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Preventive Care Utilization Among Children With and Without Special Health Care Needs: Associations With Unmet Need
Preventive Care Utilization Among Children With and Without Special Health Care Needs: Associations With Unmet Need Jeanne Van Cleave, MD; Matthew M. Davis, MD, MAPP Objective.—To compare attendance at preventive medical and dental visits for children with special health care needs (CSHCN) and children without special health care needs, and associations between attending visits and unmet need. Methods.—We analyzed data on 102 353 children aged 0 to 17 years from the National Survey of Children’s Health. We examined associations between attending preventive medical or dental visits and CSHCN status, and unmet need for medical or preventive dental care and attending preventive medical or dental visits. Results.—Medical care–CSHCN were more likely than other children to attend a well-child visit (odds ratio [95% confidence interval], 1.45 [1.12–1.93] for 0 to 5 years, 1.99 [1.74–2.28] for 6 to 11 years, 1.84 [1.64–2.06] for 12 to 17 years). CSHCN aged 12 to 17 years attending a well-child visit had lower odds of unmet medical need (0.48 [0.27–0.85]) than CSHCN not attending visits; well-child visits and unmet need were not associated for younger age groups. Dental care–CSHCN aged 3 to 5
years were more likely than other children of similar ages to attend a preventive dental visit (1.26 [1.04–1.52]). CSHCN attending a preventive dental visit had lower odds of unmet preventive dental needs than CSHCN not attending visits (0.52 [0.28–0.93] for 3 to 5 years, 0.18 [0.12–0.28] for 6 to 11 years, 0.12 [0.08– 0.17] for 12 to 17 years).
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CSHCN may receive less medical and dental preventive care than other children because of competing demands; chronic care issues may trump preventive care needs. Alternatively, CSHCN may receive more medical preventive care (well-child) visits because these visits may be an opportunity to also address ongoing chronic care concerns. Previous work in this area has been contradictory. In one previous study, children with worse health status were less likely to receive preventive care.9 Older studies suggest that children and adolescents under ongoing care of a subspecialist are less likely to receive preventive care.10,11 In addition, adults with certain chronic conditions receive fewer preventive services.12,13 However, 2 recent studies that used the Medical Expenditure Panel Survey indicate that children with chronic conditions and worse health status are more likely to attend well-child visits14 and receive anticipatory guidance.15 Parents of CSHCN who attend well-child visits report receiving care for their child’s chronic condition alongside preventive care.16 For this reason, we hypothesize that attending well-child visits may be associated with a decrease in unmet needs; this has not been specifically addressed in previous studies. Therefore, we address 2 key research questions by means of the 2003–2004 National Survey of Children’s Health (NSCH). This data set, which is considerably larger and more recent than that used for previous analyses, allows us to report population-based estimates. Our questions are as follows: How does preventive care utilization differ for children with and without special health care
Conclusions.—CSHCN attend preventive medical and dental visits at similar or higher rates than other children. CSHCN who attend visits are less likely to have unmet needs. Further research should examine differences in visit content for CSHCN and mechanisms whereby preventive care may reduce unmet need. KEY WORDS: children with special health care needs; dental care; preventive care; unmet need Ambulatory Pediatrics 2008;8:305–11
outine medical and dental preventive visits are an important component of comprehensive health care for all children. Children with special health care needs (CSHCN), who comprise 12% to 18% of children,1,2 may benefit from preventive care for several reasons. CSHCN use more inpatient and emergency care than other children, and attending preventive care visits has been shown to reduce avoidable hospitalization and emergency department use.3,4 At well-child visits, pediatric primary care providers often screen families for psychosocial problems, which are especially prevalent in CSHCN and their families.5 CSHCN may be at increased risk for subacute dental problems that could be addressed at preventive dental visits.6 CSHCN have significant unmet needs for medical and dental care7,8; preventive care visits may facilitate discussion of ongoing issues and coordination of care, which may help alleviate unmet needs. It is not clear whether CSHCN receive as much preventive care compared with other children, or whether attending preventive care visits is associated with unmet needs.
From the Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, Boston, Mass (Dr Van Cleave); Child Health Evaluation and Research Unit, Division of General Pediatrics, and Division of General Internal Medicine and Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, Mich (Dr Davis). Address correspondence to Jeanne Van Cleave, MD, 50 Staniford St #901, Boston, Massachusetts 02114 (e-mail: [email protected]). Received for publication January 26, 2007; accepted April 1, 2008. AMBULATORY PEDIATRICS Copyright Ó 2008 by Academic Pediatric Association
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needs? And is attending preventive care visits associated with having less unmet need for medical and dental care?
METHODS Survey and Study Sample We used data from the NSCH,17 a household telephone survey conducted by the National Center for Health Statistics (NCHS) from January 2003 to July 2004. This survey asked about a child’s health conditions, health care experiences, and family and community. Data were gathered on 102 353 children aged 0 to 17 years from a household member that was most knowledgeable about the child’s health. The weighted response rate was 55.3%, and estimates that use the sampling weights are generalizable to the noninstitutionalized, civilian population of children in the United States in homes with telephones. Interviews were conducted in English and Spanish. This study was approved by the University of Michigan Medical School Institutional Review Board.
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but reported not receiving all of the medical care needed, we considered these children to have an unmet need. Dental Preventive Visit We used questions from the Health Care Access and Utilization section to identify children who attended a preventive dental visit in the past year. Respondents were asked whether their child had visited a dentist in the past 12 months and whether the visit was preventive in nature. Unmet Need for Preventive Dental Care NSCH includes information on unmet preventive dental care, but not other types of dental care. If the respondent reported that the child needed routine preventive care and did not attend a preventive dental visit, or if a child attended a preventive dental visit but did not receive all preventive dental care needed, the child was considered to have an unmet need for preventive dental care.
Medical Preventive Visit We used questions that identified children who had attended a preventive-care visit at their usual source of care in the past year. Respondents were asked whether their child had a ‘‘personal doctor or nurse’’ who knew the child well and was familiar with the child’s history. Those who could identify a personal doctor or nurse were asked whether the child had visited this health professional in the past 12 months for preventive care.
