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The Centers for MedicareMedicaid Services' (CMS's) Transforming Clinical Practice Initiative (TCPi) was the largest national-scale practice transformation model. We analyzed the effect of TCPi on new enrollment into Medicare Alternative Payment Models (APMs) through January 2020 (3 months after program end), using 6958 physician practices enrolled in TCPi and a closely matched comparison group of 6958 practices. More TCPi practices enrolled in Medicare APMs and Medicare Advanced APMs relative to comparison practices overall and in subgroups, including rural, small, and specialty practices. Results suggest that large-scale technical assistance can boost participation in Medicare APMs for a diverse set of practices.

As the coronavirus pandemic continues to impact families and children, understanding parental attitudes and likely acceptance of the COVID-19 vaccine is essential. We conducted a statewide survey with a representative sample of parents in Tennessee focused on COVID-19 and influenza vaccine acceptance and perspectives. Data from 1066 parents were analyzed using weighted survey methods to generalize results to the state of Tennessee. About 53% of parents reported a likelihood to vaccinate their children against COVID-19, and 45% were likely to vaccinate their child against COVID-19 and influenza. Female parents were less likely to vaccinate their children against COVID-19, but the strongest predictor of likely COVID-19 vaccine acceptance was influenza vaccine acceptance (adjusted odds ratio = 5.46; 95% confidence interval: 3.20-9.30). Parental acceptance of COVID-19 vaccines for children is closely tied to influenza vaccine acceptance. Public health approaches to maximize vaccine uptake could focus on children who have not been receiving influenza vaccines.

BackgroundVaccination against COVID-19 will likely involve children in order to mitigate transmission risks in community settings. Successful implementation of COVID-19 immunization in the United States may hinge on factors associated with parents’ likelihood of immunizing their children and themselves.MethodsWe fielded a national household survey in English and Spanish from June 5-10, 2020 (n=1,008). Parents were asked about their likelihood of immunizing their children and themselves against COVID-19. We fit separate regression models of parents’ likelihood to vaccinate themselves and their children against COVID-19, using bivariate and multivariable approaches in analyses weighted to be nationally representative.ResultsOverall, 63% of parents (95% CI: 59%, 66%) were likely to vaccinate their children against COVID-19, and 60% (57%, 64%) were likely to get a vaccine themselves. These responses were highly correlated (Pearson’s r=0.89). Parent age, sex, marital status, education level, and income were all associated with parents’ likelihood to vaccinate their children and themselves in bivariate analyses; race/ethnicity was significantly associated with parents’ likelihood to vaccinate their children. In multivariable analyses, younger parents were significantly less likely than older parents to vaccinate their children and themselves against COVID-19, as were parents with high school or less education compared with parents with bachelor’s degrees and non-Hispanic White parents compared with Hispanic parents (all pConclusionIn this national survey, only approximately 60% of U.S. parents stated that they are likely to vaccinate their children or themselves against COVID-19. Addressing parents’ hesitancy to vaccinate themselves and their children against COVID-19 will be instrumental to achieving herd immunity in the US.

TRICARE provides health care benefits to nearly two million children of active duty, retired, National Guard, and reserve service members. Child health advocates and congressional reports have raised questions regarding the adequacy of these benefits, compared with other sources of children's health insurance. To help address these questions, we compared TRICARE benefits with benefits from Medicaid and Marketplace plans because they represent alternative sources of coverage for many of the families enrolled in TRICARE. Overall, we found that TRICARE benefits fell in the middle-between Medicaid plans' more comprehensive benefits with no cost sharing and Marketplace plans' more restrictive benefits with higher cost sharing.

