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THE DETERMINANTS OF TIMELY ACCESS TO QUALITY HEALTH CARE Presentation to  GEORGIA PUBLIC HEALTH ASSOCIATION ANNUAL MEETING...
Other Contributors <ul><li>Dave Goodman, MS, PhD </li></ul><ul><li>Katherine Kahn, MPH </li></ul><ul><li>Cherie Long, MPH ...
DCH Mission ACCESS Access   to affordable, quality health care in our communities RESPONSIBLE Responsible  health planning...
DCH Initiatives FY 2011 FY 2011 Continuity of Operations Preparedness Customer Service Emergency Preparedness   Financial ...
Presentation Outline <ul><li>Background </li></ul><ul><li>Methods </li></ul><ul><li>Results </li></ul><ul><li>Discussion <...
Background <ul><li>Definitions of Access and Quality </li></ul><ul><li>Importance of Access </li></ul><ul><li>Associated F...
Definitions of Access & Quality <ul><li>Access to care </li></ul><ul><ul><li>Timely use of personal health services to ach...
Importance of Access <ul><li>Importance of Access </li></ul><ul><ul><li>Ensuring the receipt of preventive services </li><...
Associated Factors - Access <ul><li>Insurance (continuity, type of insurance) </li></ul><ul><li>Having a personal health c...
Associated Factors - Quality <ul><li>Race/ethnicity   </li></ul><ul><li>Insurance </li></ul><ul><li>Primary household lang...
Prevalence in Georgia <ul><li>Access to care </li></ul><ul><ul><li>Identified as a major health concern for all MCH popula...
Gaps & Study Question <ul><li>No in-depth exploration of factors associated with access and quality of health care in Geor...
Methods <ul><li>Study Design </li></ul><ul><li>Dependent Variable </li></ul><ul><li>Independent Variables – Andersen’s Fra...
Study Design <ul><li>Merged dataset: </li></ul><ul><ul><li>2007 NSCH PUF (Interview completion rate: 66%) </li></ul></ul><...
Dependent Variable <ul><li>Access to quality health care </li></ul><ul><ul><li>Access to care </li></ul></ul><ul><ul><ul><...
Dependent Variable <ul><li>Access to care: Yes/No </li></ul><ul><li>Quality of Health Care: Higher/Moderate/Lower </li></u...
Independent Variables: Andersen’s Theoretical Framework
Data Analysis <ul><li>Descriptive Statistics </li></ul><ul><li>Bivariable analysis (Chi-square tests) </li></ul><ul><li>Si...
Data Analysis <ul><li>Multivariable Analysis </li></ul><ul><ul><li>Domain-specific models </li></ul></ul><ul><ul><li>Full ...
Results <ul><li>Descriptive Statistics </li></ul><ul><li>Bivariable Results – Associated Factors </li></ul><ul><li>Multiva...
Descriptive Statistics <ul><li>Access to quality health care </li></ul><ul><ul><li>Access to higher quality care (32.8%) <...
Bivariable Results –Associated Factors <ul><li>External Domain </li></ul><ul><ul><li>Having a recreation center (p=0.03) <...
Bivariable Results – Associated Factors <ul><li>Predisposing Domain contd. </li></ul><ul><ul><li>Longer stay of mother-typ...
Bivariable Results - Associated Factors <ul><li>Need Domain </li></ul><ul><ul><li>Being in excellent overall health status...
Multivariable Results  <ul><li>Detailed  results </li></ul>
Discussion <ul><li>Summary of Findings </li></ul><ul><li>Public Health Implications </li></ul><ul><li>Strengths </li></ul>...
Summary of Findings <ul><li>About a third of Georgia children ages 4-17 years had access to higher quality care </li></ul>...
Summary of Findings <ul><li>Lower odds of having access to higher/moderate quality care (vs. lower quality care) </li></ul...
Summary of Findings <ul><li>Higher odds of having access to lower quality care </li></ul><ul><ul><li>Predisposing: Black, ...
Public Health Implications <ul><li>Insurance Coverage </li></ul><ul><ul><li>Most mutable factor </li></ul></ul><ul><ul><li...
Public Health Implications <ul><li>CSHCN population </li></ul><ul><ul><li>Outreach to older children (10-17) for regular c...
Strengths <ul><li>Composite variable of access and quality </li></ul><ul><li>Contextual perspective – ARF & MUA variable <...