Sociodemographic Factors Sociodemographic variables were used in the analysis because they represent potential confounders. Having a personal health provider and dental insurance have been found to be associated with receiving preventive dental care9 and less unmet need for dental care,7 so we included these in our analysis of preventive dental visits. We used a variable delineating the child’s sex, and we used NSCH information regarding 5 categories for race/ ethnicity: non-Hispanic white, non-Hispanic black, Hispanic, multiracial, and other. To describe family structure, we categorized the families as 1 parent, 2 parent, or other. The NSCH contained a question regarding the highest level of education achieved by anyone in the household. We used 3 categories for this household member’s education: less than high school, high school diploma or equivalent, and at least some college. We also included poverty, categorized by the NCHS as annual household income of <100% of the federal poverty level (FPL), 100% to 200% FPL, and >200% FPL. Three categories of health insurance were used to represent insurance status: private, public, or uninsured. Dental insurance status was dichotomized as having dental coverage or not. Those who answered yes to the question asking whether the child had a personal doctor or nurse were designated as having a personal health provider. Because we hypothesized that preventive care use may vary by age group, we created variables representing different age groups: early childhood (0 to 5 years for preventive medical care, 3 to 5 years for preventive dental care), middle childhood (6 to 11 years), and adolescence (12 to 17 years).
Unmet Need for Medical Care We determined an unmet need for medical services by using a combination of questions. One question asked whether the child needed medical care in the past year. For those who answered affirmatively but reported not seeing a health care provider, we deemed them as having an unmet need. If a child did visit a health care professional
Analyses We performed analyses to test the hypothesis that CSHCN receive less medical preventive care and less dental preventive care than other children. Analyses of these 2 outcome variables were performed on slightly different populations. The NSCH asks only those identifying a personal doctor or nurse about medical preventive care use;
Variables Identification of CSHCN NSCH contains the Children with Special Health Care Needs Screener, a validated instrument18,19 used to identify children with a special health care need that is based on the Maternal and Child Health Bureau definition.20 The screener contains 5 stem questions assessing an ongoing (1) need for prescription medication, (2) need for more medical or mental health care, or educational services than other similar-aged children, (3) limitation in doing things normal for the child’s age, (4) need for physical, occupational or speech therapy, and (5) emotional, developmental, or behavioral problem that necessitates treatment or counseling. We used responses to this screening tool to create a dichotomous CSHCN variable. In the full NSCH sample, 18% of children had a special health care need, as defined by the screener. This is similar to previous estimates of the prevalence of special health care needs.1
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Preventive Care for Children With Special Health Care Needs
Table 1. Characteristics of Study Population for Preventive Care Utilization Analysis: CSHCN Versus Children Without Special Health Care Needs*
Characteristic Gender, % Male Female Age group, % Early childhood (0–5 y) Middle childhood (6–11 y) Adolescence (12–17 y) Health insurance type, % Private Public None Race/ethnicity, % White, non-Hispanic only Black only Hispanic only Multiracial FPL, % >200% 100–200% <100% Family structure, % Two parent One parent Other Highest education level of any household member, % More than high school High school or equivalent Less than high school
CSHCN (n ¼ 15 213)
Children Without Special Health Care Needs (n ¼ 61 478)
59 41
49 51
21 38 41
36 32 31
65 31 4
72 22 6
70 14 8 4
66 13 13 3
62 22 16
65 21 13
69 27 4
76 20 4
72 23 5
71 24 5
*P values are <.05 for all comparisons of CSHCN vs children without special health care needs. CSHCN indicates children with special health care needs; FPL indicates federal poverty level.
thus, the analyses concerning medical preventive care include only these subjects. For the analyses regarding preventive dental care, we elected to limit the sample to those children aged 3 years and older. In May 2003, the American Academy of Pediatrics (AAP) began recommending that pediatric primary care providers refer ‘‘high-risk’’ children (including CSHCN) to a dentist at 1 year of age. Before 2003, the AAP had recommended preventive dental visits starting at age 3. Meanwhile, the American Academy of Pediatric Dentists recommends visits starting at age 1. We aimed in our study to avoid
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the confounding that might result from health care providers following different policy statements, and the introduction of the new AAP policy statement. However, all policy statements are in agreement that children should be visiting the dentist for preventive care at age 3. We performed bivariate comparisons on the primary outcome variables and covariates with Pearson c2 test. We performed age-stratified survey weighted multivariate logistic regression to estimate the association between having a medical or dental visit in the past year with the primary comparison group of CSHCN status while controlling for the potential confounders described above. We then estimated the association between having an unmet need for medical or preventive dental care and attending a medical or dental preventive visit, respectively. To test this association, we developed models stratified by age group and CSHCN status, controlling for potential confounders. In models where we suspected an effect of interacting covariates, we examined interaction terms for significance. We assessed for multicollinearity among the independent variables in the regression models but found no evidence of this. All analyses were performed with Stata 9 (StataCorp, College Station, Tex). Because NCHS uses a complex sampling frame, survey weights provided by NCHS were used to extrapolate findings to the national level. RESULTS Preventive Medical Visits Sample Characteristics The sample analyzed for preventive medical visits included those aged 0 to 17 years who were identified as having a personal doctor or nurse. Among these children in this weighted sample, 20% had an ongoing special health care need. Sociodemographic characteristics of this sample for CSHCN and other children are compared in Table 1. Compared with children without special health care needs, CSHCN were older and more likely to be boys. Preventive Medical Care Utilization A greater proportion of CSHCN attended preventive medical visits compared with children without special health care needs (Table 2). These differences were most pronounced for children in middle childhood and adolescence.
Table 2. Preventive Medical Visits for Children With and Without a Special Health Care Need Characteristic Rates of attending a well-child visit in the past year, % attending visit Has a special health care need Does not have a special health care need Unadjusted odds of attending a well-child visit in the past year Has a special health care need* Adjusted odds of attending a well-child visit in the past year† Has a special health care need*
Early Childhood (0–5 y)
Middle Childhood (6–11 y)
Adolescence (12–17 y)
91.2 88.2
82.1 68.9
80.3 69.0
1.36 (1.13–1.86)
2.01 (1.77–2.28)
1.85 (1.66–2.07)
1.45 (1.12–1.93)
1.99 (1.74–2.28)
1.84 (1.64–2.06)
*Referent group is children without special health care needs (odds ratio ¼ 1.00). †Adjusted for sex, medical health insurance status, percentage of federal poverty level, adult household member education, family structure, and race/ ethnicity.