Objective Nearly 10% of all hospitalized children have a primary behavioral health diagnosis, but the effectiveness of treatment can be limited by caregivers’ challenges navigating the behavioral health system. In this study, we assessed a novel peer-support intervention (“parent partners”) designed for the caregivers of children admitted to an inpatient psychiatric unit. Methods We used a mixed-methods approach including 1) document review and interviews to assess implementation and 2) a difference-in-differences analysis using claims for Medicaid-enrolled children admitted to the intervention inpatient psychiatric unit and matched comparison children admitted to other inpatient psychiatric units to assess the impacts on health care use after discharge. Results Ninety-six percent of caregivers who were offered the intervention engaged with a parent partner. The primary challenges to implementation were accommodating the needs of parent partners to address behavioral health crises among their own children and initial limited engagement from behavioral health clinicians. The intervention leaders reported success in addressing these through adjustments to staffing policies, training parent partners in engagement with clinicians, and incorporating parent partners into team rounds. We did not find a statistically significant difference in follow-up outpatient behavioral health visits (adjusted treatment to comparison difference +3% [90% CI = −2%, +9%]), readmissions (+5% [−33%, +43%]), or behavioral health ED visits (−15% [−44%, +14%]). Conclusions This novel intervention was implemented successfully, and although our study did not find statistically significant impacts on health care use after discharge, the findings for ED visits are suggestive of benefits. Parent peer support in inpatient settings warrants additional investigation.

To provide actionable recommendations for improving care coordination programs for children with special healthcare needs (CSHCN) in Medicaid managed care.Literature review and interviews with stakeholders and policy experts to adapt lessons learned from Medicare care coordination programs for CSHCN in Medicaid managed care.We reviewed syntheses of research on Medicare care coordination programs to identify lessons learned from successful programs. We adapted findings from Medicare to CSHCN in Medicaid based on an environmental scan and discussions with experts. The scan focused on Medicaid financing and eligibility for care coordination and how these intersect with Medicaid managed care. The expert discussions included pediatricians, Medicaid policy experts, Medicaid medical directors, and a former managed care executive, all experienced in care coordination for CSHCN.We found 6 elements that are consistently associated with improved outcomes from Medicare care coordination programs and relevant to CSHCN in Medicaid: 1) identifying and targeting high-risk patients, 2) clearly articulating what outcomes programs are likely to improve, 3) encouraging active engagement between care coordinators and primary care providers, 4) requiring some in-person contact between care coordinators and patients, 5) facilitating information sharing among providers, and 6) supplementing care coordinators' expertise with that of other clinical experts.States and Medicaid managed care organizations have many options for designing effective care coordination programs for CSHCN. Their choices should account for the diversity of conditions among CSHCN, families' capacity to coordinate care, and social determinants of health.

Objective To assess how the Children's Health Insurance Program (CHIP) affects outcomes for children with special health care needs (CSHCN). Methods We used data from a survey of parents of recent and established CHIP enrollees conducted from January 2012 through March 2013 as part of a congressionally mandated evaluation of CHIP. We identified CSHCN in the sample using the Child and Adolescent Health Measurement Initiative's CSHCN screener. We compared the health care experiences of established CHIP enrollees to the pre-enrollment experiences of previously uninsured and privately insured recent CHIP enrollees, controlling for observable characteristics. Results Parents of 4142 recent enrollees and 5518 established enrollees responded to the survey (response rates, 46% recent enrollees and 51% established enrollees). In the 10 survey states, about one-fourth of CHIP enrollees had a special health care need. Compared to being uninsured, parents of CSHCN who were established CHIP enrollees reported greater access to and use of medical and dental care, less difficulty meeting their child's health care needs, fewer unmet needs, and better dental health status for their child. Compared to having private insurance, parents of CSHCN who were established CHIP enrollees reported similar levels of access to and use of medical and dental care and unmet needs, and less difficulty meeting their child's health care needs. Conclusions CHIP has significant benefits for eligible CSHCN and their families compared to being uninsured and appears to have some benefits compared to private insurance.

To test the hypothesis that infants auto-assigned to a Medicaid managed care plan would have lower primary care and higher emergency department (ED) utilization compared to infants with a chosen plan. Retrospective cohort study. Medicaid administrative data were used to identify all children 0–3 months of age at enrollment in Michigan Medicaid managed care in 2005–2008 with 18-months of subsequent enrollment. Medicaid encounter and state immunization registry data were then acquired. Auto-assigned infants were compared versus chosen plan infants on: (1) well-child visits (WCVs); (2) immunizations; (3) acute office visits; and (4) ED visits. Chi squared and rank-sum tests and logistic and negative binomial regression were used in bivariate and multivariable analyses for dichotomous and count data, respectively. 18 % of infants were auto-assigned. Auto-assigned infants were less likely to meet goal number of WCVs in 18-months of managed care enrollment (32 vs. 53 %, p < 0.001) and to be up-to-date on immunizations at 12 months of age (75 vs. 85 %, p < 0.001). Auto-assigned infants had fewer acute office visits (median: 4 vs. 5, p < 0.001) but were only slightly more likely to have 2 or more ED visits (51 vs. 46 %, p < 0.001) in 18-months of enrollment. All results were significant in multivariable analyses. Auto-assigned infants were less likely to use preventive and acute primary care but only slightly more likely to use emergency care. Future work is needed to understand mechanisms of differences in utilization, but auto-assigned children may represent a target group for efforts to promote pediatric preventive care in Medicaid.