Limitations <ul><li>Cross-sectional survey </li></ul><ul><li>Parent’s perceptions – not verified </li></ul><ul><li>Occurre...
Acknowledgements <ul><li>Deb Rosenberg, PhD, University of Illinois, Chicago </li></ul><ul><li>Kristin Rankin, PhD, Univer...
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Gapha conference the_determinantsoftimelyaccesstoqualityhealthcare_chineloogbuanu_final_041211

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  • This study is perfectly aligned with the mission of the Department of Community Health.
  • Quality health care: Institute of Medicine’s definition. Patient-centered or personalized care involves providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. AAP’s definition: Quality care, especially for children, has been defined in terms of the medical home concept which encompasses care that is accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective The words in italicized fonts are the concepts we focused on for this study
  • Preventive services such as age-appropriate vaccinations and screenings. It is also a prerequisite for the optimal management of chronic childhood diseases such as asthma, which require ongoing symptom assessments, trigger management, medication prescription, and patient education.
  • Some studies have shown that Black, NHs have greater access to care.
  • Risk factors associated with having a poorer quality medical home include: non-white race/ethnicity Being uninsured Non-English primary household language Poverty status &lt;200% FPL Parent education &lt; High School
  • Health care access has been identified as a major health concern for all maternal and child health populations especially children in Georgia through the 5-year needs assessment process for the 2010 Title V Block Grant. 88.3% of children 0-17 years of age in Georgia had a preventive medical visit in the past year (88.5% nationwide). For family-centered care, which is one of the components of medical home, the distribution based on parent’s report of ‘always’ or ‘usually’ on the component questions was as follows: HCP spends enough time (79.3%), HCP listens carefully (89.8%), HCP provides specific needed information (87.8%), and HCP helps parent feel like a partner in care (89.0%)
  • For this study, we focused on Georgia children ages 4-17 years old to ensure a level playing field, given that the guidelines of the American Academy of Pediatrics stipulate several well visits from 0 to age 3 and only one visit yearly thereafter until age 21.
  • The merge was performed using the restricted use variable – county of residence The 2007 NSCH is a national, cross-sectional, random-digit-dial landline telephone survey conducted as part of the State and Local Area Integrated Telephone Survey (SLAITS) program by NCHS, CDC in conjunction with the Maternal and Child Health Bureau, Health Services and Resources Administration (HRSA). The main objective of the survey is to determine national and state-specific prevalence estimates of various health indicators and experiences with the health care system among children aged &lt;18 years in the United States. One child was selected randomly from each household to be the focus of the parent or guardian interview. During April 2007 to July 2008, a total of 91,642 interviews were completed nationwide for the 2007 NSCH and 1,782 interviews were completed in Georgia, with a national response rate of 46.7% (the product of the telephone resolution rate – 81.9%, screener completion rate – 86.4%, and interview completion rate – 66.0%). In the ARF, which is produced by the Bureau of Health Professions, HRSA provides county-level data on several indicators, including geographic codes and classifications, health professions supply and detailed demographics, health facility numbers and types, and hospital utilization . It comprises data collected from more than 50 sources including detailed mortality and natality records from NCHS, physician specialty data from the American Medical Association, and facilities data from the American Hospital Association. The ARF is updated and issued yearly. The MUA variable for Georgia was downloaded from the HRSA website. Medically underserved areas/populations are areas or populations designated as having: too few primary care providers, high infant mortality, high poverty and/or high elderly population. Total sample size for Georgia = 1,782. For our study = 1,397. AAP guidelines: several well visits between 0-3, and then one yearly after that until 21 years of age.
  • Quality of health care - whether care received was compassionate, culturally-effective, and family-centered
  • Children who received higher quality care had a response of always to all five questions, children who received moderate quality care had a response of always or usually to all five questions, and children who received lower quality care had any other combination of responses to the five questions (such as sometimes or never to any or all the questions). In creating the composite variable, all those who had no access to care, were coded as having no access to care, irrespective of their level of quality of care. The other three levels were access to lower quality care, access to moderate quality care and access to higher quality care.