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Table 3. Association Between Attending a Well-Child Visit in the Past Year and Unmet Need for Medical Care* Characteristic Children without special health care needs Prevalence of unmet need, % Did not attend well-child visit, OR Attended well-child visit, OR (95% CI) Prevalence of unmet need, % CSHCN Did not attend well-child visit, OR Attended well-child visit, OR (95% CI)
Early Childhood (0–5 y)
Middle Childhood (6–11 y)
Adolescence (12–17 y)
0.63 1.00 (ref) 0.56 (0.27–1.17) 1.3
0.60 1.00 (ref) 0.63 (0.32–1.23) 1.7
0.67 1.00 (ref) 0.56 (0.34–0.93) 2.1
1.00 (ref) 0.63 (0.21–1.92)
1.00 (ref) 0.60 (0.28–1.31)
1.00 (ref) 0.48 (0.27–0.85)
*Controlling for sex, medical health insurance status, percentage of federal poverty level, adult household member education, and race/ethnicity. OR indicates odds ratio; 95% CI indicates 95% confidence interval; and CSHCN indicates children with special health care needs.
In unadjusted and adjusted logistic regression analyses (Table 2), we found that the association between having a special health care need and attending a well-child visit in the past year remained significant across all age groups, after controlling for potential confounders. This association was strongest for individuals in middle childhood, as these children were almost twice as likely to have had a well-child visit in the past year. Unmet Need for Medical Care The prevalence of unmet need for medical care was higher for CSHCN than for children without a special health care need in all age groups (Table 3). Although there was a consistent pattern of not having an unmet need if the child had attended a well-child visit, this association was statistically significant only for adolescents. Preventive Dental Visits Sample Characteristics The sample used for the analysis of preventive dental care consisted of children aged 3 to 17 and was not limited to those with a personal health provider. Sociodemographic characteristics were assessed for differences between CSHCN and other children, and the results were similar to the sample analyzed for medical preventive care (data not shown). In this subsample, we also assessed differences in dental insurance status and identification of a personal medical provider for CSHCN and other children. Compared with children without special health care needs, CSHCN were more likely to have dental insurance (82%
vs 77%, P < .001) and were more likely to have a personal doctor or nurse (91% vs 83%, P < .001). Preventive Dental Visit Utilization Rates of dental visits were overall higher among CSHCN than other children (Table 4), with the largest differences in the 3- to 5-year-old age group. In unadjusted and adjusted regression analyses (Table 4), CSHCN in early childhood were more likely than other children to attend a preventive dental visit; differences in rates of attendance in other age groups were not statistically significant once we controlled for confounders. Unmet Need for Preventive Dental Care The prevalence of unmet need for preventive dental care was higher for all ages of CSHCN than for other children. Attending a preventive dental visit was significantly associated with not having this unmet need in all age categories (Table 5). DISCUSSION In this study of the largest US sample to permit comparison of preventive care visit rates for CSHCN and their peers without special health care needs, CSHCN attended preventive medical and dental visits at the same or higher rates as other children. Importantly, these associations remained when controlling for sociodemographic and health insurance factors. Furthermore, attending preventive medical visits was associated with lower unmet need for services in some age
Table 4. Preventive Dental Visits for Children With and Without a Special Health Care Need* Characteristic Rates of attending a preventive dental visit in the past year (% attending visit) Has a special health care need (n ¼ 15 419) Does not have a special health care need (n ¼ 58 087) Unadjusted odds of attending a preventive dental visit in the past year, OR (95% CI) Has a special health care need† Adjusted odds of attending a preventive dental visit in the past year,‡ OR (95% CI) Has a special health care need†
Early Childhood (3–5 y)
Middle Childhood (6–11 y)
Adolescence (12–17 y)
70.5 64.5
85.3 83.4
81.8 79.3
1.31 (1.06–1.76)
1.15 (1.00–1.31)
1.17 (1.03–1.32)
1.26 (1.04–1.52)
1.14 (0.97–1.33)
0.90 (0.78–1.04)
*OR indicates odds ratio; 95% CI indicates 95% confidence interval; and CSHCN indicates children with special health care needs. †Referent group is children without special health care needs (OR ¼ 1.00). ‡Adjusted for sex, medical health insurance status, percentage of federal poverty level, adult household member education, family structure, race/ethnicity, dental insurance status, and identification of a personal health provider.
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Table 5. Association Between Attending a Preventive Dental Visit in the Past Year and Unmet Need for Preventive Dental Care* Characteristic Children without special health care needs Prevalence of unmet need, % Did not attend preventive dental visit, OR Attended preventive dental visit, OR (95% CI) CSHCN Prevalence of unmet need, % Did not attend preventive dental visit, OR Attended preventive dental visit, OR (95% CI)
Early Childhood (3–5 y)
Middle Childhood (6–11 y)
Adolescence (12–17 y)
3.8 1.00 (ref) 0.41 (0.28–0.60)
4.8 1.00 (ref) 0.21 (0.16–0.28)
5.7 1.00 (ref) 0.18 (0.13–0.26)
6.4 1.00 (ref) 0.52 (0.28–0.93)
6.4 1.00 (ref) 0.18 (0.12–0.28)
8.3 1.00 (ref) 0.12 (0.08–0.17)
*Adjusted for sex, medical health insurance status, percentage of federal poverty level, adult household member education, family structure, race/ethnicity, dental insurance status, and identification of a personal health provider. OR indicates odds ratio; 95% CI indicates 95% confidence interval; and CSHCN indicates children with special health care needs.