Abbreviations: AAP—American Academy of Pediatrics, CSHCN—children with special health care needs, NSCH—National Survey of Children's Health Abstract: Objective. To identify components of the medical home that contribute to medical home disparities for vulnerable children. Methods. Cross- sectional analysis of 2007 Na- tional Survey of Children's Health. Prevalence of components of the medical home were estimated by special health care needs (SHCN), race/ethnicity, primary language, and health insurance. Results. Medical home disparities for children with SHCN were driven by diff erences in getting help with care coordination, when needed (71% vs. 91% children without SHCN, p

To compare the prevalence of a medical home for children with public versus private insurance and identify components of the medical home that contribute to any differences.We performed a secondary data analysis of the 2007 National Survey of Children's Health. A medical home was defined as meeting each of 5 components: 1) usual source of care; 2) personal doctor/nurse; 3) family-centered care; 4) care coordination, if needed; and 5) no problems getting a referral, if needed. We estimated the national prevalence of the medical home and its components for children with public versus private insurance. Comparisons were made using logistic regression, unadjusted and adjusted for sociodemographic factors.A total of 67% of privately insured children met all 5 components of the medical home, compared with only 45% of publicly insured children (P.001). The gap in medical home prevalence between public and private groups remained significant after controlling for sociodemographic characteristics (public vs private adjusted odds ratio [AOR] 0.82; 95% confidence interval [95% CI] 0.73-0.92). Over 90% of children in both groups reported having a usual source of care and a personal doctor/nurse. Only 58% of publicly insured children reported family-centered care, compared with 76% of privately insured children (P.001). This difference was significant after adjustment for sociodemographic characteristics (public vs private AOR 0.87; 95% CI 0.77-0.99).Significant medical home disparities exist between publicly and privately insured children, driven primarily by disparities in family-centered care. Efforts to promote the medical home must recognize and address determinants of family-centered care.

Objective To assess primary care providers' experiences with and attitudes toward pediatric-focused quality reports and identify key associated physician/practice characteristics. Methods We performed a cross-sectional survey of pediatricians and family physicians providing primary care to publicly insured children in 3 states (North Carolina, Ohio, Pennsylvania). The survey included questions about receipt of pediatric quality reports, use of reports for quality improvement (QI), and beliefs about the effectiveness of reports for QI. We used multivariable analyses to assess associations between responses and physician/practice characteristics, including exposure to federally funded demonstration projects aimed at increasing quality reporting to physicians serving publicly insured children. We supplemented these analyses with a thematic investigation of data from 46 interviews with physicians, practice staff, and state demonstration staff. Results Seven hundred twenty-seven physicians responded to the survey (overall response rate: 45.2%). Most physicians were receiving quality reports related to pediatric care (79.8%; 95% confidence interval [CI], 77.2%–82.4%) and believed that quality reports can be effective in helping guide QI (70.5%; 95% CI, 67.5%–73.5%). Fewer used quality reports to guide QI efforts (32.5%; 95% CI, 29.5%–35.6%). There were no significant associations between demonstration exposure and experiences or attitudes. Interview data suggested that physicians were receptive to quality reporting, but significant barriers remain to using such reports for QI, such as limited staff time or training in QI. Conclusions Although pediatric quality reporting is considered a promising strategy, in this study, state efforts appeared insufficient to overcome the barriers to using reports to guide practice-based QI.