  • Selection of control variables was guided by the Andersen’s behavioral model of health services utilization (comprising the external environment, predisposing, enabling and need domains. The external environment domain includes factors related to the child’s neighborhood: neighborhood detracting factors (presence of litter or garbage on street or sidewalk, dilapidated housing, vandalism – broken windows/graffiti) and neighborhood amenities (presence of sidewalks or walking paths, parks or playgrounds, recreations centers, and libraries). The predisposing domain includes factors that would predispose the child to use health care and a broad array of characteristics, including social networks, social interactions and culture. The enabling domain includes community and personal enabling resources, i.e. the availability of health personnel and facilities and the personal means and know-how to get to those services and make use of them. Insurance coverage (never/intermittently insured, continuous-inadequate-private, continuous-inadequate-public, continuous-adequate-private, continuous-adequate-public). The insurance coverage variable is a composite variable created from several questions covering current insurance, gaps in insurance in the previous 12 months, adequacy of insurance in terms of benefits, providers, and out-of-pocket costs, and type of insurance (public or private). The need domain includes child’s special health care need status and child’s overall health status. Apart from four variables (number of FQHCs, number of RHCs, HPSAs, and RUCC), which were obtained from the 2008 Area Resource File (ARF), and the MUA variable downloaded from the HRSA website, all other variables were obtained from the 2007 NSCH PUF.
  • Mother-type: biological, step, foster, adoptive
  • Reference group for insurance is children with continuous-adequate-private insurance
  • First bullet: Higher odds of having access to lower quality care versus no access to care. Analysis among the subpopulation of CSHCN showed estimates generally in the same direction as those among all children aged 4-17 years. The estimates were however larger with wider confidence intervals
  • Insurance coverage is the major determinant of whether children have access to health care ( ↑ in enrollment (face-to-face versus online), elimination of gaps (economic situation or administrative bottlenecks), adequacy (providers, benefits, out-of-pocket costs). The Medicaid &amp; Peach Care for Kids program in Georgia, while providing eligible children with access to needed care, would have to ensure that pediatricians who accept to see these children are willing to provide family-centered care for them. As is well known, reimbursement rates are lower in the public insurance market than in the private market. Pediatricians who see Medicaid/Peach Care for Kids patients may not spend as much time with each patient in order to increase their volume. The state needs to provide adequate reimbursement rates to maintain and improve provider participation, and quality standards must be enforced for all providers. Race/Ethnicity It is unfortunate that minority populations (Black, NHs and Hispanics) have significantly lower odds of having access to higher/moderate quality care. Previous research supports our findings. This may not be unconnected to cultural differences between providers and patients. However, we were unable to explore this factor in our data.
  • Among the CSHCN population , younger age (4-9 years) was associated with having access to higher/moderate quality care. In order to ensure smooth transitions from pediatric providers to adult health care providers for this special population, it will be important to maintain the recommended yearly well-checkups for developmentally appropriate health assessments and counseling. The Children Medical Services (CMS) program in Georgia, a state health program charged with providing care coordination and other needed services for children (0 to 21yrs) who have an eligible chronic medical condition and meet the financial criteria, needs to ensure that their clients are making visits regularly to their pediatricians. This will create opportunities for transition plans to be made. Making this transition smooth will also meet the National Performance Measure 6: the percentage of youth with special health care needs who received the services necessary to make transitions to all aspects of adult life, including adult health care, work and independence. It may also be that the older CSHCN (10-17 years) have less access to quality health care because the pediatricians do not feel competent to handle them and so prefer not to see them or when they do see them, provide care that is not compassionate, culturally-sensitive or family-centered. For Georgia, one of our current performance measures (State Performance Measure 6) is the percent of pediatricians and family physicians who have positive attitudes toward treating children with special health care needs. As Georgia addresses this measure through activities such as an attitudinal survey of AAP-Georgia Chapter, and the Georgia Association of Family physicians, and holding meetings with leaders in Georgia medical schools to develop a strategy to expose medical students to treating CSHCN, this may go a long way to improve the kind of care that the older CSHCN receive.
  • Limitations: The NSCH survey is cross-sectional and therefore causality cannot be inferred. Responses were based on parent’s perceptions and were not validated by cross-checking the children’s medical records. Given that the survey required parents to report on occurrences in the past year, there may have been some reporting errors. In addition, given that the analyses were performed at the state level, some cells containing very small numbers had to be collapsed. Another limitation is the lack of a multilevel model to address the county level factors.
