
in comparison with English-speaking
households were more likely to have
unmet care coordination need as were
children from mother-only and other
households in comparison with 2-parent
households. Last, children without a
personal health care provider were
more likely to have unmet care coordination need than those with a personal provider (52% vs. 30%; P , .001),
and children not receiving familycentered care were more likely to have
unmet care coordination need than
those receiving family-centered care
(50% vs. 11%; P , .001).
Parents of CSHCN (72%) more often
reported that their children needed
TABLE 1 Characteristics of Children Who Need Care Coordination and Who Have Unmet Need for
Effective Care Coordination
Covariate (n)
All participants
Child gender
Male (47 535)
Female (43 997)
Child age
0–5 y (27 566)
6–11 y (27 792)
12–17 y (36 284)
Child race
Black, non-Latino (8873)
Latino (11 523)
Other (8323)
White, non-Latino (61 377)
Household income
0%–99% FPL (10 971)
100%–199% FPL (15 591)
200%–399% FPL (30 792)
$400% FPL (34 288)
Insurance status
Private (64 165)
Public (19 748)
No insurance (6808)
Language spoken at home
English (84 943)
Non-English (6643)
Family structure
Two-parent (70 620)
Mother only (14 726)
Other (5749)
Weighted Percentage in Need of Weighted Percentage With Unmet Need for
Care Coordination (n = 91 642) Effective Care Coordination of Those in Need
of Care Coordination (n = 38 006)
41
***
43
39
***
34
41
47
39
41
38
41
***
40
38
39
44
***
41
44
28
41
40
***
40
44
45
31
32
30
30
33
31
***
38
40
32
27
***
40
36
29
26
***
26
37
49
***
30
41
***
28
39
41
Sample sizes (n) are unweighted. Percentages are weighted in accordance with complex survey design. ***P , .001. FPL,
federal poverty level.
220
TOOMEY et al
care coordination than did parents of
children without special health care
needs (72% vs. 33%; P , .001; Table 2).
Of those who reported need for care
coordination, parents of CSHCN also
were more likely than parents of other
children to report unmet care coordination need (41% vs. 26%; P ,
.001). The need for care coordination
and the lack of effective care coordination among those who needed it
was higher among children with multiple conditions. Among children with
$1 specific chronic condition, the
percentage of children whose parents
reported being in need of care coordination varied by condition from
a low of 63% of children with asthma to
a high of 95% of children with brain
injury or concussion. In addition, the
percentage of children with unmet
care coordination need varied among
conditions, with lows of 33% for children with diabetes and 37% for children with asthma to highs of 58% for
children with anxiety and 62% for
children with autism.
In multivariate analysis, among parents
of children who met the criteria for
needing care coordination, the associations between unmet need for care
coordination and the sociodemographic covariates revealedin bivariate
analysis remained, except that household income was no longer significant
(Table 3). Black [adjusted odds ratio
(aOR): 1.3; P = .001] and Latino children
(aOR: 1.5; P = .001) had a higher odds of
unmet care coordination need than did
white children. In comparison with
children with private insurance, uninsured children had higher odds of
unmet care coordination need (aOR:
2.1; P , .001). CSHCN had a higher odds
of unmet care coordination need in
comparison with children without
special health care needs (aOR: 1.4;
P , .001).
The second model included parent report of having a personal provider (93%
ARTICLE
TABLE 2 Characteristics of CSHCN Who Need Care Coordination and Who Have Unmet Need for
Care Coordination
Type of Chronic Condition (n)
Weighted Percentage Who
Need Care Coordination
Weighted Percentage Who Have
Unmet Need for Coordination
CSHCN
No (74 978)
Yes (17 564)
Number of conditions
0 (71 228)
1 (12 461)
2 (3600)
$3 (4351)
***
33
72
***
33
58
74
87
***
26
41
***
26
34
44
53
Brain injury or concussion (252)
Diabetes (355)
Seizure disorder (526)
Depression (1684)
Anxiety (2669)
Autism (921)
Other developmental delay (2448)
Conduct disorder (2381)
Bone, joint, or muscle problems (2105)
Hearing problem (1227)
Tourette syndrome (151)
ADHD (5495)
Stuttering or other speech problem
(2685)
Vision problem not corrected with
glasses (1035)
Asthma (7925)
95
88
87
87
87
86
84
83
82
81
78
77
72
57
33
45
54
58
62
53
57
50
42
53
47
51
66
47
63
37
Sample sizes (n) are unweighted. After appropriate weights applied in accordance with complex survey design. Organized by
rate of need for care coordination. ***P , .001. ADHD, attention-deficit/hyperactivity disorder.
of parents reported their child had
a personal provider). Children with
a personal provider had a lower odds
of having an unmet care coordination
need (aOR: 0.4; P , .001). However, the
addition of having a personal provider did not change the measures of
association substantially for the
other factors associated with unmet
care coordination need. The third
model included parent report of receiving family-centered care (67% of
parents reported that their child received family-centered care). Children receiving family-centered care
had a lower odds of having an unmet
care coordination need (aOR: 0.2; P ,
.001). Including family-centered care
in the multivariate analysis attenuated the racial/ethnic disparities.
