title: Assessing Geographic Variation in Strabismus Diagnosis among Children Enrolled in Medicaid.
abstract: To determine how strabismus diagnosis varies within a given community and across communities among children with Medicaid health insurance.
  
  
  
  Retrospective cohort analysis.
  
  
  
  Children aged ≤10 years enrolled in Medicaid in Michigan or North Carolina during 2009.
  
  
  
  Children who met the study inclusion criteria were identified from the Medicaid Analytic Extract database, which includes claims data for all children enrolled in Medicaid throughout the United States. Residential location was determined by the last known 5-digit ZIP code for each child, which was linked to the centroid of a ZIP Code Tabulation Area (ZCTA) for geo-referencing and spatial analyses. International Classification of Diseases, 9th Revision, Clinical Modification billing codes were used to identify children diagnosed with strabismus (code 378.xx). Bayesian hierarchical intrinsic conditional autoregressive spatial probit models were used to determine the risk of a child receiving a strabismus diagnosis in communities throughout Michigan and North Carolina. Maps display communities (ZCTAs) where the 95% credible intervals for the spatial random effects estimates do not cross zero, allowing for identification of locations with increased and decreased strabismus diagnosis risk relative to other communities in the states.
  
  
  
  Likelihood of receiving a diagnosis of strabismus.
  
  
  
  In 2009, among 519 212 eligible children in Michigan, 7535 (1.5%) received ≥1 strabismus diagnosis, and in North Carolina, 5827 of 523 886 eligible children (1.1%) were diagnosed with strabismus. In both states, the proportion receiving a strabismus diagnosis among black (0.9% in Michigan; 0.7% in North Carolina) and Hispanic (1.1% in Michigan; 0.8% in North Carolina) children was lower than the proportion for white children (1.8% in Michigan; 1.6% in North Carolina). Children living in poorer communities in both states were less likely to be diagnosed with strabismus independent of their race/ethnicity.
  
  
  
  A child's likelihood of being diagnosed with strabismus is associated with characteristics of the residential community where he or she resides. The findings of this study highlight the importance of ensuring that children who live in less affluent communities have access to the necessary services and eye care professionals to properly diagnose and treat them for this condition.
authors.affiliation: Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
authors.forename: Joshua R
authors.initials: JR
authors.lastname: Ehrlich
authors.affiliation: Children's Environmental Health Initiative, Rice University, Houston, Texas.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Anthopolos
authors.affiliation: Children's Environmental Health Initiative, Rice University, Houston, Texas.
authors.forename: Joshua
authors.initials: J
authors.lastname: Tootoo
authors.affiliation: Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan.
authors.forename: Chris A
authors.initials: CA
authors.lastname: Andrews
authors.affiliation: Children's Environmental Health Initiative, Rice University, Houston, Texas; Department of Statistics, Rice University, Houston, Texas; Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
authors.forename: Marie Lynn
authors.initials: ML
authors.lastname: Miranda
authors.affiliation: Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
authors.forename: Paul P
authors.initials: PP
authors.lastname: Lee
authors.affiliation: Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan.
authors.forename: David C
authors.initials: DC
authors.lastname: Musch
authors.affiliation: Department of Ophthalmology and Visual Sciences, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan. Electronic address: jdstein@med.umich.edu.
authors.forename: Joshua D
authors.initials: JD
authors.lastname: Stein
mesh_terms: D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008484:Medicaid / Q000706:statistics & numerical data; D008824:Michigan / Q000453:epidemiology; D009657:North Carolina / Q000453:epidemiology; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D013285:Strabismus / Q000453:epidemiology*; D014481:United States