  • Transcript of "Gapha conference the_determinantsoftimelyaccesstoqualityhealthcare_chineloogbuanu_final_041211"

    1. 1. THE DETERMINANTS OF TIMELY ACCESS TO QUALITY HEALTH CARE Presentation to GEORGIA PUBLIC HEALTH ASSOCIATION ANNUAL MEETING APRIL 12 TH , 2011 CHINELO OGBUANU, MD, MPH, PHD, SENIOR MCH EPIDEMIOLOGIST
    2. 2. Other Contributors <ul><li>Dave Goodman, MS, PhD </li></ul><ul><li>Katherine Kahn, MPH </li></ul><ul><li>Cherie Long, MPH </li></ul><ul><li>Brendan Noggle, MPH </li></ul><ul><li>Suparna Bagchi, MS, DrPH </li></ul><ul><li>Danielle Barradas, PhD </li></ul><ul><li>Brian Castrucci, MA </li></ul>
    3. 3. DCH Mission ACCESS Access to affordable, quality health care in our communities RESPONSIBLE Responsible health planning and use of health care resources HEALTHY Healthy behaviors and improved health outcomes
    4. 4. DCH Initiatives FY 2011 FY 2011 Continuity of Operations Preparedness Customer Service Emergency Preparedness Financial & Program Integrity Health Care Consumerism Health Improvement Health Care Transformation Public Health Workforce Development
    5. 5. Presentation Outline <ul><li>Background </li></ul><ul><li>Methods </li></ul><ul><li>Results </li></ul><ul><li>Discussion </li></ul>
    6. 6. Background <ul><li>Definitions of Access and Quality </li></ul><ul><li>Importance of Access </li></ul><ul><li>Associated Factors – Access </li></ul><ul><li>Associated Factors – Quality </li></ul><ul><li>Prevalence in Georgia </li></ul><ul><li>Gaps & Study Question </li></ul>
    7. 7. Definitions of Access & Quality <ul><li>Access to care </li></ul><ul><ul><li>Timely use of personal health services to achieve the best possible health outcomes (IOM) </li></ul></ul><ul><li>Quality health care: </li></ul><ul><ul><li>Safe, effective, patient-centered , timely, efficient, and equitable (IOM) </li></ul></ul><ul><ul><li>Accessible, family-centered , continuous, comprehensive, coordinated, compassionate & culturally effective (AAP) </li></ul></ul>
    8. 8. Importance of Access <ul><li>Importance of Access </li></ul><ul><ul><li>Ensuring the receipt of preventive services </li></ul></ul><ul><ul><li>A prerequisite for optimal management of chronic childhood diseases </li></ul></ul><ul><ul><li>Influences children’s physical & emotional growth, development, overall health and well being </li></ul></ul>
    9. 9. Associated Factors - Access <ul><li>Insurance (continuity, type of insurance) </li></ul><ul><li>Having a personal health care provider </li></ul><ul><li>Having a usual source of care </li></ul><ul><li>Race/ethnicity </li></ul>
    10. 10. Associated Factors - Quality <ul><li>Race/ethnicity </li></ul><ul><li>Insurance </li></ul><ul><li>Primary household language </li></ul><ul><li>Income </li></ul><ul><li>Parental Education </li></ul>
    11. 11. Prevalence in Georgia <ul><li>Access to care </li></ul><ul><ul><li>Identified as a major health concern for all MCH populations especially children in Georgia </li></ul></ul><ul><ul><li>Based on 2007 NSCH (Georgia children ages 0-17) </li></ul></ul><ul><ul><ul><li>88.3% had a preventive medical visit in the past year </li></ul></ul></ul><ul><ul><ul><li>58.5% received care within a medical home </li></ul></ul></ul><ul><ul><ul><li>Family-centered component of medical home </li></ul></ul></ul><ul><ul><ul><ul><li>HCP spends enough time (79.3%); HCP listens carefully (89.8%) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>HCP provides specific needed information (87.8%) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>HCP helps parent feel like a partner in care (89.0%) </li></ul></ul></ul></ul>
    12. 12. Gaps & Study Question <ul><li>No in-depth exploration of factors associated with access and quality of health care in Georgia </li></ul><ul><li>Study Question: </li></ul><ul><ul><li>What are the determinants of access to quality health care in Georgia among children ages 4-17 years? </li></ul></ul>
