Background Few successful treatment modalities exist to address childhood obesity. Given Latinos’ strong identity with family, a family-focused intervention may be able to control Latino childhood obesity. Purpose To assess the feasibility and effectiveness of a family-centered, primary care–based approach to control childhood obesity through lifestyle choices. Design Randomized waitlist controlled trial in which control participants received the intervention 6 months after the intervention group. Setting/participants Forty-one Latino children with BMI >85%, aged 9–12 years, and their caregivers were recruited from an urban community health center located in a predominantly low-income community. Intervention Children and their caregivers received 6 weeks of interactive group classes followed by 6 months of culturally sensitive monthly in-person or phone coaching to empower families to incorporate learned lifestyles and to address both family and social barriers to making changes. Main outcomes measures Caregiver report on child and child self-reported health-related quality of life (HRQoL); metabolic markers of obesity; BMI; and accelerometer-based physical activity were measured July 2010–November 2011 and compared with post-intervention assessments conducted at 6 months and as a function of condition assignment. Data were analyzed in 2012. Results Average attendance rate to each group class was 79%. Socio-environmental and family factors, along with knowledge, were cited as barriers to changing lifestyles to control obesity. Caregiver-proxy and child-self-reported HRQoL improved for both groups with a larger but not nonsignificant difference among intervention vs control group children (p=0.33). No differences were found between intervention and control children for metabolic markers of obesity, BMI, or physical activity. Conclusions Latino families are willing to participate in group classes and health coaching to control childhood obesity. It may be necessary for primary care to partner with community initiatives to address childhood obesity in a more intense manner. Trial registration This study is registered at Clinicaltrials.partners.org 2009P001721.

WHAT'S KNOWN ON THIS SUBJECT: Parents of children with special health care needs and low-income children report more unmet specialty care needs. Care coordination is associated with increased and decreased referrals to specialty care, but whether care coordination is related to unmet needs is unknown.WHAT THIS STUDY ADDS: Among children with special health care needs, care coordination is associated with lower odds of unmet specialty care needs regardless of whether care coordination was received within a medical home. This association was independent of household income. abstract OBJECTIVES: Care coordination and the medical home may ensure access to specialty care. Children with special health care needs (CSHCN) have higher rates of specialty care use and unmet need compared with the general pediatric population. We hypothesized that care coordination, regardless of whether it was provided in a medical home, would decrease unmet specialty care needs among CSHCN and that the effect of care coordination would be greater among low-income families.METHODS: Secondary data analysis of participants in the 2009-2010 National Survey of CSHCN who reported unmet specialty care needs and for whom care coordination and medical home status could be determined (n = 18 905). Logistic regression models explored the association of unmet need with care coordination and medical home status adjusting for household income.RESULTS: Approximately 9% of CSHCN reported having unmet specialty care needs. Care coordination was associated with reduced odds of unmet specialty care need (without a medical home, odds ratio: 0.63, 95% confidence interval: 0.47-0.86; within a medical home, odds ratio: 0.22, 95% confidence interval: 0.16-0.29) with a greater reduction among those receiving care coordination within a medical home versus those receiving care coordination without a medical home. We did not find differences in the impact of care coordination by percentage of the federal poverty level. CONCLUSIONS:Care coordination is associated with family report of decreased unmet specialty care needs among CSHCN independent of household income. The effect of care coordination is greater when care is received in a medical home. Pediatrics

WHAT'S KNOWN ON THIS SUBJECT: Racial and ethnic differences exist in age at diagnosis and early access to mental and behavioral health services among children with autism spectrum disorders (ASDs). ASDs are also associated with increased rates of other medical comorbidities that may require specialty care.WHAT THIS STUDY ADDS: Significant racial and ethnic differences in use of specialty care and specialty procedures exist among children with documented ASD. abstract OBJECTIVE: To describe racial differences in use of specialty care among children with autism spectrum disorder. METHODS:We identified patients ages 2 to 21 years with an International Classification of Diseases, Ninth Revision code of autism (299.0) seen from 2000 to 2011 at a major academic health center by using a research patient data repository and determined rates of specialty provider visits and procedures by race. We then used logistic regression to determine the associations of rates of subspecialty visits and procedures with race and ethnicity, controlling for gender, age, and payer type. RESULTS:We identified 3615 patients (2935 white, 243 Hispanic, 188 African American, and 249 other). The most striking differences were in use of gastroenterology (GI)/nutrition services. Nonwhite children were less likely to use GI/nutrition specialty providers (African American, odds ratio = 0. CONCLUSIONS:We found racial and ethnic differences among children diagnosed with autism in use of care and procedures. Possible explanations for these findings include differences in presentation, referral rates, or referral follow through. Pediatrics 2013;132:94-100

The Affordable Care Act directed Medicare to update its home health prospective payment system to reflect more recent data on costs and use of services-an exercise known as rebasing. As a result, the Centers for Medicare and Medicaid Services will reduce home health payments 3.5 percent per year in the period 2014-17. To determine the impact that these reductions could have on beneficiaries using home health care, we examined the Medicare reimbursement margins and the use of services in a national sample of 96,621 episodes of care provided by twenty-six not-for-profit home health agencies in 2011. We found that patients with clinically complex conditions and social vulnerability factors, such as living alone, had substantially higher service delivery costs than other home health patients. Thus, the socially vulnerable patients with complex conditions represent less profit-lower-to-negative Medicare margins-for home health agencies. This financial disincentive could reduce such patients' access to care as Medicare payments decline. Policy makers should consider the unique characteristics of these patients and ensure their continued access to Medicare's home health services when planning rebasing and future adjustments to the prospective payment system.