Providing safe and high-quality health care for children whose parents have limited English proficiency (LEP) remains challenging. Reports of parent perspectives on navigating language discordance in health care are limited. We analyzed portions of 48 interviews focused on language barriers from 2 qualitative interview studies of the pediatric health care experiences of LEP Latina mothers in 2 urban US cities. We found mothers experienced frustration with health care and reported suboptimal accommodation for language barriers. Six themes emerged relevant to health care across settings: the "battle" of managing language barriers, preference for bilingual providers, negative bias toward interpreted encounters, "getting by" with limited language skills, fear of being a burden, and stigma and discrimination experienced by LEP families. Parents' insights highlight reasons why effective language accommodation in health care remains challenging. Partnering with families to address the management of language barriers is needed to improve health care quality and safety for LEP patients and families.

Immunoglobulin G (IgG) antibodies to three vaccine candidate preerythrocyticPlasmodium falciparumantigens were evaluated in children and adults in an epidemic-prone highland area of Kenya during rainy (high-transmission) and dry (low-transmission) seasons. The frequencies and median levels of IgG antibodies to circumsporozoite protein (CSP) and thrombospondin-related adhesive protein (TRAP) were compared to the frequencies and median levels of IgG antibodies to liver-stage antigen 1 (LSA-1) reported previously. The frequencies and median levels of IgG antibodies to CSP and TRAP were similar in children and adults in the rainy season, but they were lower in children than in adults in the dry season. The frequencies and median levels of antibodies to LSA-1 were lower in children than in adults in both the rainy and dry seasons. Antibodies to CSP and LSA-1 were primarily members of the IgG1 and IgG3 subclasses, while antibodies to TRAP were primarily members of the IgG3 and IgG4 subclasses. In a treatment-reinfection study following dry season testing, antibodies to TRAP were associated with a trend toward protection from infection in children (P= 0.051) but not in adults. Antibodies to LSA-1 and CSP did not correlate with protection in children or adults. In this highland area of Kenya with unstable transmission, IgG antibodies to preerythrocyticP. falciparumantigens vary in subjects by age and season, and the protective effects of these antibodies against infection may be different in adults and children.

Objective To examine child-serving physicians' perspectives on motivations for and support for practices in seeking patient-centered medical home (PCMH) recognition, changes in practice infrastructure, and care processes before and after recognition, and perceived benefits and challenges of functioning as a PCMH for the children they serve, especially children with special health care needs. Methods Semistructured interviews with 20 pediatricians and family physicians at practices that achieved National Committee for Quality Assurance level 3 PCMH recognition before 2011. We coded notes and identified themes using an iterative process and pattern recognition analysis. Results Physicians reported being motivated to seek PCMH recognition by a combination of altruistic and practical goals. Most said recognition acknowledged existing practice characteristics, but encouraged ongoing, and in some cases substantial, transformation. Although many physicians said recognition helped practices improve financial arrangements with payers and participate in quality initiatives, most physicians could not assess the specific benefits of recognition on patients' use of services or health outcomes. Challenges for practices in providing care for children included managing additional physician responsibilities, communicating with other providers and health systems, and building sustainable care coordination procedures. Conclusions PCMH recognition can be valuable to practices as a public acknowledgement to payers and patients that certain processes are in place, and can also catalyze new and continued transformation. Programs and policies seeking to transform primary care for children should leverage physicians' motivations and find mechanisms to build practices' capacity for care management systems and linkages with the medical neighborhood.

Multidisciplinary, multi-institutional collaboration has become a key feature of comparative effectiveness research (CER), and CER funders have made promotion of these types of collaboration an implicit, and sometimes explicit, goal of funding. An important challenge in evaluating CER programs is understanding if and how different forms of collaboration are associated with successful CER projects. This article explores the potential use of social network analysis to address research questions about the associations between collaboration and the success of CER projects.