groups. For children both with and without special health care needs, attending a well-child visit was significantly associated with not having an unmet need for medical care for adolescents, and attending a preventive dental visit was associated with not having an unmet need for preventive dental care for all age groups. Although this finding may appear tautological, we emphasize that it is still possible for a child who has received preventive care to have unmet needs, just as it is possible for a child who has received no preventive care to have no unmet needs. The question of unmet need is one of parental perception, not of fact determined by a clinician. Regarding use of preventive care services, our findings concur with more recent reports that CSHCN use more preventive care than their peers.14,15 Our findings may reflect the many changes to health care that have occurred since previous studies10,11,21 were conducted that suggested that CSHCN receive less preventive care. Expansions in Medicaid and the creation of the State Child Health Insurance Program gave vulnerable children greater access to primary care. The American Academy of Pediatrics’ medical home initiative and concurrent emphases on primary care in private and public managed care plans also may have contributed to these changes. Preventive Medical Visits Several aspects of primary care delivery to CSHCN may enhance attendance at well-child visits. Primary care physicians may tailor anticipatory guidance and screening to a child’s chronic condition; therefore, CSHCN and their parents may see more value in wellchild visits than other parents do. Also, primary care physicians may address specific aspects of a patient’s chronic condition during the well-child visit, delivering a combination of routine preventive care and chronic disease management. Primary care physicians may have a stronger relationship with CSHCN and their parents, who may perceive more benefit from a preventive visit than parents of children without such a connection. Also, CSHCN may have more frequent office visits, giving physicians a greater opportunity to remind parents that a well-child visit is due. Similar reminders have been shown in other studies to increase preventive care use in children generally.22,23 Children and adolescents in older age groups, where the effect of having a special health care need
was greatest, may see their provider regularly to manage their chronic condition, and so are more likely to either address preventive care issues at these visits or to schedule another visit. Children without special health care needs often do not attend routine annual visits during these years. Rates of well-child visit attendance are higher, and rates of unmet need for medical care were lower, for this sample compared with previous estimates.9,24–26 However, we emphasize that the question delineating well-child visit attendance was asked only of those who could identify a personal health care provider for their child. We limited our analysis to children with a personal health provider because we did not want issues of access to health care to confound our analysis of utilization. If we assume that all children without a personal health care provider did not attend a well-child visit and had more unmet needs, our estimates would be more consistent with previous studies, and the overall conclusions would remain the same. We hypothesized that attending a well-child visit would be associated with a reduced likelihood of unmet needs for medical care, especially for CSHCN. However, for CSHCN and other children, after controlling for factors known to contribute to unmet medical needs, such as poverty level and health insurance status, we found this association only in adolescents. For adolescents, well-child visits may present an opportunity for parents, patients, and physicians to address other medical issues that would otherwise go unmet, especially because adolescents may be perceived by physicians as less likely to attend follow-up visits for issues related to chronic disease. However, because of the cross-sectional nature of the NSCH, we cannot conclude causality from our findings, and any association between attending preventive visits and lower rates of unmet need may reflect better access to care overall. The nature and reason for unmet needs for younger children may be different than for adolescents and may reflect barriers that cannot be overcome through contact with the physician during well-child visits, such as insurance factors or availability of certain services. In addition, we found CSHCN had higher rates of unmet need for medical care compared with other children, despite higher rates of service use. This underscores previous work that has found a high rate of unmet need for medical care in this population.7,8
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Preventive Dental Visits In this study, we found that CSHCN do not receive less preventive dental care than other children. In fact, younger children who have a special health care need attend preventive dental visits at a higher rate than other children. This may be a result of condition-specific dental needs that require visits earlier in life. For example, parents of developmentally delayed children may have difficulty with routine tooth brushing; such children would likely need a dentist’s evaluation earlier than other children. In addition, young CSHCN may routinely take medicines delivered in sugar-based syrup, putting them at risk for caries.6 Attending a preventive dental visit in the past year was associated with a large reduction, but not an elimination, of parental report of unmet need for preventive dental care overall. This finding is consistent with previous analyses27 that insurance status and family income, which influence access to preventive dental services, contribute to the likelihood of having an unmet need. Even among children who attend a dental preventive visit, some still report an unmet need for these services. The NSCH asks whether the child attended at least 1 preventive visit in the past year; some children may have been able to attend only 1 of the 2 recommended visits per year or may have attended a preventive dental visit but were unable to attain all needed preventive services at these visits. We emphasize that because the data are cross-sectional, causal relationships cannot be determined. Additionally, unmet need for preventive dental care was associated with having a special health care need, which is consistent with previous reports7 of relatively high rates of unmet dental care needs among CSHCN. Limitations Our study has limitations that must be noted. As stated above, with cross-sectional data, we cannot determine causality in our findings, only associations. The NSCH relied on adult respondents’ recall of health care utilization over a long period of time. This may over- or underestimate the actual utilization of the population. Also, the question regarding preventive medical care that we used in this study was asked only of respondents whose child had a personal doctor or nurse. Certainly children who can identify a medical home are more likely to receive preventive care28; therefore, we cannot draw definitive conclusions about children who lack such a provider but can only postulate that preventive care rates for those children are lower. Conclusions This study has several important implications for clinical care and further research. First, this study indicates that having a chronic condition influences patterns of routine preventive health care in some age groups. Further research examining content of preventive care visits for CSHCN will be fruitful, shedding light both on mechanisms of preventive care delivery and on primary care management of CSHCN. Future studies should determine whether the content of these preventive care visits is the same for both groups of children and whether chronic illness care takes
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priority during these visits, and if so, whether this additional service influences preventive care utilization. It will also be useful to examine the connection between preventive care visits and unmet need for preventive and acute medical and dental care. Although we could not determine directionality with these cross-sectional data, perceptions of unmet need are potentially a cause and effect of health care–seeking behavior by parents on behalf of children. Regarding use of preventive dental care, disparities related to income and race/ethnicity are gradually improving29; it will be informative to see if this service is used in different ways for CSHCN in the future. ACKNOWLEDGMENT Supported in part by Robert Wood Johnson Clinical Scholars Program at the University of Michigan.
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23. Hambidge SJ, Davidson AJ, Phibbs SL, et al. Strategies to improve immunization rates and well-child care in a disadvantaged population: a cluster randomized controlled trial. Arch Pediatr Adolesc Med. 2004;158:162–169. 24. Byrd RS, Hoekelman RA, Auinger P. Adherence to AAP guidelines for well-child care under managed care. American Academy of Pediatrics. Pediatrics. 1999;104:536–540. 25. Newacheck PW, McManus M, Fox HB, Hung YY, Halfon N. Access to health care for children with special health care needs. Pediatrics. 2000;105:760–766. 26. Chung PJ, Lee TC, Morrison JL, Schuster MA. Preventive care for children in the United States: quality and barriers. Annu Rev Public Health. 2006;27:491–515. 27. Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of America’s children. Pediatrics. 2000;105(4 pt 2):989–997. 28. O’Malley AS, Forrest CB. Continuity of care and delivery of ambulatory services to children in community health clinics. J Community Health. 1996;21:159–173. 29. Hughes DC, Duderstadt KG, Soobader MP, Newacheck PW. Disparities in children’s use of oral health services. Public Health Rep. 2005; 120:455–462.
years were more likely than other children of similar ages to attend a preventive dental visit (1.26 [1.04–1.52]). CSHCN attending a preventive dental visit had lower odds of unmet preventive dental needs than CSHCN not attending visits (0.52 [0.28–0.93] for 3 to 5 years, 0.18 [0.12–0.28] for 6 to 11 years, 0.12 [0.08– 0.17] for 12 to 17 years).