However, including family-centered
care did not attenuate disparities
associated with health status or insurance status.
PEDIATRICS Volume 131, Number 2, February 2013
Our findings were robust to our 3
sensitivity analyses. The pattern of
results did not change for any of the
following: (1) changing the criteria for
having effective care coordination to
only getting as much help as needed
with arranging or coordinating care, (2)
including presence of a physical health
condition and presence of a mental
health condition, and (3) including the
number of chronic conditions in addition to CSHCN status.
DISCUSSION
This study is one of the first to estimate
nationally the degree to which parents
reported needing care coordination for
their children and the extent to which
care coordination was already delivered effectively. Overall, 41% of all
parents and 72% of parents with CSHCN
reported needing care coordination.
These findings confirm other studies
that found care coordination to be
a desirable attribute of a health care
system, particularly for those with the
greatest medical needs.1–4 It is also one
of the first studies to report the frequency at which those needing care
coordination indicate not receiving effective care coordination. It is concerning that parents of children with
the greatest medical needs and minority groups, who historically have
not received high-quality health care,
also reported having more unmet care
coordination needs more frequently
than children without special health
care needs and white children.
Care coordination was crucial for many
CSHCN, and their greater unmet need
for care coordination was likely related
to the high number of services often
involved in their care.31 Although the
amount of care coordination that each
child needed was not measured, we
were able to show that the odds of
reporting an unmet need for care
coordination increased with an increasing number of conditions. Moreover, unmet need remained after
adjusting for parent report of having
a personal provider and receiving
family-centered care. Thus, our study
suggests that more can be done in
primary care to facilitate care coordination for all children, but especially for CSHCN.
Our findings also revealed that although
all CSHCN had higher odds of having
unmet need for care coordination, not
all CSHCN had similar needs; the need
for and receipt of effective care coordination varied among chronic conditions. The differences seen in need for
care coordination may be related, in
part, to the likelihood of need for
specialist involvement. For instance,
consistent with general practice
patterns,forchildren withconditionsthat
are more likely to be treated exclusively
by primary care providers (eg, asthma
and attention-deficit/hyperactivity
221
TABLE 3 Adjusted Odds of Reporting Unmet Need for Care Coordination
Variable
Odds of Unmet Need for Care Coordination, aOR (95% CI)
Model 1
Child gender
Female
Male
Child age
0–5 y
6–11 y
12–17 y
Child race
White, non-Latino
Black, non-Latino
Latino
Other
Household income
0%–99% FPL
100%–199% FPL
200% –399% FPL
$400% FPL
Insurance status
Private
Public
No insurance
Flaga
Language spoken at home
English
Non-English
Family structure
Two-parent
Mother only
Other
CSHCN
No
Yes
Personal provider
No
Yes
Family-centered care
No
Yes
Model 2 (Add
Personal Provider)
Model 3 (Add
Family-Centered Care)
Ref
1.0 (0.9, 1.2)
Ref
1.0 (0.9, 1.1)
Ref
1.0 (0.9, 1.1)
Ref
1.1 (0.9, 1.2)
1.0 (0.9, 1.2)
Ref
1.0 (0.9, 1.2)
1.0 (0.9, 1.2)
Ref
0.9 (0.8, 1.1)
0.9 (0.7, 1.0)
Ref
1.3 (1.1, 1.6)**
1.5 (1.2, 1.8)**
1.2 (1.0, 1.5)
Ref
1.3 (1.1, 1.5)**
1.4 (1.1, 1.8)**
1.2 (1.0, 1.5)*
Ref
1.0 (0.8, 1.2)
1.2 (1.0, 1.5)
1.1 (0.9, 1.3)
Ref
1.0 (0.8, 1.2)
0.9 (0.7, 1.1)
0.9 (0.7, 1.1)
Ref
1.0 (0.8, 1.2)
0.9 (0.8, 1.1)
0.9 (0.7, 1.1)
Ref
1.0 (0.8, 1.3)
1.1 (0.9, 1.4)
1.1 (0.9, 1.4)
Ref
1.1 (0.9, 1.3)
2.2 (1.7, 2.7)***
1.6 (1.0, 2.6)*
Ref
1.1 (0.9, 1.3)
2.0 (1.6, 2.5)***
1.6 (1.0, 2.6)*
Ref
1.1 (0.9, 1.3)
1.8 (1.4, 2.4)***
1.5 (0.9, 2.3)
Ref
1.4 (1.0, 1.8)*
Ref
1.3 (1.0, 1.9)*
Ref
1.0 (0.8, 1.3)
Ref
1.3 (1.1, 1.5)**
1.6 (1.2, 2.0)**
Ref
1.3 (1.1, 1.5)**
1.6 (1.2, 2.0)***
Ref
1.3 (1.1, 1.5)**
1.5 (1.2, 2.0)**
Ref
2.0 (1.8, 2.3)***
Ref
2.1 (1.8, 2.3)***
Ref
2.2 (1.9, 2.4)***
Ref
0.4 (0.4, 0.6)***
Ref
0.6 (0.4, 0.7)***
Ref
0.2 (0.2, 0.2)***
After appropriate weights applied in accordance with complex survey design. *P # .05, **P , .01, ***P , .001. FPL, federal
poverty level; Ref, reference.
