539814

research-article2014

JPCXXX10.1177/2150131914539814Journal of Primary Care & Community HealthPark et al

Original Research

Racial Health Disparities Among Special Health Care Needs Children With Mental Disorders: Do Medical Homes Cater to Their Needs?

Journal of Primary Care & Community Health 2014, Vol. 5(4) 253­–262 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131914539814 jpc.sagepub.com

Chanhyun Park1, Xi Tan2, Isha B. Patel2, Amanda Reiff3, Rajesh Balkrishnan2, and Jongwha Chang4

Abstract Background: A health care reform has been taking place to provide cost-effective and coordinated care. One method of achieving these goals is a patient-centered medical home (PCMH) model, which is associated with provision of quality care among children belonging to racial/ethnic minorities. Despite the potential of the PCMH for children of minority backgrounds, little is known about the extent to which minorities with mental disorders have the PCMH. Objective: The study examined racial/ethnic disparities among children with mental disorders in accessing care from the PCMH. Methods: The 2009-2010 National Survey of Children with Special Health Care Needs (CSHCN) was used for this analysis. Multivariate logistic regressions were applied to capture the racial/ethnic disparities and to analyze a composite outcome of the PCMH. Results: An estimated population size of 4 677 904 CSHCN with mental disorders was included. Among them, 59.94% of children reported to have received medical homes. Compared with white children, the odds of receiving any medical home services decreased among Hispanic children (odds ratio [OR] = 0.69; P < .05) and black children (OR = 0.70; P < .05). The likelihood of having a medical home was lower for Hispanic children than white children, when they had attention deficit hyperactivity disorder (ADHD; OR = 0.57; P < .05) and development delay (OR = 0.73; P < .05). Compared with white children with ADHD or depression having a medical home, the odds of black children with ADHD (OR = 0.63; P < .05) and depression (OR = 0.68; P < .05) having a medical home were lower. Conclusions: There were significant racial/ethnic disparities among CSHCN with mental disorders, indicating several sizeable effects of each of the 5 components on Hispanic, black, and other children compared with white children. These differences could be a potential to improve racial/ethnic disparities. Keywords access to care, children, health outcomes, patient-centeredness, program evaluation

Introduction In recent years, mental disorders have surfaced as a product of much attention. Advancements in both medicine and technology have shed light on many controversial aspects that surround mental disorders; more specifically the diagnosis and treatment of mental disorders. As capabilities in the fields of science and medicine have expanded, our understanding of the disorders has increased, giving us many possible options for their treatment and management. Along with the additional treatment possibilities, there have been considerable amount of controversies, regarding the high infiltration of stimulants into the nation’s youth population.1 One child/adolescent in every 10 children/adolescents has a mental illness that can lead to impairment in the

future. According to the US Department of Health and Human Services, almost 75% to 80% children needing mental health care are unable to receive it.2 About 80% children and 40% youth residing in foster homes, respectively, have a serious behavioral or mental health condition that needs treatment.3 Unfortunately, the existent health 1

The University of Texas, Austin, TX, USA The University of Michigan, Ann Arbor, MI, USA 3 Penn State College of Medicine, Hershey, PA, USA 4 Samford University, Birmingham, AL, USA 2

Corresponding Author: Jongwha Chang, Department of Social & Administrative Sciences, McWhorter School of Pharmacy, Samford University, 800 Lakeshore Drive, Birmingham, AL 35229, USA. Email: [email protected]

Downloaded from jpc.sagepub.com at NORTHERN ARIZONA UNIVERSITY on June 7, 2015

254

Journal of Primary Care & Community Health 5(4)

Predisposing factors

Enabling factors

The need for care

Race/ethnicity Age Gender Family structure Parental educa on

Region Insurance status Family income

Severity of mental disorders comorbidity

The receipt of medical home care

1) a personal doctor or nurse 2) a usual source of care 3) family-centered care 4) problem-free referrals 5) coordinated care

Figure 1.  The Anderson model of health care utilization to explain the effects of race/ethnicity on having a medical home in children with mental disorders.