The patient-centered medical home (PCMH) is widely promoted as a model to improve the quality of primary care and lead to more efficient use of health care services. Few studies have examined the relationship between PCMH implementation at the practice level and health care utilization by children. Existing studies show mixed results.Using practice-reported PCMH assessments and Medicaid claims from child-serving practices in 3 states participating in the Children's Health Insurance Program Reauthorization Act of 2009 Quality Demonstration Grant Program, this study estimates the association between medical homeness (tertiles) and receipt of well-child care and nonurgent, preventable, or avoidable emergency department (ED) use. Multilevel logistic regression models are estimated on data from 32 practices in Illinois (IL) completing the National Committee for Quality Assurance's (NCQA) medical home self-assessment and 32 practices in North Carolina (NC) and South Carolina (SC) completing the Medical Home Index (MHI) or Medical Home Index-Revised Short Form (MHI-RSF).Medical homeness was not associated with receipt of age-appropriate well-child visits in either sample. Associations between nonurgent, preventable, or avoidable ED visits and medical homeness varied. No association was seen among practices in NC and SC that completed the MHI/MHI-RSF. Children in practices in IL with the highest tertile NCQA self-assessment scores were less likely to have a nonurgent, preventable, or avoidable ED visit than children in practices with low (odds ratio 0.65; 95% confidence interval 0.47-0.92; P.05) and marginally less likely to have such a visit compared with children in practices with medium tertile scores (odds ratio 0.72, 95% confidence interval 0.52-1.01; P = .06).Higher levels of medical homeness may be associated with lower nonurgent, preventable, or avoidable ED use by publicly insured children. Robust longitudinal studies using multiple measures of medical homeness are needed to confirm this observation.

Enhanced access services are key components of the patient-centered medical home, but they are resource-intensive and may require significant trade-offs by practices and patients. Using qualitative research methods, we interviewed 20 parents about experiences accessing primary care for their children, priorities for enhanced access, and willingness to make trade-offs. Parents had strong preferences for certain services, such as same-day sick care appointments, and were willing to make trade-offs for high-priority services. Primary care practices and medical home programs should educate families about trade-offs needed to implement new services and engage families in setting priorities for medical home implementation.

The objectives of this study are (1) to compare the prevalence of a medical home between children with public and private insurance across states, (2) to investigate the association between a medical home and state health care characteristics for children with public and private insurance. We performed a cross-sectional analysis of the 2007 National Survey of Children’s Health, estimating the prevalence of parents’ report of a medical home and its components for publicly- and privately-insured children in all 50 states and the District of Columbia. We then performed a series of random-effects multilevel logistic regression models to assess the associations between a medical home and insurance type, individual sociodemographic characteristics, and state level characteristics/policies. The prevalence of a medical home varied significantly across states for both publicly- and privately-insured children (ranges: 33–63 % and 57–76 %, respectively). Compared to privately-insured children, publicly-insured children had a lower prevalence of a medical home in all states (public–private difference: 5–34 %). Low prevalence of a medical home was driven primarily by less family-centered care. Variation across states and differences by insurance type were largely attributable to lower reports of a medical home among traditionally vulnerable groups of children, including racial/ethnic minorities and non-English primary language speakers. The prevalence of a medical home was not associated with state level characteristics/policies. There are significant disparities between states in parents’ report of a medical home for their children, especially for publicly-insured children. Interventions seeking to address these disparities will need to target family-centered care for traditionally vulnerable populations of children.

Healthy Homes programs seek to integrate the evaluation and management of a multitude of health and safety risks in households. The education of physicians in the identification, evaluation, and management of these home health and safety issues continues to be deficient. Healthy Homes programs represent a unique opportunity to educate physicians in the home environment and stimulate ongoing, specific patient-physician discussions and more general learning about home environmental health. The Case Healthy Homes and Patients Program addresses these deficiencies in physician training while providing direct services to high-risk households. Pediatric and family practice resident physicians participate in healthy home inspections and interventions for their primary care patients and follow up on identified risks during health maintenance and acute illness visits.

Efforts to transform primary care through the medical home model may have limited effectiveness if they do not incorporate families' preferences for different primary care services.To assess parents' relative preferences for different categories of enhanced access services in primary care.Internet-based survey that took place with a national online panel from December 8, 2011, to December 22, 2011. Participants included 820 parents of children aged 0 to 17 years. Hispanic and black non-Hispanic parents were each oversampled to 20% of the sample. The survey included a discrete choice experiment with questions that asked parents to choose between hypothetical primary care practices with different levels of enhanced access and other primary care services.We estimated parents' relative preferences for different enhanced access services using travel time to the practice as a trade-off and parents' marginal willingness to travel in minutes for practices with different levels of services.The response rate of parents who participated in the study was 41.2%. Parents were most likely to choose primary care offices that guaranteed same-day sick visits (coefficient, 0.57 [SE, 0.05]; P .001) followed by those with higher professional continuity (coefficient, 0.36 [SE, 0.03]; P .001). Parents were also significantly more likely to choose practices with 24-hour telephone advice plus nonurgent email advice (0.08 [0.04]; P .05), evening hours 4 or more times a week (0.14 [0.04]; P .001), and at least some hours on weekends. Parents were significantly less likely to choose practices that were closed during some weekday daytime hours or had wait times longer than 4 weeks for preventive care visits. There was very little variation in preferences among parents with different sociodemographic characteristics. Parents' marginal willingness to travel was 14 minutes (95% CI, 11-16 minutes) for guaranteed same-day sick visits and 44 minutes (95% CI, 37-51 minutes) for an office with idealized levels of all services.As primary care practices for children implement aspects of the medical home model, those that emphasize same-day sick care and professional continuity are more likely to meet parents' preferences for enhanced access. Practices should seek to engage families in prioritizing changes in practice services as part of medical home implementation.

