Medicaid a lightweight when it comes to low-birth weight kids
Medicaid is falling short in providing services for children with very low birth weight, according to a study by Boston University researchers, who say their findings reinforce the Institute of Medicine's concerns regarding inadequate outcome data and health care services for pre-term infants. The data also support the importance of enrollment in the Early Intervention Program (EIP) for children with low birth weight.
C. Jason Wang and colleagues report some 60,000 infants with very low birth weight (less than 3.3 pounds) are born each year in the U.S. Almost all are premature (less than 37 weeks' gestation) and are at greater risk than term infants for health and developmental problems and premature death. Half of the infants are extremely low birth weight (less than 2.2 pounds) and are said to be at the greatest risk for disability. No data are available about the quality of care the infants receive once they are discharged from the hospital.
Mr. Wang says improving quality of care for important medical problems such as vision and hearing loss that disproportionately affect children with very low birth weight "can greatly improve their health and long-term developmental trajectory."
Timely diagnosis and treatment for eye disease and hearing loss can ameliorate or even eliminate their negative consequences. But if left untreated, they can lead to speech and language problems, behavioral problems, and learning disabilities, all of which can harm school performance.
Need for follow-up
In the United States, most neonatal intensive care units offer high-risk follow-up clinics, but few of the clinics follow children past 1 year of age. Also, Mr. Wang says, it isn't known what proportion of extremely low birth weight children return to a high-risk follow-up clinic after discharge.
Although preschool vision screening is recommended for all children, the rate of such screening is low in the primary care setting due to the difficulty of screening young children, lack of experience with screening tests, and high numbers of false-positives associated with vision screening. Likewise, although universal newborn hearing screening now is recommended in the United States, studies have documented that the proportion of returns to follow-up for infants with risk factors for hearing loss or who failed a hearing screen is less than desired.
The researchers say they constructed a data set linking all health services files relevant to caring for children with very low birth weight receiving Medicaid in South Carolina and used previously developed quality of care indicators to determine the proportion of children with very low birth weight with nonconductive hearing loss who received hearing rehabilitation by 6 months of age and the proportion of all the children with very low birth weight who received a routine ophthalmologic examination between ages 1 and 2 years. The researchers also examined factors associated with receiving timely vision follow-up care.
Many have hearing loss
The study used data from 1996 through 1998 and found a total of 1,461 children with very low birth weight who were enrolled in Medicaid for all 12 months in the first year of their lives. Among them, 16% (241) had a diagnosis of nonconductive hearing loss and were eligible for the indicator on hearing rehabilitation. A total of 1,052 children with very low birth weight were continuously enrolled in Medicaid between ages 1 and 2 years and all were eligible for the ophthalmologic examination during the second year of life.
Among those eligible for the hearing quality indicator, 20% (48 of 241) received the service by 6 months of age. The researchers say that allowing a one-month grace period (rehabilitation by 7 months of age) raised adherence to 24%.
Expanding adherence benefits
Among very low-birth weight children eligible for the vision examination, 23% (241 or 1,052) received a recommended ophthalmologic examination. If the adherence period was expanded to start at 11 months and go to 25 months, the researchers say, the percentage receiving the service among those continuously enrolled in Medicaid increased to 27%. Similarly, if the adherence period was further expanded from 11 months to 36 months, the percentage receiving the service increased to 37%.
When the analysis was restricted to just infants with extremely low birth weight, 29% received hearing rehabilitation during the first six months and 29% received an ophthalmologic examination between 1 and 2 years of age.
With less than one-fourth of children with very low birth weight receiving recommended hearing rehabilitation or ophthalmologic examination through South Carolina Medicaid, the researchers say such gaps in critical services support the Institute of Medicine's call for improving the quality of care for pre-term infants.
Early identification key
While hearing loss in children affects cognition, educational level, social-emotional development, and family-child interaction, early identification of hearing loss and appropriate intervention within the first six months of life have been demonstrated to prevent many of the adverse consequences and facilitate language acquisition.
Also, the lifetime cost to society of pre-lingual onset of profound deafness has been estimated at $1 million per individual, largely because of special education and reduced work productivity.
The researchers say since interventions such as cochlear implants in profoundly deaf children have a positive effect on quality of life at reasonable costs and seem to result in a net savings to society, timely assessment and treatment for hearing loss are particularly important for children with very low birth weight in view of their increased risk of hearing loss and availability of effective treatments.
The researchers say they found variations in receipt of ophthalmologic services. Thus, enrollment in Medicaid programs by the time of hospital discharge for children with very low birth weight and extremely low birth weight and enrollment of children with extremely low birth weight in the early intervention program were strongly associated with receipt of needed ophthalmologic examinations. Also, children with very low birth weight with black mothers, higher birth weight, and higher Apgar scores (a standardized assessment of the health of newborns) were less likely to receive ophthalmologic examinations, whereas those born in Level 3 hospitals were more likely to receive them.
Better screening needed
The negative correlation between receipt of vision services and higher birth weight and Apgar scores may reflect a lower prevalence of vision impairment in these populations, the researchers say. And the positive association between receipt of vision services and birth in a Level 3 hospital, enrollment in Medicaid by the time of hospital discharge, and enrollment in the early intervention program may highlight the importance of enrolling eligible infants in Medicaid and EIP services.
The researchers say it also may suggest that stronger efforts may be needed to screen children for disabilities if they were born in non-Level 3 hospitals or had black mothers. "However," they add, "the overall findings indicate that children from all backgrounds may need better screening for disabilities."
Download the report from http://www.pediatrics.org.
Medicaid is falling short in providing services for children with very low birth weight, according to a study by Boston University researchers, who say their findings reinforce the Institute of Medicine's concerns regarding inadequate outcome data and health care services for pre-term infants.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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