title: Ambulatory care connections of Medicaid-insured children with sickle cell disease.
abstract: BACKGROUND
  Sickle cell disease (SCD) requires coordinated ambulatory care from generalists and hematologists. We examined when children with SCD establish ambulatory care connections, whether these connections are maintained, and how these connections are used before and after hospitalizations.
  
  
  METHODS
  We conducted a retrospective cohort study of Medicaid-insured Maryland children with SCD from 2002 to 2008. For children enrolled from birth, time to first, second, and third generalist and first hematologist visits was plotted. For all children, we analyzed ambulatory visits by age group, by emergency department (ED) and hospital use, and before and after hospitalizations.
  
  
  RESULTS
  The overall study cohort comprised 851 children; 178 provided data from birth. Ambulatory care connections to generalists were made rapidly; connections to hematologists occurred more slowly, if at all (38% of children had not seen a hematologist by age 2 years). Visits with generalists decreased as patients aged, as did visits with hematologists (54% of children in the 12-17 year age group had no hematology visits in 2 years). Children with higher numbers of ED visits or hospitalizations also had higher numbers of ambulatory visits (generalist and hematologist). Most children had visits with neither generalists nor hematologists in the 30 days before and after hospitalizations.
  
  
  CONCLUSIONS
  Medicaid-insured children with SCD rapidly connect with generalists after birth; connections to hematologists occur more slowly. The observation that connections to generalists and hematologists diminish with time and are infrequently used around hospitalizations suggests that the ambulatory care of many Medicaid-insured children with SCD may be inadequate.
authors.affiliation: Division of Quality and Safety, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA. dbundy@jhmi.edu
authors.forename: David G
authors.initials: DG
authors.lastname: Bundy
authors.forename: John
authors.initials: J
authors.lastname: Muschelli
authors.forename: Gwendolyn D
authors.initials: GD
authors.lastname: Clemens
authors.forename: John J
authors.initials: JJ
authors.lastname: Strouse
authors.forename: Richard E
authors.initials: RE
authors.lastname: Thompson
authors.forename: James F
authors.initials: JF
authors.lastname: Casella
authors.forename: Marlene R
authors.initials: MR
authors.lastname: Miller
mesh_terms: D000293:Adolescent; D000553:Ambulatory Care; D000755:Anemia, Sickle Cell / Q000628:therapy*; D002648:Child; D002675:Child, Preschool; D006760:Hospitalization; D006801:Humans; D007223:Infant; D008297:Male; D008484:Medicaid; D012189:Retrospective Studies; D014481:United States