    13. 13. Methods <ul><li>Study Design </li></ul><ul><li>Dependent Variable </li></ul><ul><li>Independent Variables – Andersen’s Framework </li></ul><ul><li>Data Analysis </li></ul>
    14. 14. Study Design <ul><li>Merged dataset: </li></ul><ul><ul><li>2007 NSCH PUF (Interview completion rate: 66%) </li></ul></ul><ul><ul><li>Selected 2007 variables from the 2008 Area Resource File </li></ul></ul><ul><ul><li>Medically Underserved Area (MUA) variable for Georgia </li></ul></ul><ul><li>Study Population </li></ul><ul><ul><li>Georgia children 4-17 years of age (N = 1,397) </li></ul></ul>
    15. 15. Dependent Variable <ul><li>Access to quality health care </li></ul><ul><ul><li>Access to care </li></ul></ul><ul><ul><ul><li>Utilization of preventive medical visit in the past year </li></ul></ul></ul><ul><ul><ul><li>No occasion of delay or denial of needed care in the past year </li></ul></ul></ul><ul><ul><li>Quality of health care </li></ul></ul><ul><ul><ul><li>Health care provider spends enough time with child </li></ul></ul></ul><ul><ul><ul><li>Listens carefully to parent </li></ul></ul></ul><ul><ul><ul><li>Is sensitive to family values and customs </li></ul></ul></ul><ul><ul><ul><li>Provides specific needed information </li></ul></ul></ul><ul><ul><ul><li>Makes parent feel like a partner in child’s care </li></ul></ul></ul>
    16. 16. Dependent Variable <ul><li>Access to care: Yes/No </li></ul><ul><li>Quality of Health Care: Higher/Moderate/Lower </li></ul><ul><li>Access to quality health care </li></ul><ul><ul><li>Access to higher quality care </li></ul></ul><ul><ul><li>Access to moderate quality care </li></ul></ul><ul><ul><li>Access to lower quality care </li></ul></ul><ul><ul><li>No access to care </li></ul></ul>
    17. 17. Independent Variables: Andersen’s Theoretical Framework
    18. 18. Data Analysis <ul><li>Descriptive Statistics </li></ul><ul><li>Bivariable analysis (Chi-square tests) </li></ul><ul><li>Significant testing – alpha=0.05 </li></ul><ul><li>Multivariable Analysis </li></ul><ul><ul><li>Multinomial logistic regression (genlogit approach) </li></ul></ul><ul><ul><li>First 2 levels of outcome were collapsed </li></ul></ul><ul><ul><li>Access to higher/moderate versus lower quality care </li></ul></ul><ul><ul><li>Access to lower quality care versus no access to care </li></ul></ul>
    19. 19. Data Analysis <ul><li>Multivariable Analysis </li></ul><ul><ul><li>Domain-specific models </li></ul></ul><ul><ul><li>Full models (all domains simultaneously) </li></ul></ul><ul><ul><li>Ρ -value=0.3 for entry into models and retainership in final models </li></ul></ul><ul><ul><li>Additional analysis on subpopulation of CSHCN (N=319) </li></ul></ul><ul><li>All analysis – SAS-callable SUDAAN 10.0.1 </li></ul>
    20. 20. Results <ul><li>Descriptive Statistics </li></ul><ul><li>Bivariable Results – Associated Factors </li></ul><ul><li>Multivariable Results </li></ul>
    21. 21. Descriptive Statistics <ul><li>Access to quality health care </li></ul><ul><ul><li>Access to higher quality care (32.8%) </li></ul></ul><ul><ul><li>Access to moderate quality care (24.8%) </li></ul></ul><ul><ul><li>Access to lower quality care (22.8%) </li></ul></ul><ul><ul><li>No access to care (19.6%) </li></ul></ul>
    22. 22. Bivariable Results –Associated Factors <ul><li>External Domain </li></ul><ul><ul><li>Having a recreation center (p=0.03) </li></ul></ul><ul><li>Predisposing Domain </li></ul><ul><ul><li>Younger age (4-9 years; p=0.05) </li></ul></ul><ul><ul><li>Parental educational level (> HS; p=0.02) </li></ul></ul><ul><ul><li>Race/Ethnicity (Being White, NH; p<0.0001) </li></ul></ul><ul><ul><li>Non-foreign born child (p=0.03) </li></ul></ul><ul><ul><li>English as primary household language (<0.0001) </li></ul></ul>