Objectives To measure the prevalence of enhanced access services in pediatric primary care and to assess whether enhanced access services are associated with lower emergency department (ED) utilization. Study design Internet-based survey of a national sample of parents (n = 820, response rate 41%). We estimated the prevalence of reported enhanced access services and ED use in the prior 12 months. We then used multivariable negative binomial regression to assess associations between enhanced access services and ED use. Results The majority of parents reported access to advice by telephone during office hours (80%), same-day sick visits (79%), and advice by telephone outside office hours (54%). Less than one-half of parents reported access to their child's primary care office on weekends (47%), after 5:00 p.m. on any night (23%), or by email (13%). Substantial proportions of parents reported that they did not know if these services were available (7%-56%, depending on service). Office hours after 5:00 p.m. on ≥5 nights a week was the only service significantly associated with ED utilization in multivariable analysis (adjusted incidence rate ratio: 0.51 [95% CI 0.28-0.92]). Conclusions The majority of parents report enhanced access to their child's primary care office during office hours, but many parents do not have access or do not know if they have access outside of regular office hours. Extended office hours may be the most effective practice change to reduce ED use. Primary care practices should prioritize the most effective enhanced access services and communicate existing services to families.

In 1998, a live, attenuated tetravalent rotavirus vaccine (RotaShield; Wyeth) was recommended for routine use in infants but was then withdrawn in 1999 after concerns arose suggesting an excess risk of intussusception among infants in the weeks following receipt of vaccine.1,2 As a result, larger prelicensure trials with more than 60 000 infants were performed for a pentavalent rotavirus vaccine (RotaTeq; Merck) and a monovalent rotavirus vaccine (Rotarix; GlaxoSmithKline), neither of which was associated with an increased risk of intussusception.3,4 Trial data led to licensure of both vaccines (RotaTeq, 2006; Rotarix, 2008) and the reintroduction of routine rotavirus vaccination for infants in the United States, with 2007 as the first full year of vaccination efforts. To date, postlicensure surveillance studies in the United States have not detected an increased risk of intussusception among rotavirus vaccine recipients.5,6 In contrast, postlicensure active surveillance studies in 69 hospitals in Mexico and Brazil found a small increased risk of intussusception (1 in 51 000 to 1 in 68 000) for infants receiving the first or second dose of monovalent rotavirus vaccine.7 In addition, a recent study in Australia found an increased risk of intussusception in the weeks following the first dose of rotavirus vaccine but no overall increase in the risk of intussusception for vaccinated children aged 1 to 9 months.8 These concerns about intussusception re-emerge at the same time that rapid national adoption of rotavirus vaccination in the United States9 has been associated with significant reductions in diarrhea-associated outpatient and emergency department (ED) visits10–12 and hospitalizations11–15 during rotavirus seasons. The small but clinically significant increased risk of intussusception now reported from international studies, combined with the widespread adoption of rotavirus vaccine in the United States, raises concern for the possibility of increasing intussusception rates with continuing widespread use of rotavirus vaccine. Given the rare incidence of intussusception, it is plausible that surveillance networks may not have the reach or statistical power to identify significant changes in patterns of this condition. Therefore, we sought to address the following question using national data: Has there been a change in hospitalizations for intussusception in infants after the reintroduction of rotavirus vaccine in the United States? To answer this question, we analyzed publicly available data from 3 different sources to examine intussusception rates over time and to estimate excess cases of intussusception that would be predicted based on available rotavirus vaccination coverage rates and the increased risk found in the recent international studies.