Article Figures & Data
Tables
- Table 1
Social Complexity Risk Factors Having Demonstrated or Hypothesized Association With Suboptimal Health Care Use Among Children
Risk Factor Definition of Risk Factor in Administrative Data Parent domestic violence13,14 Any arrest for which a charge recorded is in a domestic violence crime category Parent deatha State health department death certificates for biologic parents Parent mental illness15–18 Mental health diagnosis, service encounters, procedures, or prescribed psychotropic medications recorded in medical claims or publicly funded mental health records for either biologic parentb Parent criminal justice involvementa Any arrest or conviction recorded by state patrol or court filings, including adjudication in state court database, for any crime category for either biologic parent Child abuse/neglect17 Any family involvement (child or either biologic parent) in child welfare or child protective services system in Washington State Homelessnessa Indicates at least 1 period of homelessness, including shelter stays, recorded by a financial eligibility worker during eligibility (re)determination for public assistance for child or either biologic parent Poverty12,19–21 TANF benefit recorded for childc Parent has limited English proficiency or speaks a language other than English at home12,22 Primary language other than English and indicated need for interpreter for biologic parent and/or child Child mental illnessa Mental health diagnosis, service encounters, procedures, or prescribed psychotropic medications recorded in medical claims or publicly funded mental health records for child aged ≥5 yb Child substance abusea Substance-related diagnosis, service or encounters recorded in medical claims or publicly funded mental health records; any arrest for which a charge recorded is in a substance-related crime category (eg, driving under the influence, possession of controlled substance) for child aged ≥12 yb Child juvenile or criminal justice involvementa Any arrest or conviction recorded by state patrol or court filings, including adjudication in state court database, for any crime category for child aged ≥12 y TANF = Temporary Assistance for Needy Families.
Note: Based on Washington State administrative data. Four risk factors could not be identified using the available administrative data: (1) low parent educational attainment, (2) single parent in household, (3) adolescent exposure to intimate partner violence, and (4) discontinuous insurance coverage.
↵a Risk factor hypothesized to have an association with suboptimal health care use.
↵b Full list of codes used to identify parent/child mental illness and child substance abuse is given in the Supplemental Appendix, available at http://www.annfammed.org/content/16/1/62/suppl/DC1/.
↵c The income of a TANF family of 3 in Washington State with any housing expenses was approximately 38% of the 2008 Department of Health and Human Services Poverty Guidelines.
Characteristic All Children Children With ≥1 Emergency Department Visits <5 Years (n=180,198) 5–17 Years (n=325,169) <5 Years (n=62,512) 5–17 Years (n=69,015) Sex, female, % 48.8 49.1 47.2 49.0 Age, mean (SD), y 1.8 (1.4) 10.3 (3.6) 1.5 (1.4) 10.5 (3.8) Race or ethnicity, % Hispanic 29.5 27.3 34.6 32.0 Non-Hispanic White 36.1 48.3 32.8 44.8 African American 5.7 8.4 6.1 8.7 Asian, Native Hawaiian, or other Pacific Islander 3.6 4.4 2.9 2.7 American Indian or Alaska Native 3.3 4.8 3.9 6.0 Two or more races 1.6 2.4 1.8 2.8 Unknown race/ethnicity 20.1 4.5 17.8 3.1 Medicaid eligibility, mean (SD), mo 9.9 (3.2) 10.3 (3.2) 11.5 (1.6) 11.5 (1.7) Medical complexity, % Healthy (no chronic disease) 84.2 78.8 81.2 70.6 Noncomplex chronic disease 11.0 15.9 12.8 20.9 Complex chronic disease 4.8 5.3 6.0 8.5 Social complexity risk factors, %a Parent domestic violence 4.5 4.4 5.4 5.4 Parent death 0.4 2.1 0.3 2.4 Parent mental illness 31.1 32.7 36.8 40.3 Parent criminal justice involvement 44.0 40.4 50.2 45.6 Child abuse/neglect 27.7 34.5 32.1 41.6 Homelessness 17.0 17.0 20.4 20.7 Poverty 26.8 23.4 34.3 30.8 Limited English proficiency 25.7 18.5 28.9 20.4 Child mental illness n/a 18.4 n/a 24.1 Child substance abuse n/a 1.9 n/a 3.7 Child juvenile or criminal justice involvement n/a 3.0 n/a 5.3 Social complexity risk factors 0 factors, % 21.2 19.8 13.9 12.3 1 factor, % 30.4 26.8 28.2 23.3 2 factors, % 20.2 20.7 22.2 21.3 3 factors, % 13.5 14.7 16.3 17.1 4 factors, % 9.0 9.8 11.4 13.0 ≥5 factors, % 5.8 8.2 7.9 13.0 Mean (SD), No. 1.8 (1.5) 2.0 (1.6) 2.1 (1.5) 2.4 (1.7) Outcomes Emergency department visits, mean (SD), No. 0.7 (1.3) 0.3 (0.8) 1.9 (1.4) 1.6 (1.2) n/a=not applicable.