R
CSHCN may receive less medical and dental preventive care than other children because of competing demands; chronic care issues may trump preventive care needs. Alternatively, CSHCN may receive more medical preventive care (well-child) visits because these visits may be an opportunity to also address ongoing chronic care concerns. Previous work in this area has been contradictory. In one previous study, children with worse health status were less likely to receive preventive care.9 Older studies suggest that children and adolescents under ongoing care of a subspecialist are less likely to receive preventive care.10,11 In addition, adults with certain chronic conditions receive fewer preventive services.12,13 However, 2 recent studies that used the Medical Expenditure Panel Survey indicate that children with chronic conditions and worse health status are more likely to attend well-child visits14 and receive anticipatory guidance.15 Parents of CSHCN who attend well-child visits report receiving care for their child’s chronic condition alongside preventive care.16 For this reason, we hypothesize that attending well-child visits may be associated with a decrease in unmet needs; this has not been specifically addressed in previous studies. Therefore, we address 2 key research questions by means of the 2003–2004 National Survey of Children’s Health (NSCH). This data set, which is considerably larger and more recent than that used for previous analyses, allows us to report population-based estimates. Our questions are as follows: How does preventive care utilization differ for children with and without special health care
Conclusions.—CSHCN attend preventive medical and dental visits at similar or higher rates than other children. CSHCN who attend visits are less likely to have unmet needs. Further research should examine differences in visit content for CSHCN and mechanisms whereby preventive care may reduce unmet need. KEY WORDS: children with special health care needs; dental care; preventive care; unmet need Ambulatory Pediatrics 2008;8:305–11
outine medical and dental preventive visits are an important component of comprehensive health care for all children. Children with special health care needs (CSHCN), who comprise 12% to 18% of children,1,2 may benefit from preventive care for several reasons. CSHCN use more inpatient and emergency care than other children, and attending preventive care visits has been shown to reduce avoidable hospitalization and emergency department use.3,4 At well-child visits, pediatric primary care providers often screen families for psychosocial problems, which are especially prevalent in CSHCN and their families.5 CSHCN may be at increased risk for subacute dental problems that could be addressed at preventive dental visits.6 CSHCN have significant unmet needs for medical and dental care7,8; preventive care visits may facilitate discussion of ongoing issues and coordination of care, which may help alleviate unmet needs. It is not clear whether CSHCN receive as much preventive care compared with other children, or whether attending preventive care visits is associated with unmet needs.
From the Center for Child and Adolescent Health Policy, MassGeneral Hospital for Children, Boston, Mass (Dr Van Cleave); Child Health Evaluation and Research Unit, Division of General Pediatrics, and Division of General Internal Medicine and Gerald R. Ford School of Public Policy, University of Michigan, Ann Arbor, Mich (Dr Davis). Address correspondence to Jeanne Van Cleave, MD, 50 Staniford St #901, Boston, Massachusetts 02114 (e-mail: [email protected]). Received for publication January 26, 2007; accepted April 1, 2008. AMBULATORY PEDIATRICS Copyright Ó 2008 by Academic Pediatric Association
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needs? And is attending preventive care visits associated with having less unmet need for medical and dental care?
METHODS Survey and Study Sample We used data from the NSCH,17 a household telephone survey conducted by the National Center for Health Statistics (NCHS) from January 2003 to July 2004. This survey asked about a child’s health conditions, health care experiences, and family and community. Data were gathered on 102 353 children aged 0 to 17 years from a household member that was most knowledgeable about the child’s health. The weighted response rate was 55.3%, and estimates that use the sampling weights are generalizable to the noninstitutionalized, civilian population of children in the United States in homes with telephones. Interviews were conducted in English and Spanish. This study was approved by the University of Michigan Medical School Institutional Review Board.
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but reported not receiving all of the medical care needed, we considered these children to have an unmet need. Dental Preventive Visit We used questions from the Health Care Access and Utilization section to identify children who attended a preventive dental visit in the past year. Respondents were asked whether their child had visited a dentist in the past 12 months and whether the visit was preventive in nature. Unmet Need for Preventive Dental Care NSCH includes information on unmet preventive dental care, but not other types of dental care. If the respondent reported that the child needed routine preventive care and did not attend a preventive dental visit, or if a child attended a preventive dental visit but did not receive all preventive dental care needed, the child was considered to have an unmet need for preventive dental care.
Medical Preventive Visit We used questions that identified children who had attended a preventive-care visit at their usual source of care in the past year. Respondents were asked whether their child had a ‘‘personal doctor or nurse’’ who knew the child well and was familiar with the child’s history. Those who could identify a personal doctor or nurse were asked whether the child had visited this health professional in the past 12 months for preventive care.
Sociodemographic Factors Sociodemographic variables were used in the analysis because they represent potential confounders. Having a personal health provider and dental insurance have been found to be associated with receiving preventive dental care9 and less unmet need for dental care,7 so we included these in our analysis of preventive dental visits. We used a variable delineating the child’s sex, and we used NSCH information regarding 5 categories for race/ ethnicity: non-Hispanic white, non-Hispanic black, Hispanic, multiracial, and other. To describe family structure, we categorized the families as 1 parent, 2 parent, or other. The NSCH contained a question regarding the highest level of education achieved by anyone in the household. We used 3 categories for this household member’s education: less than high school, high school diploma or equivalent, and at least some college. We also included poverty, categorized by the NCHS as annual household income of <100% of the federal poverty level (FPL), 100% to 200% FPL, and >200% FPL. Three categories of health insurance were used to represent insurance status: private, public, or uninsured. Dental insurance status was dichotomized as having dental coverage or not. Those who answered yes to the question asking whether the child had a personal doctor or nurse were designated as having a personal health provider. Because we hypothesized that preventive care use may vary by age group, we created variables representing different age groups: early childhood (0 to 5 years for preventive medical care, 3 to 5 years for preventive dental care), middle childhood (6 to 11 years), and adolescence (12 to 17 years).