disparities among children with mental disorders are because of factors such as geographic location, socioeconomic status, race, and gender. Health disparities among children with mental health illnesses are widespread across the nation. Data from the 2001-2004 National Health and Nutrition Examination Survey indicates that approximately only half the children affected by mental disorders receive professional treatment.4 In a study looking at access to mental care among children belonging to racial minorities, it was found that white children residing in areas of high poverty were more likely to receive treatment compared with black and Hispanic children and vice versa.5 In the past couple of years in the United States, a health care reform has been taking place to provide cost-effective and coordinated patient care. One method of achieving these goals is by reorganizing primary care and moving toward a patient-centered medical home (PCMH) model. The PCMH model provides a comprehensive, team-based care that can address the different needs of a patient ranging from physical to mental health, can improve access to care by improving accessibility for a patient to receive care, can serve as a source of regular primary care and can ensure better care coordination.6-8 Children with special health care needs are defined as the children who “require health and related services of a type or amount beyond that required by children generally.”9 Medical homes are known to be associated with provision of lower quality care among racial and ethnic minority children with autism and developmental disabilities.10 A study analyzing the 2005-2006 National Survey of Children with Special Health Care Needs showed that black children with a medical home had a higher probability of visiting the emergency room compared with white children with a medical home.11 The above studies indicate that, in general, racial health disparities exist in children

with medical homes. However, there is very little research specifically focusing on the access to medical homes among children with mental diseases, and especially using the criteria of medical homes defined by the American Academy of Pediatrics. Therefore, the aim of this study was to examine racial/ethnic disparities among children with mental disorders in accessing care from a medical home.

Methods Conceptual Framework This study employs the Andersen model of health care utilization as a conceptual framework to examine the effects of race/ethnicity on having a medical home (Figure 1). The Andersen model is commonly used to assess factors that are associated with patient utilization of health care services.12-14 This model assumes that individual determinants of health care utilization are predisposing, enabling, and need factors. Predisposing factors are individual characteristics that preexist to the onset of illness and describe the propensity of individuals to use health care services.13 Second, enabling factors are factors that pertain to individuals who have the means that allow them to use health services.13 Third, the need for care describes the level of experienced illness. The actual use of health services are triggered by the need factors because the predisposing and enabling factors alone are not sufficient to do the same but are still necessary for the use of health services.13

Data Source Data from the 2009-2010 National Survey of Children with Special Health Care Needs (NS-CSHCN), conducted by the Centers for Disease Control and Prevention’s National

Downloaded from jpc.sagepub.com at NORTHERN ARIZONA UNIVERSITY on June 7, 2015

255

Park et al Center for Health Statistics State and Local Area Integrated Telephone Survey program, were used for these analyses. The NS-CSHCN is a nationally representative cross-sectional telephone survey of CSHCN and was conducted in 50 states and the District of Columbia between July 2009 and March 2011. Data were collected using a list-assisted random-­digit-dial sample of US households with at least 1 resident child aged 0 to 17 years. The sample design was stratified by state and sample type (landline or cell-phone) and clustered for children within households. A parent or guardian with knowledge of the health and health care of the children in the household participated as a respondent. The majority of the respondents were mothers (75%). A total of 40 242 interviews were completed. The response rate was 43.7% for the landline sample, 15.2% for the cellphone sample, and 25.5% for the combined sample.

Study Population The target population in this study comprised all noninstitutionalized CSHCN with mental disorders in the United States. Children were included in this study if they (1) had one or more of the following conditions—attention deficit hyperactivity disorder (ADHD), depression, anxiety problems, behavior or conduct problems, autism or other autism spectrum disorder, developmental delay, and intellectual disability or mental retardation and (2) were aged 6 to 17 years.