↵a Assessable factors from Table 1. A total of 8 factors were assessed in children aged <5 years and 11 factors were assessed in children aged 5–17 years, Supplemental Appendix, http://www.annfammed.org/content/16/1/62/suppl/DC1/.
- Table 3
Adjusted Analysis Predicting the Number of Emergency Department Visits for Children Aged Younger Than 5 Years
Predictor Model 1: Incidence Rate Ratio (95% Wald CI) Model 2: Incidence Rate Ratio (95% Wald CI) Social complexity risk factor Parent domestic violence 0.96 (0.92–1.00) – Parent death 0.85 (0.74–0.98) – Parent mental illness 1.21 (1.19–1.24)a – Parent criminal justice involvement 1.11 (1.09–1.13)a – Child abuse/neglect 1.08 (1.06–1.10)a – Homelessness 1.05 (1.03–1.08)a – Poverty 1.25 (1.23–1.28)a – Limited English proficiency 1.17 (1.14–1.19)a – Number of social complexity risk factors 1 factor – 1.24 (1.21–1.28)a 2 factors – 1.48 (1.43–1.52)a 3 factors – 1.62 (1.57–1.67)a 4 factors – 1.76 (1.70–1.83)a ≥5 factors – 1.92 (1.85–2.00)a Note: Adjusted for child sex, race/ethnicity, age, level of medical complexity, and length of Medicaid coverage (months).
↵a Significant at P <.0001 level.
- Table 4
Adjusted Analysis Predicting the Number of Emergency Department Visits for Children Aged 5 to 17 Years
Predictor Model 1: Incidence Rate Ratio (95% Wald CI) Model 2: Incidence Rate Ratio (95% Wald CI) Social complexity risk factor Parent domestic violence 1.01 (0.97–1.05) – Parent death 1.03 (0.97–1.10) – Parent mental illness 1.17 (1.15–1.20)a – Parent criminal justice involvement 1.02 (1.00–1.04)a – Child abuse/neglect 1.13 (1.11–1.15)a – Homelessness 1.09 (1.06–1.11)a – Poverty 1.25 (1.23–1.28)a – Limited English proficiency 1.04 (1.01–1.07)a – Child mental illness 1.10 (1.08–1.13)a – Child substance abuse 1.37 (1.29–1.45)a – Child juvenile or criminal justice involvement 1.40 (1.33–1.46)a – Number of social complexity risk factors 1 factor – 1.21 (1.18–1.25)a 2 factors – 1.37 (1.32–1.41)a 3 factors – 1.52 (1.47–1.57)a 4 factors – 1.71 (1.65–1.77)a ≥5 factors – 2.06 (1.99–2.14)a Note: Adjusted for child sex, race/ethnicity, age, level of medical complexity, and length of Medicaid coverage (months).
↵a Significant at P <.0001 level.
Additional Files
Supplemental Appendix
Supplemental appendix
Files in this Data Supplement:
- Supplemental data: Appendix - PDF file
The Article in Brief
Using State Administrative Data to Identify Social Complexity Risk Factors for Children
Kimberly C. Arthur , and colleagues
Background Identifying children with adverse childhood experiences is challenging but critically important, because early intervention has the potential to improve health across the lifespan. This study tests the feasibility of using an integrated state agency administrative database to identify childrens' social complexity risk factors and examine their relationship to emergency department usage.
What This Study Found State administrative data can be used to identify social risk factors for children. Researchers linked administrative data for more than 500,000 children receiving Washington State Medicaid insurance coverage with parent data to identify social complexity risk factors (individual, family, or community characteristics that can affect health outcomes), such as poverty and parent mental illness. They found that social complexity risk factors frequently co-occurred, with approximately one-half the study population having two or more risk factors. Of 11 identifiable risk factors, nine were associated with a higher rate of emergency department utilization. The magnitude of the association with the rate of emergency department utilization was small for individual risk factors, but the rate increased as the number of risk factors increased independent of medical complexity.
Implications
- Providing primary care physicians with a social complexity flag or score, the authors suggest, could facilitate targeted screening of families who are likely to have social risk, with the goal of identifying families who could benefit from care coordination or other supportive services. This, in turn, would help make best use of limited time and resources in primary care.