Unmet Need for Medical Care We determined an unmet need for medical services by using a combination of questions. One question asked whether the child needed medical care in the past year. For those who answered affirmatively but reported not seeing a health care provider, we deemed them as having an unmet need. If a child did visit a health care professional
Analyses We performed analyses to test the hypothesis that CSHCN receive less medical preventive care and less dental preventive care than other children. Analyses of these 2 outcome variables were performed on slightly different populations. The NSCH asks only those identifying a personal doctor or nurse about medical preventive care use;
Variables Identification of CSHCN NSCH contains the Children with Special Health Care Needs Screener, a validated instrument18,19 used to identify children with a special health care need that is based on the Maternal and Child Health Bureau definition.20 The screener contains 5 stem questions assessing an ongoing (1) need for prescription medication, (2) need for more medical or mental health care, or educational services than other similar-aged children, (3) limitation in doing things normal for the child’s age, (4) need for physical, occupational or speech therapy, and (5) emotional, developmental, or behavioral problem that necessitates treatment or counseling. We used responses to this screening tool to create a dichotomous CSHCN variable. In the full NSCH sample, 18% of children had a special health care need, as defined by the screener. This is similar to previous estimates of the prevalence of special health care needs.1
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Preventive Care for Children With Special Health Care Needs
Table 1. Characteristics of Study Population for Preventive Care Utilization Analysis: CSHCN Versus Children Without Special Health Care Needs*
Characteristic Gender, % Male Female Age group, % Early childhood (0–5 y) Middle childhood (6–11 y) Adolescence (12–17 y) Health insurance type, % Private Public None Race/ethnicity, % White, non-Hispanic only Black only Hispanic only Multiracial FPL, % >200% 100–200% <100% Family structure, % Two parent One parent Other Highest education level of any household member, % More than high school High school or equivalent Less than high school
CSHCN (n ¼ 15 213)
Children Without Special Health Care Needs (n ¼ 61 478)
59 41
49 51
21 38 41
36 32 31
65 31 4
72 22 6
70 14 8 4
66 13 13 3
62 22 16
65 21 13
69 27 4
76 20 4
72 23 5
71 24 5
*P values are <.05 for all comparisons of CSHCN vs children without special health care needs. CSHCN indicates children with special health care needs; FPL indicates federal poverty level.
thus, the analyses concerning medical preventive care include only these subjects. For the analyses regarding preventive dental care, we elected to limit the sample to those children aged 3 years and older. In May 2003, the American Academy of Pediatrics (AAP) began recommending that pediatric primary care providers refer ‘‘high-risk’’ children (including CSHCN) to a dentist at 1 year of age. Before 2003, the AAP had recommended preventive dental visits starting at age 3. Meanwhile, the American Academy of Pediatric Dentists recommends visits starting at age 1. We aimed in our study to avoid
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the confounding that might result from health care providers following different policy statements, and the introduction of the new AAP policy statement. However, all policy statements are in agreement that children should be visiting the dentist for preventive care at age 3. We performed bivariate comparisons on the primary outcome variables and covariates with Pearson c2 test. We performed age-stratified survey weighted multivariate logistic regression to estimate the association between having a medical or dental visit in the past year with the primary comparison group of CSHCN status while controlling for the potential confounders described above. We then estimated the association between having an unmet need for medical or preventive dental care and attending a medical or dental preventive visit, respectively. To test this association, we developed models stratified by age group and CSHCN status, controlling for potential confounders. In models where we suspected an effect of interacting covariates, we examined interaction terms for significance. We assessed for multicollinearity among the independent variables in the regression models but found no evidence of this. All analyses were performed with Stata 9 (StataCorp, College Station, Tex). Because NCHS uses a complex sampling frame, survey weights provided by NCHS were used to extrapolate findings to the national level. RESULTS Preventive Medical Visits Sample Characteristics The sample analyzed for preventive medical visits included those aged 0 to 17 years who were identified as having a personal doctor or nurse. Among these children in this weighted sample, 20% had an ongoing special health care need. Sociodemographic characteristics of this sample for CSHCN and other children are compared in Table 1. Compared with children without special health care needs, CSHCN were older and more likely to be boys. Preventive Medical Care Utilization A greater proportion of CSHCN attended preventive medical visits compared with children without special health care needs (Table 2). These differences were most pronounced for children in middle childhood and adolescence.
Table 2. Preventive Medical Visits for Children With and Without a Special Health Care Need Characteristic Rates of attending a well-child visit in the past year, % attending visit Has a special health care need Does not have a special health care need Unadjusted odds of attending a well-child visit in the past year Has a special health care need* Adjusted odds of attending a well-child visit in the past year† Has a special health care need*
Early Childhood (0–5 y)
Middle Childhood (6–11 y)
Adolescence (12–17 y)
91.2 88.2
82.1 68.9
80.3 69.0
1.36 (1.13–1.86)
2.01 (1.77–2.28)
1.85 (1.66–2.07)
1.45 (1.12–1.93)
1.99 (1.74–2.28)
1.84 (1.64–2.06)
*Referent group is children without special health care needs (odds ratio ¼ 1.00). †Adjusted for sex, medical health insurance status, percentage of federal poverty level, adult household member education, family structure, and race/ ethnicity.
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Table 3. Association Between Attending a Well-Child Visit in the Past Year and Unmet Need for Medical Care* Characteristic Children without special health care needs Prevalence of unmet need, % Did not attend well-child visit, OR Attended well-child visit, OR (95% CI) Prevalence of unmet need, % CSHCN Did not attend well-child visit, OR Attended well-child visit, OR (95% CI)
Early Childhood (0–5 y)
Middle Childhood (6–11 y)
Adolescence (12–17 y)
0.63 1.00 (ref) 0.56 (0.27–1.17) 1.3
0.60 1.00 (ref) 0.63 (0.32–1.23) 1.7
0.67 1.00 (ref) 0.56 (0.34–0.93) 2.1
1.00 (ref) 0.63 (0.21–1.92)
1.00 (ref) 0.60 (0.28–1.31)
1.00 (ref) 0.48 (0.27–0.85)
*Controlling for sex, medical health insurance status, percentage of federal poverty level, adult household member education, and race/ethnicity. OR indicates odds ratio; 95% CI indicates 95% confidence interval; and CSHCN indicates children with special health care needs.
