Quasi-Experimental Evaluations of Pediatric Health Care: Clinical Practice Guidelines and Insurance Coverage.

摘要

The underlying theme of this dissertation is the effects of clinical and federal policy on health, utilization, and expenditures among children and young adults. In Chapter 1, I evaluate the clinical and economic benefits of clinical practice guidelines recommending universal cerebrospinal fluid testing in the emergency department for febrile infants aged 29-56 days. Using a difference-in-differences approach and administrative data from 31 U.S. children's hospitals, I find that these guidelines are not associated with better clinical outcomes or lower health care spending, suggesting that many families of older infants could be spared the stress associated with cerebrospinal fluid testing without harm. The optimal management of older febrile infants in the emergency department has been debated for decades, and results from this study have the potential to change clinical practice at the hospital level.;In Chapter 2, I assess the impact of the Affordable Care Act dependent coverage provision on health care utilization, health, and health care expenditures among young adults aged 19-25 years. Using a difference-in-differences analysis of nationally representative data, I find that implementation of the provision was associated with improved self-reported health and improved financial protection against the costs of health care among young adults. These findings highlight the importance of continued efforts to expand insurance coverage in this population.;In Chapter 3, I investigate whether insurance coverage loss drives differences in access and health care utilization between older adolescents and young adults with asthma. I find that young adults with asthma are less likely to have a usual source of care, to use outpatient care, and to fill asthma medication prescriptions compared with older adolescents with asthma. Differences in insurance coverage account for large proportions of these differences. In a longitudinal analysis, I also find that older adolescents with asthma who lose insurance coverage as they transition to young adulthood are less likely to have a usual source of care. Taken as a whole, these results suggest that insurance coverage plays a crucial role in ensuring access to care and encouraging optimal health care utilization patterns for adolescents and young adults with asthma.