Measures A composite dependent variable was the receipt of a medical home. As defined by the framework of the American Academy of Pediatrics, this composite variable was generated based on the following 5 components of a medical home: (1) the child had a personal doctor or nurse, (2) the child had a usual source of care, (3) the child had familycentered care, (4) the child had problem-free referrals (when applicable), and (5) the child had coordinated care (when applicable).15,16 Two components (the child had problemfree referrals and the child had coordinated care) were used “when applicable” since some children may not need referrals or care transition and coordination, and thus these criteria were not applicable in these cases. To be considered as the receipt of a medical home, all children should meet the criteria of having a personal doctor or nurse, having a usual source of care, and having family-centered care, while they have to meet the criteria of having problem-free referrals and/or having coordinated care when applicable. The independent variable was race/ethnicity, which was categorized as whites (non-Hispanic), blacks (non-Hispanic), Hispanics, and other races. The covariates were determined based on the Andersen model. In our study, predisposing factors included age,

gender, family structure, and parental education. Age was categorized as a continuous variable and gender was dichotomized as males and females. Family structure was classified as 2-parent, single parent, and others. The parental education level was categorized as less than high school, high school, and more than high school. Enabling factors included geographic residence, family income, and insurance status. Geographic residences were categorized as Northeast, Midwest, South, and West. Family income were measured as a percentage of poverty and categorized as 100% to 200%) Middle (>200% to 400%) High (>400%) Two parents Single parent Other Less than high school High school More than high school Yes No Mental illness only Mental illness plus physical disease

59.06 (57.25, 60.84) 40.94 (39.16, 42.75) 14.81 (10.68, 20.17) 63.72 (59.25, 67.96) 13.86 (11.61, 16.46) 7.62 (6.26, 9.23) 18.58 (8.34, 36.25) 23.73 (12.57, 40.22) 39.37 (24.56, 56.42) 18.37 (8.35, 35.74) 34.99 (33.86, 36.13) 65.01 (63.87, 66.14) 44.34 (41.56, 47.15) 39.26 (36.75, 41.84) 9.85 (8.04, 12.03) 3.06 (2.46, 3.79) 3.49 (2.91, 4.18) 24.45 (22.51, 26.50) 23.19 (21.29, 25.20) 27.63 (26.24, 29.07) 24.73 (21.93, 27.76) 60.77 (58.31, 63.18) 28.73 (27.25, 30.27) 10.50 (9.29, 11.84) 12.12 (10.64, 13.76) 21.29 (19.48, 23.22) 66.59 (64.08, 69.01) 24.64 (23.32, 26.01) 75.36 (73.99, 76.68) 60.46 (58.75, 62.15) 39.54 (37.85, 41.25)

Age in years, mean (95% CI)

11.85 (11.76, 11.93)

categorical predictors in the model, (4) we rebuilt the final multivariate logistic regression model using all predictors with P value less than .05 and the variables of interest, and (5) we used Archer and Lemeshow’s design adjusted test to assess the goodness of fit of the model. The α level for statistical significance was used at .05. All analyses were performed using Stata/IC 12.1 (Stata Corp, College Station, TX).

Results Population Characteristics Table 1 shows the characteristics of the study population, that is, CSHCN with mental disorders aged 6 to 17 years. The estimated population size was 4 677 904 children met the study inclusion criteria. Among them, 59.94% children

The receipt of a medical home

Variable

(%)

0

Table 1.  Descriptive Statistics for the Study Population (Weighted N = 4 677 904 and Unweighted N = 17 059).

10 20 30 40 50 60 70 80 90 100

Journal of Primary Care & Community Health 5(4)

Black (non-Hispanic) Hispanic

Other

White (non-Hispanic)

Figure 2.  The receipt of a medical home among different races/ ethnicities.

reported to have received medical home care. The majority of the study population were males (65.01%), non-Hispanic whites (63.72%), living in the south (39.37%), had private insurance (44.34%), and lived in 2-parent households (60.77%). More children had mild-to-moderate mental disorders (75.36%) compared with severe mental disorders and had only mental disorders without physical diseases (60.46%).