    23. 23. Bivariable Results – Associated Factors <ul><li>Predisposing Domain contd. </li></ul><ul><ul><li>Longer stay of mother-type in the US (p=0.0004) </li></ul></ul><ul><ul><li>Strongly supportive neighborhood (p<0.0001) </li></ul></ul><ul><li>Enabling Domain </li></ul><ul><ul><li>Having continuous & adequate insurance (p<0.0001) </li></ul></ul><ul><ul><li>Income > 300% FPL (p=0.0009) </li></ul></ul><ul><ul><li>Having a usual source of care (p=0.02) </li></ul></ul><ul><ul><li>Having a personal doctor (p=0.01) </li></ul></ul>
    24. 24. Bivariable Results - Associated Factors <ul><li>Need Domain </li></ul><ul><ul><li>Being in excellent overall health status (p=0.0033) </li></ul></ul>
    25. 25. Multivariable Results <ul><li>Detailed results </li></ul>
    26. 26. Discussion <ul><li>Summary of Findings </li></ul><ul><li>Public Health Implications </li></ul><ul><li>Strengths </li></ul><ul><li>Limitations </li></ul>
    27. 27. Summary of Findings <ul><li>About a third of Georgia children ages 4-17 years had access to higher quality care </li></ul><ul><li>Higher odds of having access to higher/moderate quality care (vs. lower quality care) </li></ul><ul><ul><li>Environmental: No presence of vandalism </li></ul></ul><ul><ul><li>Predisposing: Being female, living in a strongly supportive neighborhood </li></ul></ul><ul><ul><li>Enabling: Having a usual source of care </li></ul></ul><ul><ul><li>Need: CSHCN status, excellent/very good health status </li></ul></ul>
    28. 28. Summary of Findings <ul><li>Lower odds of having access to higher/moderate quality care (vs. lower quality care) </li></ul><ul><ul><li>Predisposing: Black, NH and Hispanic children </li></ul></ul><ul><ul><li>Enabling: </li></ul></ul><ul><ul><ul><li>Children in all other categories of insurance (except ref. group) </li></ul></ul></ul><ul><ul><ul><li>Children living in >100-200%, >200-300%, and above 400% of the FPL </li></ul></ul></ul>
    29. 29. Summary of Findings <ul><li>Higher odds of having access to lower quality care </li></ul><ul><ul><li>Predisposing: Black, NH & Hispanic children </li></ul></ul><ul><ul><li>Enabling: </li></ul></ul><ul><ul><ul><li>Children with continuous-adequate-public insurance </li></ul></ul></ul><ul><ul><ul><li>Children living in >200-300% and 400% of the FPL </li></ul></ul></ul><ul><li>CSHCN population </li></ul><ul><ul><li>Predisposing: Children ages 4-9yrs (higher odds of having access to higher/moderate quality care) </li></ul></ul><ul><ul><li>Enabling: Children with a usual source of care (higher odds of having access to lower quality care) </li></ul></ul>
    30. 30. Public Health Implications <ul><li>Insurance Coverage </li></ul><ul><ul><li>Most mutable factor </li></ul></ul><ul><ul><li>Needs to be continuous and adequate </li></ul></ul><ul><ul><li>Public programs (Medicaid & Peach Care for Kids) </li></ul></ul><ul><li>Minority race/ethnicity </li></ul><ul><ul><li>Cultural differences between providers and patients </li></ul></ul>
    31. 31. Public Health Implications <ul><li>CSHCN population </li></ul><ul><ul><li>Outreach to older children (10-17) for regular check ups </li></ul></ul><ul><ul><ul><li>May help with transition plans </li></ul></ul></ul><ul><ul><li>Training to help pediatricians feel more competent </li></ul></ul>
    32. 32. Strengths <ul><li>Composite variable of access and quality </li></ul><ul><li>Contextual perspective – ARF & MUA variable </li></ul><ul><li>State-level estimates to inform program operations </li></ul><ul><li>Well established theoretical framework </li></ul>
    33. 33. Limitations <ul><li>Cross-sectional survey </li></ul><ul><li>Parent’s perceptions – not verified </li></ul><ul><li>Occurrences in the past year </li></ul><ul><li>Small numbers – cells had to be collapsed </li></ul><ul><li>Lack of multilevel modeling - - future studies </li></ul>
    34. 34. Acknowledgements <ul><li>Deb Rosenberg, PhD, University of Illinois, Chicago </li></ul><ul><li>Kristin Rankin, PhD, University of Illinois, Chicago </li></ul><ul><li>Stephanie Robinson, MPH, Research Data Center </li></ul><ul><li>Alex Erhlich, MPH, Research Data Center </li></ul>
    35. 35. Questions?
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