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Stephen E. Saunders, M.D., M.P.H. Associate Director for Family Health

Impact of Family Case Management and WIC on Birth Outcomes of Medicaid Recipients in Illinois 2000-2002. Stephen E. Saunders, M.D., M.P.H. Associate Director for Family Health Illinois Department of Human Services. Co-authors. Mary Ellen Simpson, R.N., Ph.D. William Sappenfield, M.D., M.P.H.

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Stephen E. Saunders, M.D., M.P.H. Associate Director for Family Health

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  1. Impact of Family Case Management and WIC on Birth Outcomes of Medicaid Recipients in Illinois2000-2002 Stephen E. Saunders, M.D., M.P.H. Associate Director for Family Health Illinois Department of Human Services

  2. Co-authors • Mary Ellen Simpson, R.N., Ph.D. • William Sappenfield, M.D., M.P.H. • Ralph Schubert, M.A., M.Sc. • Arden Handler, Dr.PH • Deb Rosenberg, Ph.D.

  3. 12.4 million people 2/3 of population in Chicago and “Collar Counties” 70% of counties are rural (<50,000 pop.) >99% of population served by a local health department 180,000 live births 44% of live births covered by Medicaid Welcome to Illinois

  4. Family Case Management • Outreach and Case Finding • Assessment and Care Plan Development • Referral and Follow-up • Advocacy

  5. Family Case Management • Statewide • 116 Local Agencies • Local Health Departments • Federally Qualified Health Centers • Community Based Organizations • $44 Million Budget • 281,000 Pregnant Women and Infants Served Annually

  6. Special Supplemental Nutrition Program for Women, Infants and Children (WIC) • Nutrition education • Breastfeeding education and support • Supplemental nutritious foods • Access to health care services

  7. WIC Program Characteristics • Statewide • 100 Local Agencies • Local Health Departments • Community Based Agencies • $34 Million Budget (+ Food) • 508,300 Women, Infants and Children Served Annually

  8. Theoretical Model of FCM Positive Resulton PregnancyTest Prenatal Care WICFood Supplement FCMAssessment Domestic Violence screening HealthEducation Care Plan Provides continued follow up and Linage to the following servicesHOME VISIT Education Housing UltimateGoal Mentoring Support Mental Health Substance Abuse Treatment • Lower Prematurity • Raise Birthweight • Lower Intrauterine Growth Restriction Smoking Cessation

  9. Study Background • Results of previous research examining programmatic effects of perinatal case management services using linked program and vital records computer files has been questioned because of preterm delivery bias and selection bias

  10. Research Question • Does enrollment in Family Case Management and/or WIC reduce the likelihood of early preterm, late preterm or term SGA births?

  11. Selection Bias • Participants were not randomly assigned to the intervention and comparison groups, so they may not be equivalent with regard to race, age, parity, medical risk factors use of prenatal care or other variables.

  12. Program Entry (Prematurity) Bias • Some of the women in the comparison group may have given birth before they would typically have enrolled in WIC or FCM • Some of the women in the intervention group may have enrolled in WIC or FCM after it was possible to have a preterm delivery.

  13. Controlling For Selection Bias • Women with no PNC or late PNC were not included in the study • All have PNC started before the 5th month of pregnancy • Logistic regression

  14. Controlling For Program Entry Bias • Women who enrolled after possible preterm delivery were included as non-program participants

  15. Controlling For Medical Risk Factor Bias • Models adjusted for medical risk factors • There were more adverse medical risk factors in women who participated in the programs • This bias is against the program effect

  16. Controlling for the “Black Box” of FCM • We were unable to examine referrals and content of FCM because of data limitations.

  17. 2000 n=71,384 2001 n=75,158 2002 n=75,601 Program Both Programs 59.3% 62.2% 66.1% WIC Only 13.3% 11.7% 10.0% FCM Only 10.0% 9.6% 8.7% Neither Program 17.4% 16.5% 15.3% Program Participation by Year

  18. Cornerstone MIS • Supports FCM, WIC, Immunization & Others • Common Enrollment • Case Management & Service Delivery • 117 Screens • 300+ Locations • 3,000 Workstations

  19. Methods • Link Birth Certificate, Medicaid and Cornerstone Management Information System files • Concatenated 2000-2002 files • Analyze singleton births on Medicaid

  20. Methods • Measure completed months of pregnancy • Entered programs prior to gestational age of outcome measured • Entered prenatal care before 5th month of pregnancy • Enrolled in programs at least 1 month

  21. Logistic Regression Models • Outcomes: early preterm birth (5-6th month), late preterm birth (7th month) and term SGA births (8th month or more) • Adjusted for socio-demographic factors and health-related factors

  22. Results: Early Preterm Birth (5-6th mo.) • Odds Ratio: 0.76 • 95% Confidence Interval: 0.69 -- 0.83 • Adjusted for age, education, race, ethnicity, material status, smoking, alcohol, parity risk for age, medical risks, & parity • N=203,450 • 50th Percentile birth weight (g) for early preterm birth 496g-1637g

  23. Program Effect O.R. 95% C.I. WIC & FCM 0.76 0.69 – 0.83 WIC only 0.65 0.56 – 0.75 FCM only 0.80 0.70 – 0.92 Neither 1.00 Reference Results: Early Preterm Birth N=203,450 Adjusted for age, education, race, ethnicity, marital status, smoking, alcohol, medical risk factors & parity

  24. Effect Odds Ratio 95% C.I. WIC regardless of FCM 0.73 0.68 – 0.78 FCM regardless of WIC 0.86 0.81 – 0.93 Results: Late Preterm Birth (7th mo.) *Adjusted for medical risks, race, smoking, parity risk for age, & marital status N=199,413 50th Percentile birth weight (g) for late preterm birth: 1918g-2667g

  25. Odds Ratio Effect 95% C.I. WIC regardless of FCM 0.97 0.94– 1.01 FCM regardless of WIC 0.97 0.94 – 1.01 Results: SGA Term Birth (8th month or more) *Adjusted for medical risks, race, marital status, smoking, alcohol, and parity risk for age N=184,224

  26. Conservative Estimates • Excluded women without prenatal care • Moved women who entered WIC or FCM late in pregnancy into the comparison group • Adjusted for a wide array of demographic and health status variables • Addressed 4 of 5 sources of bias reported in previous studies

  27. Limitations • No randomization (Observational study design) • Did not account for variations in service delivery after enrollment

  28. Conclusions • FCM & WIC showed a protective effect for both early and late preterm delivery • 24% reduction in extreme prematurity • Neither program impacts term SGA births • Program benefits are in addition to those of PNC • More rigorous control for bias

  29. Public Health Implications • Substantiate previous studies that WIC or FCM reduces the risk of early and late preterm delivery • FCM effects may be due to nutrition, health education or social service programs

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