Receipt of a Medical Home Among Children With Mental Disorders Figure 2 shows the receipt of a medical home among different races/ethnicities. Overall, 63.74% white children, 49.87% black children, and 49.25% Hispanic children received receiving medical home services. The results for the 6 logistic models on the 5 components of a medical home and the composite of these components in children with any mental disorders are reported in Table 2. In the composite model, the race/ethnicity, age, gender, family structure, parental education, region, insurance status, family income, severity of mental disorders, and comorbidity variables were used as the potential significant predictors in the initial multivariate logistic regression model; and then the family structure, parental education variables were excluded by the design-adjusted Wald test to evaluate the categorical predictors. Finally, the race/ethnicity, age, gender, region, insurance status, family income, severity of mental disorders, and comorbidity variables were used in the final multivariate logistic regression model. All designadjusted Wald tests showed that all included predictors in the final multivariate logistic regression model were statistically significant. Among the predisposing factors, race/ethnicity, age and gender were retained in the final models. Overall, the odds

Downloaded from jpc.sagepub.com at NORTHERN ARIZONA UNIVERSITY on June 7, 2015

257

Park et al Table 2.  The Likelihood of Having a Medical Home and 5 Components of a Medical Home Among All Children With Any Mental Disorder.a Odds Ratio (95% CI) Variable

Composite Model

Predisposing factors Race  Hispanic 0.69 (0.59, 0.81)***   Black, non-Hispanic 0.70 (0.56, 0.88)**  Other 0.84 (0.69, 1.02) Age 0.99 (0.97, 1.01) Gender  Male 0.86 (0.78, 0.96)** Enabling factors Region  Midwest 1.21 (1.02, 1.44)*  South 1.06 (0.91, 1.25)  West 0.88 (0.75, 1.02) Insurance type  Private 2.17 (1.67, 2.84)***  Public 1.85 (1.37, 2.49)***   Both private and public 2.18 (1.66, 2.86)***  Other 2.81 (1.88, 4.18)*** Poverty level of the household   ≤100% 0.63 (0.52, 0.78)***   >100% to 200% 0.72 (0.62, 0.83)*** >200% to 400% 0.85 (0.75, 0.98)* The need for care Severity of mental illness  Severe 0.66 (0.56, 0.78)*** Comorbidity   Mental and physical 0.89 (0.81, 0.98)*** disease

Model 1: Personal Doctor/Nurse

Model 2: Usual Source of Care

Model 3: FamilyCentered Care

1.00 (0.72, 1.40) 0.72 (0.56, 0.94)* 0.72 (0.49, 1.08) 0.97 (0.93, 1.01)

0.65 (0.51, 0.83)** 0.87 (0.66, 1.16) 0.84 (0.65, 1.10) 0.99 (0.96, 1.02)

0.66 (0.53, 0.84)** 0.58 (0.40, 0.84)** 0.98 (0.72, 1.33) 0.98 (0.96, 1.01)

0.97 (0.75, 1.25)

0.81 (0.66, 0.99)*

0.85 (0.69, 1.04)

0.91 (0.71, 1.17) 0.87 (0.68, 1.10) 0.80 (0.63, 1.01)

0.73 (0.58, 0.92)** 0.76 (0.62, 0.95)* 0.76 (0.62, 0.93)**

1.40 (1.12, 1.75)** 1.07 (0.79, 1.45) 1.05 (0.81, 1.36) 1.09 (0.79, 1.49) 1.09 (0.87, 1.37) 0.71 (0.52, 0.97)*

3.05 (1.83, 5.08)*** 2.64 (1.82, 3.84)*** 2.65 (1.73, 4.05)*** 3.39 (2.47, 4.65)*** 3.18 (1.93, 5.24)*** 2.78 (1.90, 4.06)*** 3.52 (1.70, 7.31)** 3.87 (1.78, 8.40)**

2.16 (1.52, 3.07)*** 1.56 (0.93, 2.61) 2.06 (1.24, 3.44)** 1.88 (1.05, 3.36)*

Model 4: ProblemModel 5: Free Referrals Coordinated Care   0.53 (0.41, 0.70)*** 1.78 (1.27, 2.49)** 1.05 (0.76, 1.47) 0.79 (0.47, 1.31) 0.97 (0.67, 1.41) 1.22 (0.87, 1.72) 0.99 (0.95, 1.02) 0.98 (0.95, 1.02)   1.02 (0.89, 1.18) 0.90 (0.72, 1.14)**

