Health and Dental Insurance and Health Care Utilization Among Children, Adolescents, and Young Adults With CKD: Findings From the CKiD Cohort Study

Abstract

Rationale & objective: To understand the association between health and dental insurance status and health and dental care utilization, and their relationship with disease severity in a population with childhood-onset chronic kidney disease (CKD).

Study design: Observational cohort study.

Settings & participants: Nine hundred fifty-three participants contributing 4,369 person-visits (unit of analysis) in the United States enrolled in the Chronic Kidney Disease in Children (CKiD) Study from 2005 to 2019.

Exposures: Health insurance (private vs public vs none) and dental insurance (presence vs absence) self-reported at annual visits.

Outcomes: Self-reported suboptimal health care utilization in the past year, defined separately as not visiting a private physician, visiting the emergency room, visiting the emergency room at least twice, being hospitalized, and self-reported suboptimal dental care utilization over the past year, defined as not receiving dental care.

Analytical approach: Repeated measures Poisson regression models were fit to estimate and compare utilization by insurance type and disease severity at the prior visit. Additional unadjusted and adjusted models were fit, as well as models including interactions between insurance and Black race, maternal education, and income.

Results: Those with public health insurance were more likely to report suboptimal health care utilization across the CKD severity spectrum, and lack of dental insurance was strongly associated with lack of dental care. These relationships varied depending on strata of socioeconomic status and race but the effect measure modification was not significant.

Limitations: Details of insurance coverage were unavailable; reasons for emergency care or type of private physician visited were unknown.

Conclusions: Pediatric nephrology programs may consider interventions to help direct supportive resources to families with public insurance who are at higher risk for suboptimal utilization of care. Insurance providers should identify areas to expand access for families of children with CKD.

Keywords: Chronic kidney disease; dental health; dental insurance; epidemiology; health care utilization; health insurance; pediatric nephrology; socioeconomic markers; socioeconomic position.

Graphical abstract

Figure 1

Change in health insurance status over time, stratified by under 19 years versus 19 years of age or older. The percentage reporting each health insurance type is on the y-axis, and the time in 3-year bins is presented on the x-axis. Person-visits contributed by those under the age of 19 years are represented by triangles (▴) and by circles (•) for those 19 years of age or older. Black markers represent private insurance, gray represents public insurance, and red represents no health insurance coverage. The numbers of person-visits and individual participants contributing to each time period and age group are listed across the top of each plot. No data are shown for those 19 years of age or older in the 2005-2007 time period because fewer than 20 person-visits were present.

Figure 2

(A) Proportion per person-visits and 95% confidence intervals (CIs) of past year health care use by health insurance status and chronic kidney disease (CKD) risk stage (A, B, C, D, E, or F) at the previous study visit. Number of person-visits (denominators) are shown above each health insurance status and CKD risk stage group. Statistically significant pairwise P values comparing those with private versus public insurance are indicated within each CKD risk stage. (B) Proportion per person-visits and 95% CIs of past year dental care use by dental insurance status and CKD risk stage (A, B, C, D, E, or F) at the previous study visit. Number of person-visits (denominators) are shown above each dental insurance status and CKD risk stage group. Statistically significant pairwise P values comparing those with yes versus no dental insurance are indicated within each CKD risk stage.