a Flag denotes a dummy variable flagging that the value is imputed (created for those variables that had .1% missing data).
disorder) the need for care coordination was lower. We found that, on
average, for those in need of care coordination, the percentage of children
with physical conditions (eg, asthma
and diabetes) who had effective care
coordination was higher than children
with mental health conditions (eg,
conduct disorder and depression); this
finding was consistent with findings in
other studies.27
Although our study did not find racial/
ethnic differences in the need for
222
TOOMEY et al
care coordination, it identified disparities in receipt of effective care coordination. Black and Latino children
had a higher odds of having unmet need
for care coordination compared with
white children. This is consistent with
other studies that suggest that racial/
ethnic disparities in health care are
pervasive, affecting not only whether
patients can gain access to health care
providers but whether they receive
quality care processes even after they
enter the health care system.32–35
Our study is also the first to find
a differential impact of 2 different
components of the PCMH, having a
personal provider and receiving
family-centered care. Whereas both
tenets are considered essential components of the PCMH and associated
with improved pediatric health care
quality and outcomes,19,20,36–38 receipt
of family-centered care not only
was associated with decreased
odds of unmet need but also attenuated racial/ethnic disparities. As a result, those interested in narrowing
disparities while improving care generally may need to focus more on providing family-centered care, partnering
with families as integral members
of the care team and grounding care
in families’ preferences and values.
However, studies have revealed
that black and Latino children are less
likely to have family-centered care.39
Thus, although receipt of familycentered care might address the
inequities in the delivery of care coordination, the overall underlying
inequities in the care they receive
remains. Further research is needed to
better understand the barriers for receipt of family-centered care to inform
intervention development and health
policies on or for promoting care
coordination.
The NSCH is the most recent and largest
nationally representative survey of
child health in the United States. However, there are several limitations. Data
came from parent report, which could
have caused misclassification if
parents failed to recognize that their
child needed care coordination. The
NSCH definition of who is in need of care
coordination has limitations. Parent
report of receiving $2 health-related
services or being in need of specialist
care might either include children who
do not need significant care coordination (eg, a child with an uncomplicated broken arm who saw an
ARTICLE
orthopedist once) or not include children
with significant need for coordination
of non–medical care services (eg,
a child with developmental delay
followed by early intervention). More
generally, the cross-sectional design of
the NSCH prevents us from making
causal inference.
Nonetheless, findings from our study
support the emphasis that the 2010 Patient Protection and Affordable Care Act
placed on the importance and need to
improve care coordination for children
generally, and for meeting the needs of
CSHCN and narrowing racial/ethnic disparities in health care more specifically.
ACKNOWLEDGMENTS
We thank David J. Klein, MS, of the Division
of General Pediatrics at Boston Children’s
Hospital, for support with the analysis
and Vinay Kampalath, BA, of the Division
of General Pediatrics at Boston Children’s Hospital, for support with preparing the manuscript for submission.
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UNREST IN THE SCHOOL CAFETERIA: The dietary preferences of my children have
been different: for long periods of time one only ate bran flakes and refined sugar
products, while another only ate meat. Since we paid for a school ‘credit card’
that students use for purchasing food from the cafeteria, we could scan an
itemized list of what each child had purchased the previous month. While bottled
water and bagels with cream cheese seemed popular for many years, each
periodically bought the school lunch. What we did not know was whether our
children actually ate the purchased lunch. As reported in The New York Times
(N.Y./Region, October 5, 2012), students in many communities are not only boycotting school lunches, they are throwing the food away. Apparently, school
lunches featuring smaller portions, fewer calories, healthier choices, and a slight
increased cost are not popular. At issue is the Healthy, Hunger-Free Kids Act,
which required public schools to follow new nutritional guidelines in order to
qualify for additional federal aid. The act requires lunches to include fruits and
vegetables, limit fat and sodium, and reduce the total number of calories. While
pizza is still available, the portion size is smaller, and the meal includes a fruit and
skim milk. It also costs a bit more than before: up 10 cents to $2.60. Many students
have reacted by boycotting the lunch program. In some districts, participation in
the school lunch program has dropped 70%. Other students simply throw the fruit
or vegetables into the trash. Although student-directed videos depicting students
acting weak from hunger have gone viral, all lunches must contain at least 750
calories. As most parents know, getting children to eat their vegetables can be
challenging. Perhaps the best practice for the schools is simply to give the
program more time. Children need to be exposed to vegetables over and over
before finally trying and then liking them. I know from first-hand experience—
even my carnivore now eats vegetables and fruits.
Noted by WVR, MD
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