In unadjusted and adjusted logistic regression analyses (Table 2), we found that the association between having a special health care need and attending a well-child visit in the past year remained significant across all age groups, after controlling for potential confounders. This association was strongest for individuals in middle childhood, as these children were almost twice as likely to have had a well-child visit in the past year. Unmet Need for Medical Care The prevalence of unmet need for medical care was higher for CSHCN than for children without a special health care need in all age groups (Table 3). Although there was a consistent pattern of not having an unmet need if the child had attended a well-child visit, this association was statistically significant only for adolescents. Preventive Dental Visits Sample Characteristics The sample used for the analysis of preventive dental care consisted of children aged 3 to 17 and was not limited to those with a personal health provider. Sociodemographic characteristics were assessed for differences between CSHCN and other children, and the results were similar to the sample analyzed for medical preventive care (data not shown). In this subsample, we also assessed differences in dental insurance status and identification of a personal medical provider for CSHCN and other children. Compared with children without special health care needs, CSHCN were more likely to have dental insurance (82%
vs 77%, P < .001) and were more likely to have a personal doctor or nurse (91% vs 83%, P < .001). Preventive Dental Visit Utilization Rates of dental visits were overall higher among CSHCN than other children (Table 4), with the largest differences in the 3- to 5-year-old age group. In unadjusted and adjusted regression analyses (Table 4), CSHCN in early childhood were more likely than other children to attend a preventive dental visit; differences in rates of attendance in other age groups were not statistically significant once we controlled for confounders. Unmet Need for Preventive Dental Care The prevalence of unmet need for preventive dental care was higher for all ages of CSHCN than for other children. Attending a preventive dental visit was significantly associated with not having this unmet need in all age categories (Table 5). DISCUSSION In this study of the largest US sample to permit comparison of preventive care visit rates for CSHCN and their peers without special health care needs, CSHCN attended preventive medical and dental visits at the same or higher rates as other children. Importantly, these associations remained when controlling for sociodemographic and health insurance factors. Furthermore, attending preventive medical visits was associated with lower unmet need for services in some age
Table 4. Preventive Dental Visits for Children With and Without a Special Health Care Need* Characteristic Rates of attending a preventive dental visit in the past year (% attending visit) Has a special health care need (n ¼ 15 419) Does not have a special health care need (n ¼ 58 087) Unadjusted odds of attending a preventive dental visit in the past year, OR (95% CI) Has a special health care need† Adjusted odds of attending a preventive dental visit in the past year,‡ OR (95% CI) Has a special health care need†
Early Childhood (3–5 y)
Middle Childhood (6–11 y)
Adolescence (12–17 y)
70.5 64.5
85.3 83.4
81.8 79.3
1.31 (1.06–1.76)
1.15 (1.00–1.31)
1.17 (1.03–1.32)
1.26 (1.04–1.52)
1.14 (0.97–1.33)
0.90 (0.78–1.04)
*OR indicates odds ratio; 95% CI indicates 95% confidence interval; and CSHCN indicates children with special health care needs. †Referent group is children without special health care needs (OR ¼ 1.00). ‡Adjusted for sex, medical health insurance status, percentage of federal poverty level, adult household member education, family structure, race/ethnicity, dental insurance status, and identification of a personal health provider.
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Table 5. Association Between Attending a Preventive Dental Visit in the Past Year and Unmet Need for Preventive Dental Care* Characteristic Children without special health care needs Prevalence of unmet need, % Did not attend preventive dental visit, OR Attended preventive dental visit, OR (95% CI) CSHCN Prevalence of unmet need, % Did not attend preventive dental visit, OR Attended preventive dental visit, OR (95% CI)
Early Childhood (3–5 y)
Middle Childhood (6–11 y)
Adolescence (12–17 y)
3.8 1.00 (ref) 0.41 (0.28–0.60)
4.8 1.00 (ref) 0.21 (0.16–0.28)
5.7 1.00 (ref) 0.18 (0.13–0.26)
6.4 1.00 (ref) 0.52 (0.28–0.93)
6.4 1.00 (ref) 0.18 (0.12–0.28)
8.3 1.00 (ref) 0.12 (0.08–0.17)
*Adjusted for sex, medical health insurance status, percentage of federal poverty level, adult household member education, family structure, race/ethnicity, dental insurance status, and identification of a personal health provider. OR indicates odds ratio; 95% CI indicates 95% confidence interval; and CSHCN indicates children with special health care needs.
groups. For children both with and without special health care needs, attending a well-child visit was significantly associated with not having an unmet need for medical care for adolescents, and attending a preventive dental visit was associated with not having an unmet need for preventive dental care for all age groups. Although this finding may appear tautological, we emphasize that it is still possible for a child who has received preventive care to have unmet needs, just as it is possible for a child who has received no preventive care to have no unmet needs. The question of unmet need is one of parental perception, not of fact determined by a clinician. Regarding use of preventive care services, our findings concur with more recent reports that CSHCN use more preventive care than their peers.14,15 Our findings may reflect the many changes to health care that have occurred since previous studies10,11,21 were conducted that suggested that CSHCN receive less preventive care. Expansions in Medicaid and the creation of the State Child Health Insurance Program gave vulnerable children greater access to primary care. The American Academy of Pediatrics’ medical home initiative and concurrent emphases on primary care in private and public managed care plans also may have contributed to these changes. Preventive Medical Visits Several aspects of primary care delivery to CSHCN may enhance attendance at well-child visits. Primary care physicians may tailor anticipatory guidance and screening to a child’s chronic condition; therefore, CSHCN and their parents may see more value in wellchild visits than other parents do. Also, primary care physicians may address specific aspects of a patient’s chronic condition during the well-child visit, delivering a combination of routine preventive care and chronic disease management. Primary care physicians may have a stronger relationship with CSHCN and their parents, who may perceive more benefit from a preventive visit than parents of children without such a connection. Also, CSHCN may have more frequent office visits, giving physicians a greater opportunity to remind parents that a well-child visit is due. Similar reminders have been shown in other studies to increase preventive care use in children generally.22,23 Children and adolescents in older age groups, where the effect of having a special health care need