1.20 (0.85, 1.68) 1.10 (0.78, 1.58) 0.81 (0.55, 1.20)

2.83 (1.72, 4.65)*** 0.74 (0.32, 1.70) 2.60 (1.62, 4.15)*** 0.96 (0.52, 1.78) 3.25 (1.91, 5.54)*** 1.65 (0.73, 3.73) 2.61 (1.34, 5.09)** 1.56 (0.77, 3.17)

0.32 (0.21, 0.50)*** 0.44 (0.31, 0.63)*** 0.55 (0.37, 0.82)** 0.88 (0.63, 1.24) 0.47 (0.32, 0.68)*** 0.61 (0.43, 0.85)** 0.56 (0.42, 0.74)*** 0.75 (0.53, 1.05) 0.67 (0.49, 0.93)* 0.73 (0.58, 0.93)* 0.61 (0.51, 0.74)*** 1.04 (0.77, 1.43)

1.30 (0.77, 2.21) 1.13 (0.81, 1.58) 1.04 (0.74, 1.47)

1.05 (0.83, 1.31)

1.24 (0.91, 1.68)

0.83 (0.64, 1.09)

0.60 (0.46, 0.79)*** 0.93 (0.58, 1.50)

1.24 (0.95, 1.62)

1.49 (1.12, 1.97)**

0.94 (0.80, 1.11)

0.73 (0.60, 0.91)** 1.28 (0.99, 1.65)

a

Reference categories: female, white, northeast, uninsured, poverty level of the household >400% federal poverty level, not having severe mental illness, mental illness only. The race/ethnicity, age, gender, family structure, parental education, region, insurance status, family income, severity of mental disorders, comorbidity variables were used in the initial multivariate logistic regression model; and after the design-adjusted Wald test, the race/ ethnicity, age, gender, region, insurance status, family income, severity of mental disorders, comorbidity variables were used in the final multivariate logistic regression model. *P < .05. **P < .01. ***P < .001.

of receiving medical home services decreased among Hispanic children (odds ratio [OR] = 0.69; 95% confidence interval [CI] = 0.59-0.81) and black children (OR = 0.70; 95% CI = 0.56-0.88) compared with white children. Regarding each of the specific 5 components, when compared with white children, Hispanic children were less likely to have a usual source of care (OR = 0.65; 95% CI = 0.51-0.83), family-centered medical home (OR = 0.66; 95% CI = 0.53-0.84), and problem-free referrals (OR = 0.53; 95% CI = 0.41-0.70) whereas black children were less likely to have a personal doctor or nurse (OR = 0.72; 95% CI = 0.56-0.95) and family-centered medical home (OR = 0.58; 95% CI = 0.40-0.84) respectively. Hispanic children were more likely to have coordinated care than white children (OR = 1.78; 95% CI = 1.27-2.49). With regard to other

predisposing factors, male children were associated with a lower likelihood of having a medical home compared with female children (OR = 0.86; 95% CI = 0.78-0.96), indicating significantly lower probability of having usual source of care and coordinated care. All the enabling factors were retained in the final models. Regarding insurance status, children with insurance had a higher likelihood of having a medical home compared with those without insurance depending on the type of insurance; specifically, the likelihoods of having a medical home were 2.17 times higher in children with private insurance, 1.85 times higher in children with public insurance, and 2.18 times higher in children with both private and public insurance than that in children without insurance, controlling for the other predictor. Additionally, the odds of

Downloaded from jpc.sagepub.com at NORTHERN ARIZONA UNIVERSITY on June 7, 2015

258

Journal of Primary Care & Community Health 5(4)

having a personal doctor or nurse, usual source of care, and problem-free referrals increased across all types of insurance. Regarding FPL, compared with households with FPL higher than 400%, the odds of having a medical home were significantly lower in households with (1)

Racial health disparities among special health care needs children with mental disorders: do medical homes cater to their needs?

A health care reform has been taking place to provide cost-effective and coordinated care. One method of achieving these goals is a patient-centered m...
427KB Sizes 0 Downloads 3 Views