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Primary and Dental Care Utilization Among Children with Neurodevelopmental Disorders in Federally Qualified Health Centers

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Dina Ghanim, BA

Kaiser Permanente Bernard J. Tyson School of Medicine

Dina.Ghanim@kp.org

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Background & Significance

    • Neurodevelopmental Disorders (NDDs)
      • New categorization of clinical conditions described in DSM-5
      • Variations in brain develops affects how a child functions socially, academically
      • Appear early in child development
    • Common Types of NDDs:
      • Autism Spectrum Disorder (ASD), Attention-Deficit/Hyperactivity Disorder (ADHD), Speech Disorder, Intellectual Disability, Learning Disability, Developmental Coordination Disorder (DCD), Behavioral Disorder
    • 1 in 6 children in the U.S. are diagnosed with an NDD by age 8
      • 1 in 4 publicly insured children are diagnosed by age 8

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Background & Significance

    • Children with NDD more likely to be on public health insurance (low-income families) are more likely to face disparate outcomes in pediatric primary care and specialized care services
      • Delayed Diagnoses
      • Reduced Access to Preventive Care --> Fewer Well-Child Visits, lower rates immunizations
      • Reduced access to specialist able to provide them with care
      • Increased levels of unmet health needs
    • Barriers include lack of specialized providers, transportation issues, and inadequate insurance coverage

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Background & Significance

    • FQHCs are community-based healthcare providers offering comprehensive primary care to underserved populations, regardless of their ability to pay
    • Pediatric visits at FQHCs have increased over the last decade
      • By 2023, FQHCs served over 9 million children annually
      • Increasing role in providing care for children with NDD and Children with Special Healthcare Needs (CSHCN)
    • FQHCs are an important part of the safety net healthcare system
    • FQHCs have unique care models that may facilitate access and utilization of care and overcome barriers
      • Enabling services (i.e. translators, transportation services, case managers, community health workers), Integrated dental services

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Aim

To assess whether receiving care at FQHCs improves the likelihood of:

    • At least one well-child care (WCC) visit per year among children with NDDs
    • At least one preventive dental visit per year among children with NDDs

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    • Study Design: Cross-sectional analysis
    • Data Source: Medicaid claims data (2018)
    • Population: Children aged 2–18 with NDD diagnoses
    • Primary Exposure: Primary Care Provider Status
      • Majority of primary care billed visits were at an FQHC
    • Outcomes: At least one annual WCC and dental visit
    • Analysis: Multivariable logistic regression (adjusted odds ratios, 95% confidence intervals)

Methods – Study Design & Data Source

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Key Variables- Outcome

Well-Child Care (WCC) Visit

    • Identification: Claims with Current Procedural Terminology (CPT) codes for preventive services (e.g., 99381–99385, 99391–99395) and Healthcare Common Procedure Coding System (HCPCS) codes (e.g., S0302, G9964), as recommended by the American Academy of Pediatrics (AAP) and aligned with Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) guidelines.
    • Having at least one routine pediatric preventive care visit per year
    • Binary outcome (Yes / No)

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    • Definition: At least one dental care visit per year.
    • Identification: Claims with Current Dental Terminology (CDT) codes D0100–D9999, encompassing diagnostic, preventive, and treatment services.
    • Binary outcome (Yes / No)

Dental Visit

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Primary Care Provider Status (FQHC vs. Non-FQHC)

    • Definition:
      • Receiving majority (≥50%) of primary care visits at an FQHC
    • Primary Care Visit
      • Visits for preventive care (e.g., Well-child care visits)
      • Acute care visits: Appointments for common illnesses or injuries
      • Chronic condition management: Follow-up visits for ongoing health issues
      • Post-hospitalization follow-ups: Visits after discharge to ensure recovery and prevent readmission
    • Categorization:
      • FQHC group: ≥50% of these primary care visits at an FQHC
      • Non-FQHC group: <50% of primary care visits at an FQHC

Key variables- Primary explanatory

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    • Age (2–5, 6–8, 9–11, 12–14, 15–18)
    • Sex (Male/Female)
    • Race/Ethnicity (White, Black, Hispanic, Other)
    • Geographic Region (Northeast, Midwest, South, West)
    • Urban/Rural (binary Census designation)
    • Medicaid Coverage Type (Managed Care vs. Fee-for-Service)
    • CHIP (Binary Yes/No)

Key variables- covariates

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    • Descriptive statistics for all variables
    • Bivariate Analysis
      • Chi-square tests to examine unadjusted associations between WCC/Dental visit, primary exposure and covariates
    • Multivariable Logistic Regression
      • Multivariable logistic regression to estimate adjusted odds of WCC/Dental visit
      • Models adjusted for child, healthcare factors

Statistical Analysis

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Results

Table 1. Sample Characteristics by Primary Care Provider Status

    • Age groups were simplified, Sex, some racial/ethnic groups (American Indian/Alaska Native, Asian, Hawaiian/Pacific Islander, Multiracial) not included in this graph - none showed significant difference across FQHC patient status

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Results

Table 1. Sample Characteristics by Primary Care Provider Status

    • Age groups were simplified, Sex, some racial/ethnic groups (American Indian/Alaska Native, Asian, Hawaiian/Pacific Islander, Multiracial) not included in this graph - none showed significant difference across FQHC patient status

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Results

Figure 1. Bivariate Associations Between School Readiness and Neighborhood Asset Level

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Results

Table 3. Adjusted Odds Ratios for Factors Associated with WCC/Dental Visit

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    • Receiving care at FQHCs is significantly associated with better primary and dental care utilization in children with NDDs
    • Emphasize the critical role of FQHCs in addressing disparities and improving healthcare access for children with NDD on Medicaid
    • Policy implications: Expand support for FQHCs to enhance equity

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Implications & Clinical Implications

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    • Cross-sectional study limits causality inference
    • Potential for unmeasured confounding
      • Currently including control for co-occurring NDD condition
      • Currently including control for Pediatric Medical Complexity Algorithm (PMCA) to control for clinical complexity
    • Suggest future longitudinal or intervention studies for stronger evidence

Limitations & Next Steps

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Questions & Discussion