was greatest, may see their provider regularly to manage their chronic condition, and so are more likely to either address preventive care issues at these visits or to schedule another visit. Children without special health care needs often do not attend routine annual visits during these years. Rates of well-child visit attendance are higher, and rates of unmet need for medical care were lower, for this sample compared with previous estimates.9,24–26 However, we emphasize that the question delineating well-child visit attendance was asked only of those who could identify a personal health care provider for their child. We limited our analysis to children with a personal health provider because we did not want issues of access to health care to confound our analysis of utilization. If we assume that all children without a personal health care provider did not attend a well-child visit and had more unmet needs, our estimates would be more consistent with previous studies, and the overall conclusions would remain the same. We hypothesized that attending a well-child visit would be associated with a reduced likelihood of unmet needs for medical care, especially for CSHCN. However, for CSHCN and other children, after controlling for factors known to contribute to unmet medical needs, such as poverty level and health insurance status, we found this association only in adolescents. For adolescents, well-child visits may present an opportunity for parents, patients, and physicians to address other medical issues that would otherwise go unmet, especially because adolescents may be perceived by physicians as less likely to attend follow-up visits for issues related to chronic disease. However, because of the cross-sectional nature of the NSCH, we cannot conclude causality from our findings, and any association between attending preventive visits and lower rates of unmet need may reflect better access to care overall. The nature and reason for unmet needs for younger children may be different than for adolescents and may reflect barriers that cannot be overcome through contact with the physician during well-child visits, such as insurance factors or availability of certain services. In addition, we found CSHCN had higher rates of unmet need for medical care compared with other children, despite higher rates of service use. This underscores previous work that has found a high rate of unmet need for medical care in this population.7,8
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Preventive Dental Visits In this study, we found that CSHCN do not receive less preventive dental care than other children. In fact, younger children who have a special health care need attend preventive dental visits at a higher rate than other children. This may be a result of condition-specific dental needs that require visits earlier in life. For example, parents of developmentally delayed children may have difficulty with routine tooth brushing; such children would likely need a dentist’s evaluation earlier than other children. In addition, young CSHCN may routinely take medicines delivered in sugar-based syrup, putting them at risk for caries.6 Attending a preventive dental visit in the past year was associated with a large reduction, but not an elimination, of parental report of unmet need for preventive dental care overall. This finding is consistent with previous analyses27 that insurance status and family income, which influence access to preventive dental services, contribute to the likelihood of having an unmet need. Even among children who attend a dental preventive visit, some still report an unmet need for these services. The NSCH asks whether the child attended at least 1 preventive visit in the past year; some children may have been able to attend only 1 of the 2 recommended visits per year or may have attended a preventive dental visit but were unable to attain all needed preventive services at these visits. We emphasize that because the data are cross-sectional, causal relationships cannot be determined. Additionally, unmet need for preventive dental care was associated with having a special health care need, which is consistent with previous reports7 of relatively high rates of unmet dental care needs among CSHCN. Limitations Our study has limitations that must be noted. As stated above, with cross-sectional data, we cannot determine causality in our findings, only associations. The NSCH relied on adult respondents’ recall of health care utilization over a long period of time. This may over- or underestimate the actual utilization of the population. Also, the question regarding preventive medical care that we used in this study was asked only of respondents whose child had a personal doctor or nurse. Certainly children who can identify a medical home are more likely to receive preventive care28; therefore, we cannot draw definitive conclusions about children who lack such a provider but can only postulate that preventive care rates for those children are lower. Conclusions This study has several important implications for clinical care and further research. First, this study indicates that having a chronic condition influences patterns of routine preventive health care in some age groups. Further research examining content of preventive care visits for CSHCN will be fruitful, shedding light both on mechanisms of preventive care delivery and on primary care management of CSHCN. Future studies should determine whether the content of these preventive care visits is the same for both groups of children and whether chronic illness care takes
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priority during these visits, and if so, whether this additional service influences preventive care utilization. It will also be useful to examine the connection between preventive care visits and unmet need for preventive and acute medical and dental care. Although we could not determine directionality with these cross-sectional data, perceptions of unmet need are potentially a cause and effect of health care–seeking behavior by parents on behalf of children. Regarding use of preventive dental care, disparities related to income and race/ethnicity are gradually improving29; it will be informative to see if this service is used in different ways for CSHCN in the future. ACKNOWLEDGMENT Supported in part by Robert Wood Johnson Clinical Scholars Program at the University of Michigan.
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17. Blumberg SJ, Olson L, Frankel MR, Osborn L, Srinath KP, Giambo P. Design and operation of the National Survey of Children’s Health, 2003. National Center for Health Statistics. Vital Health Stat. 2005;1. 18. Child and Adolescent Health Measurement Initiative. Children with special health care needs screener. Available at: http://www.cahmi. org/. Accessed April 16, 2008. 19. Bethell CD, Read D, Stein RE, Blumberg SJ, Wells N, Newacheck PW. Identifying children with special health care needs: development and evaluation of a short screening instrument. Ambul Pediatr. 2002;2:38–48. 20. Stein RE, Silver EJ. Operationalizing a conceptually based noncategorical definition: a first look at US children with chronic conditions. Arch Pediatr Adolesc Med. 1999;153:68–74. 21. Raddish M, Goldmann DA, Kaplan LC, Perrin JM. The immunization status of children with spina bifida. Am J Dis Child. 1993;147: 849–853. 22. Minkovitz CS, Belote AD, Higman SM, Serwint JR, Weiner JP. Effectiveness of a practice-based intervention to increase vaccination rates and reduce missed opportunities. Arch Pediatr Adolesc Med. 2001; 155:382–386.
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23. Hambidge SJ, Davidson AJ, Phibbs SL, et al. Strategies to improve immunization rates and well-child care in a disadvantaged population: a cluster randomized controlled trial. Arch Pediatr Adolesc Med. 2004;158:162–169. 24. Byrd RS, Hoekelman RA, Auinger P. Adherence to AAP guidelines for well-child care under managed care. American Academy of Pediatrics. Pediatrics. 1999;104:536–540. 25. Newacheck PW, McManus M, Fox HB, Hung YY, Halfon N. Access to health care for children with special health care needs. Pediatrics. 2000;105:760–766. 26. Chung PJ, Lee TC, Morrison JL, Schuster MA. Preventive care for children in the United States: quality and barriers. Annu Rev Public Health. 2006;27:491–515. 27. Newacheck PW, Hughes DC, Hung YY, Wong S, Stoddard JJ. The unmet health needs of America’s children. Pediatrics. 2000;105(4 pt 2):989–997. 28. O’Malley AS, Forrest CB. Continuity of care and delivery of ambulatory services to children in community health clinics. J Community Health. 1996;21:159–173. 29. Hughes DC, Duderstadt KG, Soobader MP, Newacheck PW. Disparities in children’s use of oral health services. Public Health Rep. 2005; 120:455–462.