Assessing the impact of routine preventive care on health outcomes in a Medicaid population continuously enrolled in managed care

Access to primary medical care is an essential component of any health care delivery system. Studies have shown that people who lack access to primary care are less likely to receive age appropriate preventive services and more likely to rely on more costly alternatives such as hospital-based emergency departments and inpatient stays. They are also conceivably more likely to experience other morbid outcomes as a result of poor utilization of preventive services. This thesis focuses on the efficacy of three distinct types of preventive care: prenatal care, routine preventive care during the first year of life and children being treated for asthma.; The first study was designed to assess the role of prenatal care as a confounder, effect modifier or intermediary in the causal pathway between traditional risk factors and low birthweight. Our results identified several health services risks that were associated with late entry into prenatal care and one that was also an independent risk for low birthweight. As other studies, we found that prenatal care was a significant independent risk for low birthweight, but its impact was mitigated in a multiple logistic regression model that included other sociodemographic and medical risks. Furthermore, we found little evidence that prenatal care confounded any of the traditional risk factors. Evidence of effect modification was found in subgroup analyses that showed that the magnitude and direction of some traditional risks changed across strata of our prenatal care variable. There was no evidence of prenatal care acting as an intermediary in the causal pathway between traditional risk factors and low birthweight.; The second study was designed to assess the effectiveness of routine pediatric care during the first year of life on morbidity during the second year of life. We hypothesized that infants who receive standard pediatric care during their first year of life would enter their second year of life healthier and require less acute care such as outpatient sick visits, emergency department visits, and inpatient stays during their second year of life. We found that children who received substandard care were somewhat more likely to be hospitalized and use hospital-based emergency departments but were actually less likely as opposed to more likely to use multiple outpatient sick care during the second year of life.; Finally, the third study was designed to assess the impact of a gap or disruption in enrollment on the management of asthma in children aged 3-18. Here we expected to find that asthmatic children with a gap in their health insurance coverage would be more likely to use a hospital-based emergency department within 90 days than asthmatic children with no disruption in enrollment. While our results were inconclusive, we found evidence that gaps in enrollment were more disruptive of continuity of care among mild to moderate asthmatics and among children who had not filled a prescription of a 'rescue' drug within the past 30 days.